The Role of Staphylococcus aureus in Mastitis : A Multidisciplinary Working Group Experience.

BACKGROUND: Breastfeeding women are at risk of developing mastitis during the lactation period. Staphylococcus aureus has emerged as the community-acquired pathogen responsible for virulence (methicillin resistance and Panton-Valentine leukocidin toxin producing). RESEARCH AIM: The aim was to compare the microorganisms responsible for mastitis and breast abscesses during breastfeeding. METHODS: This observational study was conducted with a sample of women (N = 60) admitted to our hospital between 2016 and 2018. Participants affected by mastitis and breast abscess were studied and cared for by a multidisciplinary working group. A diagnostic breast ultrasound identified the pathology. RESULTS: Twenty-six participants (43.3%) were affected by mastitis and 34 (56.7%) by breast abscess. The most common microorganism identified was Staphylococcus aureus (S. aureus; mastitis, n = 13; abscesses, n = 24). Methicillin resistance was identified in 21 (44.7%) S. aureus strains: 17 (80.9%) cases of abscess and four (19.1%) cases of mastitis. The median number of months of breastfeeding was smaller in the methicillin-resistant S. aureus (MRSA) cases (median = 3, range = 1-20 months) than in the methicillin-sensitive S. aureus (MSSA) cases (median = 6.5, range = 3-21 months). The Panton-Valentine leukocidin toxin gene was detected in 12 (25.5%) cases (MRSA, n = 8, 66.7%; MSSA, n = 4, 33.3%). Hospitalization was required more frequently in MRSA (n = 8, 38%; five Panton-Valentine leukocidin positive) than in MSSA cases (n = 5, 19%; one Panton-Valentine leukocidin positive). Four women out of the eight MRSA cases (50%) that were Panton-Valentine leukocidin positive stopped breastfeeding during mammary pathologies, three (37.5%) participants continued breastfeeding until the follow-up recall, and one case was lost at follow-up. CONCLUSION: Clinical severity was probably complicated by the presence of the Panton-Valentine leukocidin toxin, which required hospitalization more frequently.

Long-Term Incremental Prognostic Value of Cardiovascular Magnetic Resonance After ST-Segment Elevation Myocardial Infarction: A Study of the Collaborative Registry on CMR in STEMI.

OBJECTIVES: This study sought to investigate whether early post-infarction cardiac magnetic resonance (CMR) parameters provide additional long-term prognostic value beyond traditional outcome predictors in ST-segment elevation myocardial infarction (STEMI) patients. BACKGROUND: Long-term prognostic significance of CMR in STEMI patients has not been assessed yet. METHODS: This was a longitudinal study from a multicenter registry that prospectively included STEMI patients undergoing CMR after infarction. Between May 2003 and August 2015, 810 revascularized STEMI patients were included. CMR was performed at a median of 4 days after STEMI. Infarct size, microvascular obstruction (MVO), and left ventricular (LV) volumes and function were measured. Primary endpoint was a composite of all death and decompensated heart failure (HF). RESULTS: During median follow-up of 5.5 years (range 1.0 to 13.1 years), primary endpoint occurred in 99 patients (39 deaths and 60 HF hospitalization). MVO was a strong predictor of the composite endpoint after correction for important clinical, CMR, and angiographic parameters, including age, LV systolic function, and infarct size. The independent prognostic value of MVO was confirmed in all multivariate models irrespective of whether it was included as a dichotomous (presence of MVO, hazard ratio [HR]: 1.985 to 1.995), continuous (MVO extent as % LV, HR: 1.095 to 1.097), or optimal cutoff value (MVO extent ≥2.6% of LV; HR: 3.185 to 3.199; p < 0.05 for all). MVO extent ≥2.6% of LV was a strong independent predictor of all death (HR: 2.055; 95% confidence interval: 1.076 to 3.925; p = 0.029) and HF hospitalization (HR: 5.999; 95% confidence interval: 3.251 to 11.069; p < 0.001). Finally, MVO extent ≥2.6% of LV provided incremental prognostic value over traditional outcome predictors (net reclassification improvement index: 0.16 to 0.30; p < 0.05 for all models). CONCLUSIONS: Early post-infarction CMR-based MVO is a strong independent prognosticator in revascularized STEMI patients. Remarkably, MVO extent ≥2.6% of LV improved long-term risk stratification over traditional outcome predictors.

Enterocutaneous fistulas: a primer for radiologists with emphasis on CT and MRI.

