Melanoma: BRAFi Rechallenge.

Melanoma is the most aggressive type of skin cancer. Half of melanoma cases are characterized by the mutation BRAF V600. The case presented concerns a 41-year-old patient with locally advanced melanoma, being positive in mutation BRAF V600. The patient underwent surgery and received additional targeted therapy as part of a clinical study. In subsequent disease progression, immunotherapy was used. When the disease progressed again while the patient was in a good performance status, targeted therapy was administered again, and a good response was noted, making the patient reach a statistically significant overall survival, exceeding four years. Targeted therapy has proven to be an important tool in the treatment of melanoma. The use of BRAFi targeted therapy does not exclude the option of readministration at subsequent disease progression (BRAFi rechallenge). Preclinical models suggest that the resistance mechanism of cancer cells to BRAFi therapy bends, as these cell clones lose their evolutionary advantage after stopping BRAFi. Cell clones sensitive to BRAFi may then outcompete, making the treatment effective again. Therapeutical dilemmas in the management of patients with locally advanced melanoma that progresses to metastatic cancer are discussed.

Idiopathic Multicentric Castleman Disease with Cutaneous Manifestation: Case Report.

Castleman disease constitutes a rare class of lymphoproliferative disorders, with an estimated incidence of 21 to 25 per million patient years. The idiopathic subtype exhibits a significantly diverse clinical presentation, which can imitate many autoimmune, malignant, and infectious diseases. Cutaneous manifestations are uncommon and require in-depth investigation, especially when concurrent lymphadenopathy is present. A 79-year-old female, with a chronic, complicated erysipelas-like lesion, presented with bilaterally enlarged inguinal lymph nodes; after surgical excision, their histopathological examination revealed Castleman disease. Even though it is a benign condition, patients are often predisposed to developing certain types of malignancies, which can deteriorate their prognosis. An accurate and early diagnosis, along with effective treatment and prevention of recurrence, is of utmost importance in order to increase the patients' overall survival and quality of life.

Extramammary Paget's Disease of the Vulva: Report of Two Cases.

Extramammary Paget's disease is a rare condition, affecting 6.5% of all patients with Paget's disease. The most common extramammary site is the vulvar area. Although diagnosis in some patients is difficult to set, early diagnosis is of high importance in order to detect the irreversible progression of the lesion early and prevent distant metastasis. An 89-year-old female and a 69-year-old female presented within three months with an eczematous lesion with leukoplakia in the vulva. The incisional biopsy of the skin revealed extramammary Paget's disease. Both patients underwent a surgical wide local excision of the lesion and the specimens were sent for histopathological examination. Extramammary Paget's disease has a high potential for distant malignancies and local recurrence, dictating that surgical excision is the most efficient treatment. The rareness of the condition and the diagnostic difficulties underline the need for early skin biopsy, which is the most efficient diagnostic tool.

Total Pancreatectomy with Splenectomy for Multifocal Intraductal Tubulopapillary Neoplasm (ITPN) of the Pancreas Associated with Invasive Component: Report of a Rare Case.

BACKGROUND Pancreatic intraductal tubulopapillary neoplasm (ITPN) was first described by Yamaguchi in 2009 and was recognized by World Health Organization as a distinct entity in 2010. Since then few case reports and case series have been published. Little is known about its clinicopathologic features and treatment outcomes. We present the seventh case of total pancreatectomy for ITPN reported in the English literature. CASE REPORT Our patient was an 82-year-old male with a previous history of acute evolving-to-chronic pancreatitis. After 2 years of medical consultation, an abdominal magnetic resonance imaging was suspicious for multifocal pancreatic neoplasia. A computed tomography-guided biopsy of the lesion was performed which indicated pancreatic intraductal neoplasia with intermediate dysplasia. After oncology consultation, the patient underwent pylorus-preserving total pancreatectomy with splenectomy. The pathology report showed pancreatic ITPN with intermediate to severe dysplasia and associated invasive carcinoma. All 21 resected lymph nodes were non-metastatic (pT3N0). The postoperative course of the patient was uncomplicated. He received adjuvant gemcitabine (single agent) for 6 months. At 18 months after surgery he was diagnosed with hepatic metastases; he was still alive at the time of this reporting. CONCLUSIONS ITPN has been associated with previous history of acute pancreatitis in some patients. Early diagnosis, radical surgical resection, and adjuvant chemotherapy may lead to long-term survival rates even in cases with associated invasive component. Total pancreatectomy may be a preferable procedure for ITPN in selected patients.

