Colorectal Cancer Prevention in Lung Transplant Recipients: The Need for an Enhanced Surveillance Protocol.

BACKGROUND: Solid organ transplant recipients are at increased risk for noncutaneous neoplasms, including colorectal cancer (CRC). We evaluated precancerous lesions detected by post-transplant surveillance colonoscopy to infer the rate at which new adenomas develop in this population. STUDY DESIGN: We reviewed all patients who underwent lung transplant between January 2013 and August 2017 at our institution. Those with post-transplant survival <1 year, personal history of CRC, previous lung transplant, and lack of pretransplant colonoscopy were excluded. RESULTS: During the study period, 411 patients underwent lung transplant; 237 met inclusion criteria. Median age at transplant was 63.6 (interquartile range [IQR] 59.2-68.3) years. Most recipients were immunosuppressed with a combination of prednisone, tacrolimus, and mycophenolate mofetil. At least 1 adenoma was found in 92 patients (38.8%) pretransplant and in 118 patients (49.8%) from 1 to 5 years post-transplant, with 68.6% identified at 1 year. Most adenomas were identified proximal to the splenic flexure. Multiple (≥3) adenomas were found in 31.4% of positive colonoscopies. Within 5 years after transplant, patients with a positive pretransplant colonoscopy had significantly more positive post-transplant colonoscopies than patients with a negative pretransplant colonoscopy (63.0% vs 41.4%, p < 0.001). No de novo CRC was identified. CONCLUSIONS: Lung transplant recipients have a significantly higher risk of adenoma formation than average-risk adults (25%-30% national detection rate). This increase occurs in the early post-transplant period (within 3 years). An enhanced CRC surveillance protocol for lung transplant recipients is needed.

A Large Sporadic Intra-abdominal Desmoid-Type Fibromatosis in a Young Male: A Case Report.

Desmoid type fibromatosis (DTF) is a rare benign tumor of connective tissue origin. While these tumors are typically not malignant, they can exhibit aggressive growth patterns causing mass effect on surrounding organs. These tumors typically present in the extremities and abdominal wall, rarely occurring in the mesentery, and abdominal organs. Due to the rarity of this tumor and the variable size and origin, it is difficult to provide exact prognosis, recurrence, and treatment efficacy regarding desmoid tumors arising from the ileocolic mesentery. We present a case of a young male with a sporadic 31 × 25 × 12 cm DTF arising from the ileocolic mesentery that was complicated by mass effect on bowel and intra-abdominal organs requiring surgical intervention. On presentation, the patient exhibited weight gain and abdominal pressure. Abdominal distension without tenderness on palpation was noted on physical examination. The tumor biopsy confirmed the diagnosis of DTF. No evidence of familial adenomatous polyposis or Gardner syndrome was identified. The tumor was surgically excised and intimately associated with the bowel requiring ileocolonic resection with primary anastomosis. At 3-months follow up, surveillance MRI showed no residual or recurrent lesion. A multi-disciplinary approach to this patient's diagnosis and treatment allowed for an accurate diagnosis, efficient treatment, and follow up plan.

Pneumatosis Intestinalis in Adult Bilateral Lung Transplant Patients: A Single Institution Experience and Literature Review.

Pneumatosis intestinalis (PI) is a radiologic finding which is characterized by the accumulation of gas within the bowel wall. This radiologic finding is traditionally thought of in the sense of intestinal ischemia. An uncommon cause of this finding is post organ transplantation. We did an institutional and literature review of this finding to demonstrate its distinct imaging features and benign nature. It was observed to occur in approximately 5.2% of patients post lung transplant (23/442). On imaging, it displays an expansile/bubbly appearance of gas within the bowel wall that is distinct from the traditional findings seen in intestinal ischemia. Clinical review showed that posttransplant patients with PI can be successfully managed conservatively with early enteral nutrition, oxygen, antibiotics, and limited follow-up imaging. With the increasing use of organ transplantation, PI is being diagnosed with increased frequency. It is important to let clinicians know of this entity and its potential outcomes.

Management and Outcomes of Diverticulitis After Lung Transplantation.

INTRODUCTION: Most lung transplant patients are older than 50 years. Complications from colonic diverticula are not uncommon, especially with chronic immunosuppression. However, limited data exist regarding the optimal management of these patients. We sought to investigate the incidence, risk factors, and outcomes of diverticulitis after lung transplant. METHODS: We conducted a retrospective study to review patients undergoing lung transplant between 2007 and 2016 with posttransplant acute colonic diverticulitis. Patients were grouped based on medical or surgical management. RESULTS: Of 512 transplant recipients, 17 (3.32%) developed 26 episodes of diverticulitis over a median follow-up of 39 months. Nine patients had documented diverticulosis on pretransplant colonoscopy. These patients had a higher incidence of surgical intervention for diverticulitis, were more likely to have recurrent diverticulitis, and had longer lengths of stay than patients without pretransplant diverticulosis. Six (35.3%) of 17 patients required surgery (ie, Hartmann procedure; 4 during the initial episode and 2 during their third and fourth episodes); 11 patients (64.7%) were managed with antibiotics alone. Patients in the surgical group presented earlier posttransplant (P = .004) and were on higher doses of tacrolimus (P = .03). Six (46.1%) of 13 patients with medically managed first episodes of diverticulitis experienced recurrence. No recurrence occurred after surgical management. No deaths were attributable to diverticulitis in either group. CONCLUSIONS: Patients with pretransplant diverticulosis experienced earlier, more complicated episodes of diverticulitis posttransplant than patients without. Surgical patients received higher doses of tacrolimus and presented earlier than medical patients. Uncomplicated diverticulitis in posttransplant patients can be managed medically, even in the case of recurrent, uncomplicated disease.