Enterocutaneous fistulas (ECFs) represent abnormal communications between the gastrointestinal tract and the skin. Nowadays, the majority (~80%) of ECFs develops secondary to abdominal surgeries; alternative, less common causes include chronic inflammatory bowel diseases (IBD) such as Crohn's disease, tumours, and radiation enteritis in descending order of frequency. These rare disorders require thorough patient assessment and multidisciplinary management to limit the associated morbidity and mortality. This pictorial review includes an overview of causes, clinical manifestations, complications and management of ECFs. Afterwards, the imaging appearances, differential diagnoses, and therapeutic options of post-surgical, IBD-related, and malignant ECFs are presented with case examples. Most of the emphasis is placed on the current pivotal role of CT and MRI, which comprehensively depict ECFs providing cross-sectional information on the underlying postsurgical, neoplastic, infectious, or inflammatory conditions. Radiographic fistulography remains a valid technique, which rapidly depicts the ECF anatomy and confirms communication with the bowel. The aim of this paper is to increase radiologists' familiarity with ECF imaging, thus allowing an appropriate choice between medical, interventional, or surgical treatment, ultimately resulting in higher likelihood of therapeutic success. TEACHING POINTS: • Enterocutaneous fistulas may complicate abdominal surgery, sometimes Crohn's disease and tumours. • The high associated morbidity and mortality result from sepsis, malnutrition and metabolic imbalance. • The multidisciplinary management of ECFs requires thorough imaging for correct therapeutic choice. • Radiographic fistulography rapidly depicts fistulas and communicating bowel loops in real-time. • Multidetector CT and MRI provide cross-sectional information on fistulas and underlying diseases.

Non-perforated peptic ulcer disease: multidetector CT findings, complications, and differential diagnosis.

Despite availability of effective therapies, peptic ulcer disease (PUD) remains a major global disease, resulting from a combination of persistent Helicobacter pylori infection and widespread use of nonsteroidal anti-inflammatory drugs. Albeit endoscopy definitely represents the mainstay diagnostic technique, patients presenting to emergency departments with unexplained abdominal pain generally undergo multidetector CT as an initial investigation. Although superficial ulcers generally remain inconspicuous, careful multiplanar CT interpretation may allow to detect deep ulcers, secondary mural and extraluminal signs of peptic gastroduodenitis, thereby allowing timely endoscopic verification and appropriate treatment. This pictorial essay aims to provide radiologists with an increased familiarity with CT diagnosis of non-perforated PUD, with emphasis on differential diagnosis. Following an overview of current disease epidemiology and complications, it explains the appropriate CT acquisition and interpretation techniques, and reviews with several examples the cross-sectional findings of uncomplicated PUD. Afterwards, the CT features of PUD complications such as ulcer haemorrhage, gastric outlet obstruction, biliary and pancreatic fistulisation are presented. TEACHING POINTS: • Gastric and duodenal peptic ulcers are increasingly caused by nonsteroidal anti-inflammatory drugs • Multiplanar CT interpretation allows detecting deep ulcers and secondary signs of gastroduodenitis • CT diagnosis of uncomplicated peptic disease relies on direct and indirect signs • Currently the commonest complication, haemorrhage may be treated with transarterial embolisation • Other uncommon complications include gastric outlet obstruction and biliopancreatic fistulisation.

Myocardial Fatty Foci in Adult Patients with Tuberous Sclerosis Complex: Association with Gene Mutation and Multiorgan Involvement.

PURPOSE: To estimate the association between myocardial fatty foci (MFF) on chest computed tomographic (CT) images and type of gene mutation or multiorgan involvement in patients with tuberous sclerosis complex (TSC). MATERIALS AND METHODS: This retrospective case-control study was approved by the ethics committee, which waived the need for patient consent. Forty-eight patients with definite TSC (41 women; mean age, 35 years ± 11 [standard deviation]) and 96 age- and sex-matched patients without TSC who had undergone chest CT were evaluated. Two blinded readers independently scored MFF as low-attenuation areas within the myocardium. Patient history, gene mutation, and multiorgan involvement were obtained from clinical records. Cohen κ, Mann-Whitney U, χ(2) or Fisher exact, Kruskal-Wallis, and Spearman statistics were calculated. RESULTS: One or more MFF was detected in 50% (24 of 48) of patients with TSC; however, no MFF was detected in control patients (P < .001). MFFs were oval (62%, 15 of 24) or linear (38%, nine of 24) and involved the left ventricle in 13 patients and both ventricles in 24 patients (mostly the apical or midleft ventricle); median size was 127 mm(2). After four patients with TSC and unknown mutational status (two with MFF) were excluded, MFF was detected in 53% (10 of 19) of patients with TSC1 mutation, 65% (11 of 17) of patients with TSC2 mutation, and 12% (one of eight) of patients with TSC but without an identified mutation (P = .044). MFF presence was associated with brain (P = .011) and multiorgan (P = .008) involvement. The number of MFF per patient correlated with the degree of multiorgan involvement (P = .014). With MFF considered predictive of TSC, 50% (24of 48) sensitivity, 100% (96 of 96) specificity, 100% (24 of 24) positive predictive value, and 80% (96 of 120) negative predictive value were obtained. CONCLUSION: MFF was highly specific for TSC. MFF presence was associated with TSC gene mutations and with brain or multiorgan involvement; their number per patient was correlated with the degree of multiorgan involvement.

