Factors predicting occurrence and therapeutic choice in malignant colorectal polyps: a study of 13 years of colonoscopic polypectomy.

Colorectal carcinoma represents a major cause of mortality and 0.2-12% of resected colonic polyps have malignant cells inside. We performed a retrospective study of patients with resected polyps during a period of 13 years. A total of 905 patients had 2033 polyps removed; 122 polyps (109 patients) had malignant cells. Prevalence of malignant polyps with submucosal invasion was 1.23% and for all polyps with malignant cells was 6%; malignant polyps had a larger size (23.44 mm mean diameter) vs benign polyps (9.63 mm); the risk of malignancy was increased in polyps larger than 10 mm, in lateral spreading lesions and in Paris types 0-Ip, 0-Isp, in sigmoid, descending colon and rectum, in sessile serrated adenoma and traditional serrate adenoma subtypes of serrated lesions and in tubulovillous and villous adenoma. In 18 cases surgery was performed, in 62 patients only colonoscopic follow-up was made and in 35 patients no colonoscopic follow-up was recorded. From initially endoscopic resected polyps, recurrence was noted in seven (11.3%) cases; there was a trend toward association with depth of invasion, piecemeal resection, right and rectum location, sessile and lateral spreading type and pathological subtype. In surgical group, post-therapeutic staging was available in 11 cases; nodal involvement was noted in three (27.27%) cases; none had lymphatic or vascular invasion in endoscopically resected polyps. Four patients with no macroscopic local recurrence underwent surgery with no residual tumor. The rate of metastasis was 16.67% in surgical group and 1.61% in endoscopic group. Evaluation of lymph node (LN) invasion was available for 11 operated patients, with LN invasion (N1) in three patients, local residual tumoral tissue in one patient with incomplete resection and no residual tumor (R0 resection) in four patients with endoscopic resection before surgery.

An unusual onset of Crohn's disease with oral aphthosis, giant esophageal ulcers and serological markers of cytomegalovirus and herpes virus infection: a case report and review of the literature.

Isolated esophageal ulcerations in Crohn's disease pose a great challenge in diagnosing and providing the correct treatment. We present the case of a 23-year-old woman with recurrent episodes of oral aphthosis, dysphagia, odynophagia and heartburn. Upper digestive endoscopy revealed an irregular mucosa with multiple ulcerations with irregular margins within the mid-esophagus. Immunoglobulin G (IgG) for cytomegalovirus and herpes virus were both positive. Four years after, she presented with the same symptoms and the involvement of ileo-colonic lesions, with pathological findings helped establish the Crohn's disease diagnosis. Crohn's disease represents an idiopathic chronic inflammatory gut disease, which can affect any part of the digestive tract. The onset by esophageal disease and no intestinal involvement is rare and challenging for a proper diagnosis.

Indication of total parathyroidectomy for an Epstein syndrome patient with end-stage renal disease.

Epstein syndrome is an extremely rare genetic disorder characterized by the association of nephritis, deafness and megathrombocytopenia. We present the case of a 21-year-old patient diagnosed with Epstein syndrome and hyperparathyroidism secondary to chronic kidney disease. The main particularity of this case resides in the association between megathrombocytopenia and secondary hyperparathyroidism requiring surgery, which could lead to a series of concerns regarding the intra- and postoperative hemorrhagic risk of the procedure. Nevertheless, both the surgical procedure and the postoperative recovery were uneventful, suggesting that the lower threshold for preoperative thrombocyte count in megathrombocytopenia should be specifically considered on an individual case analysis.

Advanced metastatic breast cancer in pregnancy: the imperative of physical breast examination in pregnancy.