Treatment of a Gastrointestinal Stromal Tumor (GIST) Adherent to the Spleen and the Tail of the Pancreas: A Case Report.

BACKGROUND Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal gastrointestinal tumors (GIT). Usually, they appear in patients ages 55-65 years, with no apparent difference between males and females. Their annual incidence is about 11-14 per 106. They generally do not present with any prominent symptoms, appearing with the atypical symptoms of abdominal pain, weight loss, early satiety, and occasionally bleeding. Adequate surgical treatment involves sphenoid resection of the tumor within clear margins. If adjacent organs are involved, en bloc resection is the procedure of choice. CASE REPORT A 62-year-old male patient presented to the Emergency Department complaining of melena for 1 week. He underwent gastroscopy, colonoscopy and abdominal computed tomography scan, which revealed a large, exophytic, lobular mass (12.6×9.7×12 cm) of the greater curvature of the stomach. The patient underwent en bloc sphenoid gastrectomy, splenectomy, and caudal pancreatectomy. The histopathologic examination revealed findings compatible with a gastrointestinal stromal tumor located at the stomach, with low-grade malignancy (G1) and T4N0 according to TNM classification. He was discharged from the hospital on the 7th postoperative day. CONCLUSIONS GISTs are uncommon tumors of the gastrointestinal system that usually do not invade neighboring organs or develop distant metastases; therefore, local resection is usually the treatment of choice. However, in cases of large GISTs that are adherent to neighboring organs, en bloc resection and resection of adjacent organs may be inevitable.

Primary hepatocellular carcinoma in a patient with history of treated breast cancer: a case report with challenging diagnosis and treatment.

INTRODUCTION: Breast cancer is the most common malignancy in women worldwide. Long-term survivors among patients treated for breast cancer are at a high risk for developing a second primary malignancy. Hepatocellular carcinoma is the most frequent primary hepatic malignancy and should be ruled out in breast cancer patients who are diagnosed with solitary hepatic lesions. False diagnosis may lead to inappropriate oncologic staging and treatment of the disease. CASE PRESENTATION: We present the case of a 73-year-old female patient who had been treated for invasive ductal breast cancer 7 years ago and was diagnosed with a solid hepatic lesion at segments VI and VII and a small, calcified lesion at the tail of the pancreas on follow-up with an abdominal computed tomography. Oncology council decided that both lesions could be resected after determining whether they were metastatic or second primary malignancies. The patient underwent laparotomy and rapid biopsy which showed primary hepatocellular carcinoma and fibrosis of the pancreas. We performed hepatic segmentectomy (VI-VII) and cholecystectomy, while the pancreatic lesion was left intact. The postoperative course of the patient was uncomplicated and she remains disease free 2 years after the operation without any adjuvant therapy. CONCLUSION: All hepatic lesions detected in breast cancer patients should be evaluated with open mind and liver biopsy should be performed to get a definitive diagnosis and implement the proper treatment strategy.

Endoscopically Assisted Laparoscopic Gastric Resection for Benign and Malignant Lesions: A Report of Two Cases.

BACKGROUND The first gastric resection for stomach cancer was performed in 1879, and the first gastric resection for gastric ulcer disease was performed in 1882. During the 1990s, the first laparoscopic gastrostomies were reported. During the past decade, laparoscopic techniques have developed rapidly, gaining wide clinical acceptance. Minimally invasive surgery is now shifting the balance away from traditional open methods. We report 2 cases of endoscopically assisted laparoscopic local gastric resections for both gastric cancer and gastric ulcer disease. CASE REPORT The first case involves a 67-year-old male patient who suffered from recurrent bleeding from a gastric ulcer located 4-5 cm from the gastroesophageal junction. The patient was subjected to endoscopically assisted laparoscopic wedge resection of the affected part of the stomach, had an uneventful recovery and was discharged on the third postoperative day. The second case involves a 60-year-old female patient who was diagnosed with intramucosal gastric adenocarcinoma and was also subjected to endoscopically assisted laparoscopic wedge gastrectomy. This patient also had an uneventful recovery and was discharged on the second postoperative day. CONCLUSIONS Endoscopically assisted laparoscopic local gastric resection is a minimally invasive procedure which allows the surgeon to operate under direct visualization of the internal part of the stomach. Thus, it enables the surgeon to safely remove the affected part within healthy margins, providing the patient with all the advantages of laparoscopic surgery.