MUC2 but not MUC5 expression correlates with prognosis in radically resected pancreatic cancer patients.

INTRODUCTION: Pancreatic cancer is one of the most aggressive gastrointestinal cancer with less than 10% long-term survivors. The apoptotic pathway deregulation is a postulated mechanism of carcinogenesis of this tumor. The present study investigated the prognostic role of MUC2 and MUC5 apomucin expression in a series of surgically resected pancreatic cancer patients. RESULTS: By univariate analysis, survival was influenced by MUC2 expression but not by MUC5 expression. The MUC2 overexpression was associated with better prognosis (p = 0.003). By a multivariate Cox regression analysis, MUC2 overexpression maintained the prognostic statistical value. In particular, patients with high MUC2 staining showed a longer survival. Moreover the present study does report the absence of a prognostic role of MUC5 expression in this type of cancer. MATERIAL AND METHODS: All patients affected by pancreatic ductal adenocarcinoma and treated with surgical resection from 1988-2003 were considered for the study. MUC2 and MUC5 expression were evaluated by immunohistochemical staining. Tumor specimens of 59 resected patients were included in the study. CONCLUSIONS: The study demonstrated the prognostic relevance of MUC2 expression in pancreatic cancer and underlined its potential role as target gene in the field of therapy research.

A case-control study on the effect of p53 and p73 gene polymorphisms on gastric cancer risk and progression.

The p53 protein and its functional homologue p73 share several functions in modulating cell-cycle control and apoptosis. Based on the functional interaction between p53 and p73 in carcinogenesis, we investigated the combined effect of p73 G4C14-to-A4T14 and p53 gene polymorphisms and their interaction with selected environmental factors, on the risk for gastric cancer in a hospital-based case-control study conducted in Italy. The effect of these polymorphisms on cancer progression was also investigated. One hundred and fifteen gastric cancer cases and 295 hospital controls were genotyped for p73 G4C14-to-A4T14, and p53 exon 4 (Arg72Pro), intron 3 and intron 6 polymorphisms. An increased risk for gastric cancer was found to be associated with the inheritance of the p73 homozygous variant genotype among the gastric cancer intestinal histotype (odds ratio (OR)=6.75; 95% confidence interval (95% CI)=1.88-24.24). An effect modification of the p73 variant allele by gender was observed [(OR=2.82; 95%CI=1.24-6.40) among females, versus an OR of 0.70 (95%CI=0.32-1.54) among males; p-value for homogeneity among strata estimates =0.03]. Gene-gene interaction analyses demonstrated that individuals with combined p53 exon 4 and intron 6 variant alleles are borderline significantly protected from gastric cancer (OR=0.52; 95% CI=0.26-1.07; p-value for interaction =0.005), which was confirmed by the haplotype analysis. Finally, a poorer survival was observed among carriers of the variant allele of p53 intron 6 if compared with those carrying both wild-type alleles (p-value for log-rank test =0.02). This study shows that the p73 G4C14-to-A4T14 polymorphism may be a risk factor for gastric cancer, as reported from other studies in different tumour sites among Caucasians. Along with the protective effect of p53 exon 4-intron 6 allelic variants, already noted for breast and lung cancer, our results require confirmation from larger studies.

[Laparoscopic repair of incisional and ventral hernia]. / Trattamento laparoscopico delle ernie incisionali e ventrali della parete addominale.