An Unusual Presentation and Aggressive Course of Metastatic Myoepithelial Carcinoma.

Myoepithelial carcinomas are rare tumors that make up 1 to 2 percent of all salivary gland neoplasms. We present a case of a 55-year-old man with myoepithelial carcinoma that developed into widespread cutaneous, lung, and brain metastases refractory to treatment, including newer immunotherapies. Newer strategies or treatments are needed for the future benefit of patients with advanced disease.

Pneumatosis intestinalis in solid organ transplant recipients.

Pneumatosis intestinalis (PI) is an uncommon medical condition in which gas pockets form in the walls of the gastrointestinal tract. The mechanism by which this occurs is poorly understood; however, it is often seen as a sign of serious bowel ischemia, which is a surgical emergency. Since the early days of solid organ transplantation, PI has been described in recipients of kidney, liver, heart, and lung transplant. Despite the dangerous connotations often associated with PI, case reports dating as far back as the 1970s show that PI can be benign in solid organ transplant recipients. This is an important observation, as operative intervention in these patients carries greater risk than surgical procedures in the general population. The higher operative risks in the transplant population are partly due to their immunosuppressed status and poor wound healing. Furthermore, no clear consensus exists on the optimal management of PI. Various treatment strategies such as bowel rest, antibiotics, and parenteral feeding have been implemented with similar levels of success. With the increasing use of solid organ transplantation, PI is being recognized with increasing frequency. In this review, we provide a summary of the incidence, presentation, diagnosis, and management of PI, particularly as it affects recipients of solid organ transplantation.

A predictive model for lymph node yield in colon cancer resection specimens.

OBJECTIVE: To develop a predictive model of lymph node yield in a series of colon cancer resection specimens with detailed anatomic and surgical technique data. BACKGROUND: Lymph node yield in colon resection specimens has been associated with accuracy of staging and cancer outcomes. We hypothesized that lymph node yield is associated with multiple factors including patient, tumor,and surgical variables. METHODS: The pathology specimens from 152 elective colon neoplasm resections were prepared so that the lymph nodes were separated according to their anatomic relationship to the vascular pedicles and to the tumor. Prior to dissection, the specimen was measured. A linear regression analysis of a priori identified predictors and confounders of lymph node quantity was performed. Potential predictors in the model were age, gender, tumor stage, size, location,and differentiation, presence of lymphovascular or perineural invasion,mucinous histology, number of vascular pedicles, and use of endoscopic tattoo. Potential confounders were American Society of Anesthesiologists class, body mass index, count of lymph node metastasis, and specimen length. RESULTS: Tumor size, tumor location, number of resected pedicles, and use of tattoo had a significant linear or quadratic relationship with lymph node yield when controlling other variables. 23% of the variation in lymph node count was explained by the 15 variables in the model. A model with the 4 significant variables explained 19% of the variation. CONCLUSION: Multiple tumor and surgical factors are associated with lymph node yields in colon specimens. A standard minimum of lymph nodes may not be applicable to all colon cancer resections.

Clinical and pathologic factors that predict lymph node yield from surgical specimens in colorectal cancer: a population-based study.

BACKGROUND: The National Quality Forum endorses the recommendation of examining at least 12 lymph nodes (LNs) from colorectal cancer (CRC) specimens. However, heterogeneity in LN harvest exists. The objective of this study was to investigate the clinicopathologic factors that influence LN yield. METHODS: The authors used the Surveillance, Epidemiology, and End Results database to identify patients who were diagnosed with stage I, II, and III CRC between 1994 and 2005. Poisson regression was used to model the number of LNs examined as a function of individual clinicopathologic factors, including age, sex, race, year of diagnosis, geographic region, anatomic site, preoperative radiation, tumor size, tumor classification, tumor differentiation, and LN positivity. RESULTS: In total, 153,483 patients with CRC were identified. The mean number of LNs examined (+/- standard deviation) was 12 (+/-9.3). Separate multivariate analyses revealed that age, year of diagnosis, tumor size, and tumor classification were significant predictors of LN yield for colon and extraperitoneal rectal cancers (P < .01 for all covariates). Tumor location and radiotherapy were significant predictors of LN yield in patients with colon cancer and rectal cancer, respectively. Overall LN yields increased between 2% and 3% annually. CONCLUSIONS: Despite the increasing yields observed over time, patients with rectal cancer and older patients who had distally located, early colon cancer were less likely to meet the benchmark yield of 12 LNs. Further investigation into how LN yield is influenced by alterable factors, such as the extent of mesenteric resection and the pathologic technique, as well as nonalterable factors, such as patient age and tumor location, may reveal innovative ways to improve current staging methods.

