Peritoneal Metastases from Gastroenteropancreatic Neuroendocrine Tumors: Incidence, Risk Factors and Prognosis.

BACKGROUND: Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are rare neoplasms and data on peritoneal metastases (PM) from these tumors are scarce. OBJECTIVE: The aim of this study was to present population-based data on the incidence, risk factors, and survival of synchronous PM in GEP-NETs. METHODS: Data from all patients diagnosed with a GEP-NET during 2007-2013 were collected from the Netherlands Cancer Registry. Age-standardized incidence rates were calculated and risk factors for developing PM were determined using multivariable logistic regression analysis. Survival was investigated using Kaplan-Meier and Cox regression analyses. RESULTS: A total of 4114 patients were diagnosed with a GEP-NET. PM were diagnosed in 234 patients (19% of patients with metastasized disease, representing 6% of all GEP-NETs). The incidence of patients diagnosed with PM was 1.6:1,000,000 persons per year. Risk factors for developing PM were higher age (odds ratio [OR] 1.4, 95% CI 1.0-2.0) and primary tumor location in the small intestine (OR 3.5, 95% CI 2.1-5.7) or colon (OR 2.5, 95% CI 1.4-4.4). Small intestinal NETs with PM had the best survival, while appendiceal NETs with PM had the poorest survival (5-year survival rates of 67 and 7%, respectively). Multivariate analysis showed that survival in patients with PM was worse compared with patients without metastases; however, the presence of PM among all metastasized patients was not associated with worse survival. CONCLUSIONS: This nationwide population-based study provides relevant insight into the incidence and risk factors of PM in GEP-NETs, and reveals detailed site-specific data on the presence of PM and survival data that may contribute to develop individualized treatment strategies in patients with these heterogeneous neoplasms.

Peritoneal carcinomatosis of gastric origin: a population-based study on incidence, survival and risk factors.

Peritoneal carcinomatosis (PC) is an important cause of morbidity and mortality among patients with gastric cancer. The aim of the current study was to provide reliable population-based data on the incidence, risk factors and prognosis of PC of gastric origin. All patients diagnosed with gastric cancer in the area of the Eindhoven Cancer Registry between 1995 and 2011 were included. Incidence and survival were computed and risk factors for peritoneal carcinomatosis were determined using multivariate logistic regression analysis. In total, 5,220 patients were diagnosed with gastric cancer, of whom 2,029 (39%) presented with metastatic disease. PC was present in 706 patients (14%) of whom 491 patients (9%) had PC as the only metastatic site. Younger age (<60 years), female gender, advanced T- and N-stage, primary tumor of signet ring cells or linitis plastica and primary tumors covering multiple anatomical locations of the stomach were all associated with a higher odds ratios of developing PC. Median survival of patients without metastases was 14 months, but only 4 months for patients with PC. PC is a frequent condition in patients presenting with gastric cancer, especially in younger patients with advanced tumor stages. Given the detrimental influence of PC on survival, efforts should be undertaken to further explore the promising results that were obtained in preventing or treating this condition with multimodality strategies.

Incidence, prognosis, and treatment options for patients with synchronous peritoneal carcinomatosis and liver metastases from colorectal origin.

BACKGROUND: Peritoneal carcinomatosis and liver metastases are common metastatic sites in patients who have colorectal cancer. Quite frequently, patients present with both synchronous liver and peritoneal metastases, which may result in a dilemma regarding the optimal treatment. OBJECTIVE: In the absence of reliable data, the aim of the current study was to provide population-based data on such patients and to review the literature for possible treatment options. DESIGN: This study is a retrospective analysis of a prospective database and a review. PATIENTS: All patients diagnosed between 1995 and 2010 with synchronous peritoneal carcinomatosis and liver metastases were identified from the Eindhoven Cancer Registry. OUTCOME MEASURES: Incidence and survival were analyzed. Next, the literature was reviewed for articles reporting on the results of treatment with curative intent. RESULTS: In total, 27,632 patients were diagnosed with colorectal cancer, of whom 5638 patients (20%) presented with metastasized disease. Synchronous liver metastasis and peritoneal carcinomatosis were present in 440 patients, being 11% of patients with liver metastases, 34% of patients with peritoneal carcinomatosis, 8% of patients with metastasized disease, and 2% of all patients diagnosed with colorectal cancer. Median survival for patients with liver metastasis and peritoneal carcinomatosis was 5 months, in comparison with 95 months for patients with nonmetastasized disease. No improvement in survival was noted over time. None of the patients underwent treatment with curative intent during this period. LIMITATIONS: No data on the extent of peritoneal carcinomatosis and liver metastases were available in the population-based study. This complicates comparison with treated patients from the literature review, which probably reflects a highly selected patient population. CONCLUSIONS: Both liver metastasis and peritoneal carcinomatosis were present in 8% of patients presenting with metastasized colorectal cancer. Population-based survival was only 5 months, with none of the patients undergoing treatment with curative intent. Median survival rates of up to 36 months after treatment with curative intent as published in the literature may be regarded as promising for selected patients.