The application of laparoscopic principles to ventral or incisional hernia repair has recently been shown to be a safe and effective alternative to open procedures. In this study we analyzed our recent experience with laparoscopic incisional-ventral hernia repair. The outcomes of 75 consecutive patients (January 2002 to July 2006) who underwent laparoscopic repair for incisional-ventral hernia were reviewed. Patient's demographics, hernia parameters, and intraoperative and postoperative data were collected. Of the 75 patients, 44 were females and 31 males. Mean age was 59.1 yrs (range 29-80 yrs). Mean BMI was 25.9 (range 19.4-36.7). Twenty-one patients had primary ventral hernias while 54 patients had an incisional hernia. Fifty-three patients had a single defect and 22 patients multiple defects. In 45 cases the incisional hernia was a primary hernia; in 4 cases it was a first recurrence; in 2 cases a 2nd recurrence; and in 3 cases a 3rd recurrence. The mean defect size was 52,7 cm2 (range 4-432). Laparoscopic hernia repair was successfully performed in 71 cases (94.7%). The mean mesh size was 211 cm2 (range 63-694). Mean operating time was 101 min (range 50-220 min). The mean hospital stay was 4.7 days. The postoperative morbidity rate was 14%. After a mean follow-up of 24.6 months (range 7-56) the recurrence rate was 7% (5/71). Laparoscopic repair of incisional-ventral hernias seems to be safe and effective. Medium-term outcomes were promising with a relatively low rate of conversion to open surgery, a low complication rate and a low risk of recurrence.

[Immediate and long-term results after laparoscopic primary ventral hernia repair]. / La chirurgia laparoscopica nelle ernie ventrali primitive della parete addominale: risultati immediati ed a distanza.

OBJECTIVE: Umbilical and epigastric hernias are relatively frequent amounting to about 10% of all primary hernias. The aim of this study was to evaluate the efficacy and safety of laparoscopic primary ventral hernia repair. MATERIAL AND METHODS: From January 2002 through July 2007 a total of 23 consecutive patients were treated by laparoscopy for primary ventral hernia. Main demographics, intraoperative and postoperative data were collected. RESULTS: There were 14 males and 9 females with a mean age of 53.1 yrs (range 28-70 yrs). Mean body mass index was 25.2 kg/m2 (range 19.4 - 35.2). Fifteen patients had an umbilical hernia, 6 patients had an epigastric hernia and 2 a Spigelian hernia. Mean defect size was 8,4 cm2 (range 1.7 - 81.6). Mean mesh size was 115.9 cm2 (range 62.8-310.8). Mean operating time was 76.1 min (range 50-130). Mean hospital stay was 3,4 days (range 2-8). The median postoperative pain score (evaluated by a visual analog scale - VAS) was 2 at day 1, 4 at day 3 and 1 at day 7. Morbidity rate was 4.3%. After a mean follow-up of 28.5 months none recurrences were observed. CONCLUSIONS: Our study confirmed the feasibility of laparoscopic repair in terms of postoperative morbidity and recurrence rate. Thus laparoscopic primary ventral hernia repair should be considered an effective alternative to open techniques.

Methylenetetrahydrofolate reductase C677T and A1298C polymorphisms and susceptibility to gastric adenocarcinoma in an Italian population.

Methylenetetrahydrofolate reductase (MTHFR) plays a central role in the metabolism of folate, which provides a methyl donor for DNA methylation and deoxynucleoside synthesis. We performed a case-control study to explore the relationship between two common MTHFR polymorphisms (C677T and A1298C), their combination and interaction with environmental exposures, on gastric adenocarcinoma susceptibility and progression in an Italian population. One hundred and two cases and 254 hospital controls, matched by age and gender, were enrolled. Individuals carrying the MTHFR 677T allele showed an increased risk of gastric cancer (odds ratio (OR) 1.62, 95% confidence interval (CI) 0.98-2.67), particularly among ever smokers (OR 2.10, 95% CI 1.07-5.33) and, among 677 TT individuals, those with a low intake of fruit and vegetables (OR 2.18, 95% CI 1.05-4.54). The strongest effect, however, was noted for the MTHFR 677 TT genotype among the diffuse gastric cancer histotype (OR 2.92, 95% CI 1.12-7.60). No association was detected for the effect of MTHFR A1298C polymorphism. Survival analysis did not show any association between each polymorphism on the overall survival, although when the analysis was restricted to the first year of follow-up after the surgical intervention an improved survival was noted among MTHFR 677 CC subjects compared with the T allele carriers (p value for log-rank test 0.02). In conclusion, MTHFR 677 (any T genotype) appears to modulate an individual's susceptibility to gastric cancer, particularly when combined with cigarette smoking and among those with a low intake of fruit and vegetables. Our results also suggest that an aberrant DNA methylation pattern, through impaired folate metabolism, might play a key role in gastric carcinogenesis. A possible survival effect of the MTHFR C677T genotype in gastric cancer patients deserves further investigations with larger sample sizes.