Interferon-γ and Colorectal Cancer: an up-to date.

Colorectal cancer still remains the third cause of cancer death among cancer patients. Early diagnosis is crucial and they can be either endoscopic or with blood biomarkers. Endoscopic methods consist of gastroscopy and colonoscopy, however; in recent years, endoscopic ultrasound is being used. The microenvironment is very important for the successful delivery of the treatment. Several proteins and hormones play a crucial role in the efficiency of the treatment. In the current mini review we will focus on interferon-γ.

Gallbladder Hypoplasia, a Congenital Abnormality of the Gallbladder: A Case Report.

BACKGROUND There are different variations in the anatomy of the gallbladder. Congenital abnormalities of the gallbladder such as agenesis and hypoplasia are rare conditions and difficult to diagnose with imaging studies. Patients are usually asymptomatic or have symptoms that mimic gallstone disease. The diagnosis is often made intraoperatively and is established by histopathological examination. CASE REPORT We report a case of a 62-year-old male who had cholelithiasis symptoms and was falsely diagnosed with gallstone disease by abdominal ultrasound scan. The patient underwent an operation which revealed a rudimentary gallbladder. The histology result showed hypoplastic gallbladder tissue. CONCLUSIONS This case suggests that surgeons need to take into consideration congenital anomalies of the gallbladder intraoperatively in order to avoid any iatrogenic injury to biliary tract during a routine laparoscopic cholecystectomy. Intraoperative cholangiography can be a useful tool to avoid unnecessary surgical risky interventions.

Episode of Familial Mediterranean Fever-Related Peritonitis in the Second Trimester of Pregnancy Followed by Acute Cholecystitis: Dilemmas and Pitfalls.

BACKGROUND: Differential diagnosis of acute abdomen in pregnant patients is one of the greatest challenges for the clinician. Occurrence of Familial Mediterranean Fever (FMF) paroxysm of peritonitis and acute cholecystitis during pregnancy is a unique clinical entity that leads to serious diagnostic and therapeutic dilemmas. CASE REPORT: We present the case of a 33-year-old Armenian patient at 16 weeks' gestational age with a history of FMF, who was admitted twice within 1 month with acute abdomen. The first episode was attributed to FMF and successfully treated conservatively with colchicine. The second episode was diagnosed as acute cholecystitis and led to emergent laparoscopic cholecystectomy and lysis of peritoneal adhesions from previous FMF attacks. The patient presented an uneventful postoperative clinical course and had a normal delivery of a healthy infant at the 39th week of gestation. CONCLUSIONS: Pregnant patients with acute abdomen should be evaluated with open mind. To the best of our knowledge, this is the first published report of the coexistence of 2 different causes of acute abdomen during pregnancy. Meticulous history and thorough physical, laboratory, and radiologic examination are the keys to reach a correct diagnosis. Treatment of pregnant patients with acute abdomen should be individualized. Administration of colchicine should be continued during conception, pregnancy, and lactation in patients with FMF history. Laparoscopic intervention in pregnant patients with surgical abdomen such as acute cholecystitis is the optimal method of treatment.

Laparoscopic Excision of a Pedunculated Uterine Leiomyoma in Torsion as a Cause of Acute Abdomen at 10 Weeks of Pregnancy.

BACKGROUND: Pregnancy outcomes after laparoscopic myomectomy are generally favorable, with a pregnancy rate that is comparable to or even higher than the rate associated with abdominal myomectomy. The purpose of this article is to present the case of a pregnant patient at 10 weeks of gestation who was submitted to successful laparoscopic myomectomy of a twisted pedunculated uterine leiomyoma. CASE REPORT: A 31 year-old Greek pregnant woman complaining about acute abdominal pain was submitted to diagnostic laparoscopy which revealed a huge twisted uterine leiomyoma. Subsequently laparoscopic myomectomy was successfully carried out. CONCLUSIONS: Laparoscopic myomectomy is a technically challenging procedure with surgeon-specific limitations. Laparoscopy during pregnancy should be performed with utmost care and it proves to be a safe and effective procedure in hands of clinicians with sufficient experience in laparoscopic surgery.