Gastrointestinal schwannomas: a rare but important differential diagnosis of mesenchymal tumors of gastrointestinal tract.

BACKGROUND: Schwannomas of gastrointestinal tract are rare, mostly benign and notably different neoplasms from conventional schwannomas that arise in soft tissue or the central nervous system. These tumors are of clinical importance since they should always be considered in the differential diagnosis of submucosal lesions of gastrointestinal tract. METHODS: Seven patients with a pathologically proven gastrointestinal schwannoma were identified in our series of mesenchymal tumors and reviewed retrospectively. Clinicopathological and immunohistochemical parameters along with the follow-up results were analysed. RESULTS: The series included two males and five females, with a mean age 69 years (range, 39-81). Most patients were asymptomatic on presentation, except for two patients with abdominal pain. In the other cases (n = 5), the tumor was an incidental finding during other medical, imaging or surgical procedures. The tumors were located in the stomach (n = 4) and in the small intestine (n = 3) with an average size of 29 mm (range, 12-70). A preoperative diagnosis was achieved only in one case with a CT-guided core biopsy. Otherwise the clinical, intraoperative, endoscopic or radiological findings were unspecific. Patients with gastric tumor underwent either laparoscopic (n = 2) or open (n = 2) gastric wedge resection of the tumor; in the cases of intestinal tumor (n = 3) a segmentectomy was performed. Pathological examination revealed solid homogenous tumors, which were highly cellular and composed of spindle cells with positive staining for S100 protein, and confirmed the diagnosis of schwannoma. All tumors were negative for c-Kit, smooth muscle actin, desmin and DOG-1 and showed very low proliferation index. There were negative resection margins and no malignant variants were recognized. At an average follow-up of 60 months (range, 24-185) all patients were free of disease with no signs of recurrence or metastases and acceptable gastrointestinal function. CONCLUSIONS: Schwannomas are rare, slow-growing and mostly asymptomatic gastrointestinal mesenchymal tumors. They are difficult to be diagnosed preoperatively as endoscopic and radiological findings are nonspecific but histological and immunohistochemical features are of paramount importance to differentiate between benign and malignant schwannomas, or other spindle cell sarcomas. The treatment of choice is complete surgical excision without a conclusive preoperative diagnosis, and the long-term outcome is excellent as these lesions are mostly benign.

Posttraumatic transdiaphragmatic intercostal hernia: report of a case and review of the literature.

Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient's postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.

Surgical treatment for large hepatocellular carcinoma: does size matter?

Despite significant progress in the management of hepatocellular carcinoma (HCC), patients with large HCC (defined as >10 cm) continue to present a significant challenge. The goal of this paper is to review the existing literature regarding large HCC, with emphasis on identifying the issues and challenges involved in approaching these tumours surgically. A computerized search was made of the Medline database from January 1992 to December 2010. The MESH heading 'large' or 'huge' in combination with the keyword 'hepatocellular carcinoma' was used. After excluding further studies that identified 'large' HCC as less than 10 cm and/or sequential publications with overlapping patient populations, the search produced a study population of 22 non-duplicated papers, reporting on a total of 5223 patients with HCC tumours >10 cm. Regarding resection for large HCC, the overall 5-year survival in these studies ranged from 25% to 45%, with few outliers on both sides, whereas in most studies, the 5-year disease-free survival ranged between 15% and 35%, with the only exception being studies with patients with single lesions and no cirrhosis showing disease-free survival of 41% and 56%, respectively. Risk factors identified included vascular invasion, cirrhosis, high level of alpha-fetoprotein and the presence of multiple lesions. Finally, liver transplantation, although an attractive concept, did not appear to offer a survival benefit in any of the studies. In conclusion, identifying the risk factors that affect the outcome in patients undergoing surgery for large HCC is critical. The reason is that surgical resection can have excellent outcomes in carefully selected patients.