COX-2 expression of ampullary carcinoma: correlation with different histotypes and clinicopathological parameters.

Epidemiological studies suggest that regular intake of nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with reduced incidence of gastrointestinal cancer. Several lines of evidence indicate that the antineoplastic effect of NSAIDs is attributable to COX-2 inhibition. The aim of our study was to assess COX-2 expression in a series of primary untreated ampullary carcinomas and its possible correlation with clinicopathological parameters. In the present study, 45 surgical specimens of invasive ampullary carcinomas were histologically classified into pancreaticobiliary, intestinal, and unusual types. COX-2 expression by immunohistochemical method was analyzed. High COX-2 expression was detected in 35 (77.8%) ampullary carcinomas. Among these, 20/21 (95.2%) were classified as intestinal, 9/18 (50%) pancreaticobiliary, and 6/6 (100%) unusual type. A significant statistical difference in terms of COX-2 expression was found between pancreaticobiliary vs intestinal type (P=0.002). Furthermore, a negative significant statistical correlation was found between T factor and COX-2 expression (P=0.047). The different COX-2 expression among histopathological types supports the concept of histogenetical difference of ampullary carcinomas. Furthermore, the high rate of COX-2 expression in the intestinal subtype of ampullary carcinoma may represent the rational for a histotype-tailored therapy targeting COX-2.

Apoptotic index or a combination of Bax/Bcl-2 expression correlate with survival after resection of pancreatic adenocarcinoma.

In the present study, the prognostic impact of factors involved in the apoptosis pathway were tested on 67 consecutive patients treated with surgical resection. Included in the study were all patients resected for pancreatic adenocarcinoma from 1988 to 2003. Expression analysis for p53, Bax, and Bcl-2 were performed by immunohistochemical staining. Apoptotic cells were identified by the TUNEL method. These data were correlated with survival. Sixty-seven tumor specimens were included in the study. A strong positive correlation was recorded between p53 overexpression and Bax expression levels (P < 0.001). By univariate analysis, overall survival seemed to be improved with Bcl-2 and Bax expression (respectively, P = 0.0379 and 0.0311). The median survival time in patients with low apoptotic index was better versus those with a high index (P = 0.0127). Lymph node involvement was the only clinico-pathologic parameter that significantly correlated with overall survival (P = 0.0202). By a multivariate Cox regression analysis, the only immunohistochemical parameter that influenced overall survival was the apoptotic index (P = 0.040). Tumor's overexpression of both Bax and Bcl-2 resulted the strongest independent prognostic factor (P = 0.013). This is the first study to report a statistically significant association of apoptosis to overall survival for pancreatic cancer patients treated with surgical resection. The contemporary overexpression of Bax and Bcl-2 represents the strongest prognostic factor.

Cyclooxygenase-2 overexpression is associated with a poor outcome in resected ampullary cancer patients.

PURPOSE: To identify potential prognostic molecular factors in ampullary adenocarcinoma that could be of significant importance. To this end, we examined the possible prognostic significance of cyclooxygenase-2 (Cox-2) and Survivin expression and the apoptotic index in a cohort of uniformly treated patients with ampullary cancer treated with radical surgical excision. EXPERIMENTAL DESIGN: The entry criteria were that the patients have a pathologic diagnosis of ampullary cancer which had been resected. Expression analysis for Cox-2 and Survivin was done by immunohistochemical staining. Apoptotic cells were identified by the terminal deoxyribonucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) method. RESULTS: Thirty-nine tumor specimens from resected ampullary adenocarcinoma patients were included. By univariate analysis, overall survival was affected by Cox-2 expression and TUNEL staining (respectively, P = 0.0003 and 0.03). Survivin expression did not influence the overall survival in our patient population (P = 0.123). Patients' clinicopathologic features (gender, age, and T and N factors) did not influence outcome. In multivariate Cox regression analysis, Cox-2 expression (relative risk, 4.330; P = 0.005) was the only variable that significantly affected overall survival. CONCLUSIONS: The results of the present article provide, for the first time, evidence that Cox-2 expression, but not Survivin expression, may represent a significant prognostic factor after surgical resection in patients affected by cancer of the ampulla of Vater. Further studies are required to determine whether Cox-2 inhibitors may be useful for the therapy or prevention of ampullary carcinoma.