Breast cancer is the most frequent cancer diagnosed among women; its association with pregnancy is not encountered. As childbearing age is increasing, the diagnosis of breast cancer associated pregnancy tends to be more often than years ago. Here we report a case of a 37-year-old patient, gravida 7, para 7, diagnosed at 30 weeks gestation with metastatic breast cancer. The patient presented to hospital due to an altered performance status. Obstetrical evaluation was within normal range. A metastatic infiltrating breast cancer poorly differentiated (G3) with satellite skin lesions (T4b), ipsilateral axillary and supraclavicular lymph nodes (N3), lung metastasis bilateral with pleural effusion and hepatic metastasis (M1), were diagnosed. The tumor was positive for estrogen receptor (ER) and progesterone receptor (PR) status and negative for human epidermal receptor protein-2 (HER-2)÷neu immunostaining. Due to a significant worsening of the patient's dyspnea, a Caesarean section was performed under spinal anesthesia, at 30 + 2 days; and a newborn weighing 1700 g was delivered without malformations. The unsuccessful management of the cancer was inevitable and the patient died two weeks later. Despite her hospitalizations for six prior deliveries (last birth was one year ago), the presence of a palpable tumor was never observed. We aim to highlight the importance of the clinical examination at any given point in pregnancy in order to detect, investigate and treat any suspect tumor of the breast.

The prognostic role of Bcl-2, Ki67, c-MYC and p53 in diffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous group of lymphoid malignancies, which counts for more than a third of non-Hodgkin's lymphoma cases. The aim of the current study is to evaluate the prognostic role of several immunohistochemical (IHC) markers involved in the pathological process of DLBCL. This is a retrospective analysis of the 97 de novo DLBCL patients admitted between January 2007 and December 2016 in the Department of Hematology, "Filantropia" Municipal Hospital, Craiova, Romania. The expression of Bcl-2, Ki67, c-MYC and p53 was assessed by immunohistochemistry. A significant level of association was observed between high prognostic index values and Bcl-2, Ki67, c-MYC and p53 positive cases. Moreover, overall survival and disease-free survival were higher in patients with negative expression for these markers. Bcl-2, Ki67, c-MYC and p53 could make important diagnostic and therapeutic targets; therefore, their routine assessment should be mandatory.

Primary squamous cell carcinoma of the thyroid: a case report.

Primary squamous cell carcinoma of the thyroid is a very rare thyroid malignancy (less than 1% of thyroid cancers) with unfavorable clinical evolution and median survival less than one year, due to highly local tumor invasiveness with airway obstruction, metastases and treatment complications. We present a 62-year-old female patient with a fixed, rapidly increasing 5 cm right thyroid nodule, generating compressive signs and significant weight loss, resembling anaplastic thyroid carcinoma. Thyroid hormones, antithyroid antibodies and calcitonin were normal. Computed tomography (CT) scan revealed mediastinal extension of the tumor and excluded the presence of lymph nodes or other tumors (T3N0M0). Total thyroidectomy was performed and histopathological evaluation revealed squamous cell carcinoma, which was confirmed by immunohistochemistry, showing diffuse positivity for CK7, CK19, CK34ßE12, galectin-3, EGFR, focal positivity for p63 and negativity for TTF-1 and CD5. Subsequently, the patient underwent chemotherapy (Paclitaxel, Cisplatin, Epirubicin) and radiotherapy (40 Gy), but tumor recurrence was noticed one month after surgical resection and continued to grow despite treatment. Nodal and metastases status remained negative at regular follow-up. The patient died within one year after diagnosis. External radiotherapy and chemotherapy were not efficient in our case. New treatment options are needed to improve outcome in primary squamous cell carcinoma of the thyroid.

Severe upper gastrointestinal bleeding from gastrointestinal stromal tumor of the stomach.

Gastrointestinal stromal tumor (GIST) is a mesenchymal tumor originating from the Cajal interstitial cells, immunologically characterized by the c-kit gene. The evolution may be asymptomatic, discovered by chance during a necropsy, upper gastrointestinal endoscopy or due to complications of type-algic, occlusive or hemorrhage. We present the case of a voluminous gastric GIST complicated with serious upper gastrointestinal bleeding in a patient with multiple hard associated diseases, undergoing an emergency surgery in hemorrhagic shock. The surgery consisted in the resection of the upper polar esogastric, the pathological and immunohistochemistry tests confirming the diagnosis of GIST. The evolution was unfavorable at discharge after 45 days after surgery by an anastomotic fistula.

Neuro-neoplastic interrelationships in colorectal level - immunohistochemical aspect in three cases and review of the literature.