An update on laparoscopic resection for rectal cancer.

BACKGROUND: In the current age of minimally invasive surgery, laparoscopic surgery for colon cancer has been established as oncologically equivalent to conventional open surgery. The advantages of laparoscopic surgery have translated into smaller incisions and shorter recovery. However, the narrow confines of the bony pelvis and angling limits in current stapling technology, along with the standard practice of autonomic nerve-sparing total mesorectal excision, have made laparoscopic surgery in the setting of rectal cancer more challenging. The available literature focusing on laparoscopic resection for rectal cancer has been predominantly retrospective in nature, with a limited number of prospective studies. METHODS: This article discusses the current status of laparoscopic rectal cancer resection. A review of the more recent retrospective and prospective data specifically on laparoscopic resection for mid to low rectal cancer was performed. RESULTS: The number of prospective randomized trials addressing laparoscopic rectal cancer resection is limited. In the largest trial (MRC CLASICC), an initial increased rate of positive circumferential margins within the laparoscopic anterior resection cohort, although nonsignificant, raised concerns regarding its oncologic adequacy. These concerns did not translate into a difference in local recurrence at 3 years. Improved short-term outcomes, including quicker recovery times, shorter hospital stays, and reduced analgesic requirements (albeit at the price of longer operative times and higher overall cost), have been demonstrated in some studies. CONCLUSIONS: In view of the limited prospective data, laparoscopic resection for mid to low rectal cancer is still investigational in the United States. While feasibility studies are promising, open surgical resection remains the current standard of care. It is hoped that the long-term results of ongoing and newly initiated multi-institutional trials will fully define the role of laparoscopy in the treatment of mid to low rectal cancer.

Anorectal melanoma.

The authors review the epidemiologic, clinicopathologic, and molecular features of anorectal melanoma, and discuss the differences between this uncommon and lethal disease and the more common and curable cutaneous form. Observations regarding outcomes after surgical resection will also be discussed, as well as predictors of survival and the use of adjuvant therapies. The recent discovery that the KIT oncogene may be aberrantly activated in a subset of patients with anorectal melanoma creates a realm of possibility for the development of targeted molecular therapy. Melanoma of the anorectum is an extremely rare tumor that is often difficult to diagnose. Its surgical management is controversial, and the prognosis remains poor.

Late sigmoid colon internal herniation into the jejuno-jejunostomy mesenteric defect after laparoscopic Roux-en-Y gastric bypass.

A 49-year-old female with morbid obesity (BMI 42) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). 10 months after the operation, she presented to the hospital with intermittent mid-abdominal pain. An internal hernia of the sigmoid colon through a mesenteric defect of the jejuno-jejunostomy was found. Although small bowel internal herniation has been widely documented, the finding of large bowel internal herniation has not been previously reported. Maintaining a high index of suspicion and a low threshold for urgent intervention are required when evaluating patients with vague abdominal complaints after LRYGBP.

Educational needs of rural and remote Australian non-specialist medical practitioners for obstetric ultrasound.

OBJECTIVE: To determine the educational needs of rural and remote non-specialist Australian doctors for obstetric ultrasound. DESIGN: Survey design. SETTING: The study surveyed rural and remote doctors practising in a variety of settings including general practice, rural hospitals, Aboriginal communities and flying doctor organisations throughout Australia. SUBJECTS: Subjects included 314 solo and group practice rural general practitioners, rural hospital medical superintendents, senior medical officers, Aboriginal community controlled health service doctors, flying doctors, rural locums, registrars and two rural obstetricians. A total of 55% of the subjects were general practitioners in group practice. Respondents included 68 (22%) women and 246 (78%) men. RESULTS: The response rate was 32%. The highest priority areas of need for education included detecting foetal abnormalities and anomalies (19.1%), basic routine ultrasonography (17.17%), placental position (17.17%), dating (17.17%), foetal viability (12.88%) and morphology scan (12.26%). The main areas where doctors stated they lacked confidence included detecting foetal abnormalities (29.09%), basic routine ultrasonography (including machine use), such as, carrying out and interpreting obstetric ultrasound scans (27.27%), morphology scans (16.36%) and placental position (14.54%). CONCLUSION: The study showed there was a large unmet need for education in obstetric ultrasound among rural and remote non-specialist doctors. Information from the needs assessment was used to develop the Australian College of Rural and Remote Medicine national obstetric ultrasound professional development program. WHAT IS ALREADY KNOWN: The authors could not find any published work on the educational needs of Australian non-specialist rural and remote doctors for obstetric ultrasound. There is research about the outcome of obstetric ultrasound education for urban family physicians in the USA, but no information about rural doctors' educational needs or education outcomes. The study needed to be done so that obstetric ultrasound professional development program of the Australian College of Rural and Remote Medicine could be based on the real needs of the target group. WHAT THIS PAPER ADDS: As a result of this research, there is now information on the educational needs of rural and remote Australian non-specialist medical practitioners that can be used by education providers to develop quality education programs in obstetric ultrasound.