Cavernous hemangioma of the gallbladder. Case report and review of the literature.

UNLABELLED: Hemangiomas are common benign tumors; they frequently occur in the liver but very rarely in the gallbladder, with only seven cases reported in the scientific literature to date. We here report an additional patient, a 49-year-old white woman presenting with an echogenic lesion of the gallbladder that was incidentally discovered. Cholecystectomy was performed after computed tomography had revealed a gallbladder neoplasm; pathological examination showed the mass to be a cavernous hemangioma. No postoperative complications occurred and the patient is alive and free of recurrence five years after the operation. We present a review of the literature on this topic with special emphasis on the diagnostic and therapeutic challenges these lesions may entail. Hemangiomas of the gallbladder may have extremely variable presentations (from non-specific abdominal pain to acute syndromes resembling cholangitis or choledocholithiasis) and can mimic different lesions (liver tumors, sarcoma). Only surgical exploration can provide a correct diagnosis. Excision is indicated as these lesions may grow to huge sizes, compress adjacent structures or bleed. CONCLUSIONS: Gallbladder hemangiomas are uncommon benign tumors. A preoperative diagnosis is difficult to make. Surgical excision is mandatory both in reaching a final diagnosis and in preventing bleeding or compression of vital structures.

Chemoradiation with raltitrexed and oxaliplatin in preoperative treatment of stage II-III resectable rectal cancer: Phase I and II studies.

PURPOSE: Two separate studies were conducted, the first to evaluate the maximal tolerated dose and the second the efficacy of raltitrexed plus oxaliplatin in conjunction with preoperative chemoradiation in patients with resectable T3 rectal carcinoma. METHODS AND MATERIALS: A total of 48 patients received radiotherapy (50 Gy) administered to the posterior pelvis 5 d/wk for 5 weeks. Combination raltitrexed (3 mg/m(2)) and oxaliplatin (60 to 130 mg/m(2)) was administered on Days 1, 19, and 38. RESULTS: The recommended dose of oxaliplatin is 130 mg/m(2) (maximal tolerated dose not reached). No patients developed Grade 4 acute toxicity. Grade 3 acute toxicity occurred in 9 patients (18.7%). It was hematologic in 1 patient and GI in 1 patient; 7 patients had an asymptomatic increase of transaminase. Surgery was performed in 47 (98%) of 48 patients. Of the 47 patients, 42 underwent sphincter-saving surgery; in 19, the tumor at diagnosis was located <30 mm from the anorectal ring. Chemoradiation in combination with raltitrexed and oxaliplatin produced high rates of tumor response. The overall tumor downstaging rate was 73% for T and N stages. A complete pathologic tumor response (pT0) or microscopic tumor foci (pTmic) was observed in 28 patients. The tumor regression grade (TRG), using the Mandard scoring system, was TRG1 in 16 patients (43.2%), TRG2 in 12 (32.4%), TRG3 in 12 (32.4%), TRG4 in 6 (16.2%), and TRG5 in 1 patient (2.7%). CONCLUSION: Raltitrexed plus oxaliplatin combined with pelvic radiotherapy was effective and well tolerated in patients with resectable T3 rectal carcinoma.

Gastric adenocarcinoma associated with granulomatous gastritis. Case report and review of the literature.

AIMS: We describe the fourth reported case of granulomatous gastritis associated with gastric adenocarcinoma, with a review of the literature and considerations about the prognostic implications of this association. RESULTS: A 48-year-old woman who had been suffering from gastritis for ten years was admitted to our institute for increasing left epigastric pain associated with vomiting. After an endoscopic biopsy had revealed an ulcerated signet ring cell carcinoma, the patient was submitted to subtotal gastrectomy with regional lymph node dissection. Pathological examination of the resected specimen revealed a superficial signet ring cell carcinoma (early cancer) associated with multiple granulomas. The granulomas, which were observed within the mucosa and the submucosa at the periphery of the carcinoma, were composed of CD68-positive, CD15-negative epithelioid and giant cells of the Langhans type, confirming their true histiocytic nature, and were also extensively found within the dissected lymph nodes. Since no ocular, skin, pulmonary or other gastrointestinal lesions were found and the granulomas were negative for acid-fast and fungal stain, a diagnosis of granulomatous gastritis was made. CONCLUSIONS: To the best of our knowledge this is the fourth example of gastric adenocarcinoma and granulomatous gastritis. These cases suggest an association between granulomatous gastritis and early gastric cancer.