Colorectal cancer represents a severe public health issue. Recent studies have shown the essential role played by nerves and their neurotransmitters in tumor initiation and progression. The aim of this study is to asses the expression of beta 2-adrenergic receptors (ß2A) for adrenaline and noradrenaline, and the expression of M3 muscarinic receptors (M3R) for acetylcholine (neurotransmitters produced and released by sympathetic and parasympathetic afferents of the digestive tract and also by the enteric nervous system) in different tumor gradings of colorectal adenocarcinoma, and also the tropomyosin receptor kinase A (TrkA) for the nerve growth factor produced by the cells of colorectal adenocarcinoma. Beta 2-adrenergic receptors were expressed both in normal colic tissue and in the tumor tissues, from the three patients included in the study. It was observed that both area and integrated optical density (IOD) are more elevated for this type of receptor in tumor tissues than in normal colic tissue. For the M3 muscarinic receptors, similarly to beta 2-adrenergic receptors, it was observed a growth both of the area and of the IOD with the tumor grading. The presence of TrkA receptors was also observed both in the normal colic mucosa and in the tumor tissues examined, but with a significant reduction of the signal in the poorly differentiated tumor tissue. Understanding the neurobiology of cancer in this context becomes necessary for establishing much more complex and targeted molecular targeted therapies.

Retroperitoneal ancient schwannoma - case presentation.

Retroperitoneal ancient schwannomas are rare tumors, more usually found in the head, neck and flexor surfaces of the extremities. Ancient schwannomas are a subtype of classic schwannomas with a predominance of degenerative changes, calcifications, hemosiderin deposition, interstitial fibrosis and vascular hyaline degeneration. A 33-year-old male was referred on our hospital with a painful mass in left iliac fossa. The patient underwent surgery and intra-operatively the cystic encapsulated mass was found to be retroperitoneal, between the left psoas major muscle and left iliac muscle. On microscopic examination, we found the presence of Schwann cells in regions with high and low cellularity (Antoni A and B areas) and S100 protein immunohistochemical examination was intensely positive, being consistent with the diagnosis of schwannoma. Complete excision is the only method of the surgical treatment; schwannomas are not sensitive to radiotherapy and chemotherapy. Some authors consider that a complete excision of the tumor, while others believe that enucleated or partial excision of the tumor is sufficient. The prognosis is good, and the most common complication is recurrence, possibly by incomplete excision of it being reported in 5-10% of cases. In conclusion, retroperitoneal schwannomas is usually identified incidentally on tomographic images. Diagnosis is based on histopathological examination after surgery and immunohistochemical examination.

Pitfalls in diagnosing a pancreatic neuroendocrine tumor: a case report.

Pancreatic neuroendocrine tumors are a rare subset of pancreatic neoplasms. We report the case of a 33-year-old female patient who was admitted to the Diabetes Clinic of Craiova, Romania, due to a two-year history of episodic neuroglycopenic hyperinsulinemic hypoglycemic symptoms, suggestive for insulinoma associated with facial and upper trunk flushing characteristic to carcinoid syndrome. During these episodes, the laboratory investigations showed hypoglycemia (38 mg/dL), hyperinsulinemia (54.72 µU/mL) and normal values of beta-hydroxybutyrate, chromogranin A, serotonin, anti-insulin antibodies and urinary levels of 5-hydroxyindoleacetic acid. Endoscopic ultrasound with SonoVue and 3T MRI revealed an 18.3/16.3 mm hypervascular tissular mass situated in the uncinate process of the pancreatic head in close contact with the superior mesenteric vein without invasion and no other detectable secondary lesions in the pancreas or any other abdominal viscera. Patient underwent enucleation of pancreatic tumor. The histological and immunohistochemical findings indicated a functional well-differentiated pancreatic neuroendocrine tumor, G1 category according to the World Health Organization (WHO) criteria, with uncertain behavior (Ki67 index was 3%), confined to the pancreas, but with tumoral invasion of the delimiting conjunctive capsule. No evidence of tumoral CK19 staining, mitoses and necrosis, angioinvasion or extra-pancreatic invasion was observed. A post-operative nine-month follow-up showed resolution of hypoglycemic symptoms, normalized blood glucose and insulin levels and no evidence of recurrence. Our case report highlights the pitfalls in diagnosing a functional pancreatic neuroendocrine tumor due to atypical symptoms, the difficulty of identification and precise location of the small-size tumor and uncertain histopathological and immunohistochemical behavior.