Thoracic Endovascular Aneurysm Repair and Tracheal Stenting for Respiratory Failure due to a Thoracic Aortic Aneurysm: A Case Report.

An 82-year-old male was referred to the emergency department for severe respiratory distress. Computed tomography angiography showed tracheal compression due to a large ruptured saccular aneurysm of the descending thoracic aorta. Emergency Thoracic Endovascular Aneurysm Repair (TEVAR) was performed. To reduce tracheal compression, an endotracheal stent was placed (silicone Dumon©). Following surgery, respiratory function improved. Two days after the surgery, the patient refused further invasive treatment, including mechanical mucus aspiration from the endotracheal stent, and palliative sedation was initiated. Conventional treatment to reduce tracheal compression by a saccular aortic aneurysm is open surgical aneurysm repair. If open repair is contraindicated because of patient age, comorbidity, or in case of severe hemodynamic instability following aneurysm rupture, TEVAR with endotracheal stent placement may serve as a bridge to definite surgery to reduce tracheal compression.

The dangers of pets and horses, animal related injuries in the Emergency department.

INTRODUCTION: Every year patients present to the emergency department due to bites, scratches and falls caused by animals. Although bite and scratch injuries have been described in literature, the exact number of patients that visit the emergency department due to all animal related injuries has never been described before. METHODS: A retrospective analysis of all emergency department visits throughout a 1-year period was performed from April 2015 until March 2016. RESULTS: 516 Patients were treated at the emergency department because of animal related injuries. Most were female and the median age was 38 years. The animals causing most injuries were horses, followed by dogs and cats. Animal related injuries more often caused fractures (n = 165) or contusions (n = 171) compared to wounds (n = 135). No lethal injuries were recorded. However, three animals did not survive the event. CONCLUSIONS: The incidence of animal related injuries is 2.8% and this is probably an underestimation. The injuries have noteworthy origins and have potentially severe physical injury as result. Awareness in the general population on the potential dangers of pets and horses could reduce the number and severity of animal related injuries.

Pain Experience and Perception in the Obese Subject Systematic Review (Revised Version).

Pain is an integral part of life and has an important protective function. Pain perception has been shown to differ between subjects and changes with gender, race, and culture. In addition, it has been suggested that obesity influences pain perception and that obesity can be a risk factor for increased pain thresholds. The aim of this systematic review was to examine pain thresholds in obese subjects compared to non-obese subjects. The electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE were searched using combinations of terms for obese, pain measurement, visual analog scale, quantitative sensory testing, and pain perception. Studies without comparison as well as cross-sectional studies, case series, and case reports were excluded. The search was conducted without restrictions on language or date of publication. From a total of 1818 identified studies, seven studies fulfilled the inclusion criteria, whereby only one study tested the pain threshold difference between obese and non-obese and also before and after body weight loss surgery. Two studies showed a lower pain threshold and four studies a higher pain threshold in obese subjects compared to non-obese subjects. Two studies showed no difference in pain threshold before and after substantial body weight loss due to surgery. Weight loss after surgery was not identified as a factor for higher pain thresholds in obese subjects. In view of the heterogeneity of the studies, the variability of the subjects and differences in methodological quality, a meta-analysis could not be performed. From the available literature, there is a tendency towards higher pain thresholds in obese subjects. Neither substantial weight loss, nor gender, were factors explaining difference in threshold. Future randomized, controlled trials should explore demographic variables that could influence pain perception or pain thresholds in obese individuals, and multimodal pain testing is necessary for better understanding of the apparent differences in pain thresholds in obese individuals.

A Collective Review on Mesh-Based Repair of Umbilical and Epigastric Hernias.

In accordance with the tension-free principles for other hernias, umbilical and epigastric hernia repair should probably be mesh-based. The number of randomized studies is increasing, most of them showing significantly less recurrences with the use of a mesh. Different devices are available and are applicable by several approaches. The objective of this review was to evaluate recent literature for the different types of mesh for umbilical and epigastric hernia repair and recurrences after mesh repair. A multi-database search was conducted to reveal relevant studies since 2001 reporting mesh-based repair of primary umbilical/epigastric hernia and their outcomes in adult patients. A total of 20 studies were included, 15 of them solely involved umbilical hernias, whereas the remaining studies included epigastric hernias as well. A median of 124 patients (range, 17-384) was investigated per study. Three quarters of the included studies had a follow-up of at least 2 years. Six studies described the results of laparoscopic approach, of which one reported a recurrence rate of 2.7 %; in the remaining studies, no recurrences occurred. Two comparative studies reported a lower incidence of complications and postoperative pain after laparoscopic repair compared to open repair. Seventeen studies reported results of open techniques, of which seven studies showed no recurrence. Other studies reported recurrence rates up to 3.1 %. A wide range of complication rates were reported (0-33 %). This collective review showed acceptable recurrence rates for mesh-based umbilical and epigastric hernia repair. A wide range of devices was investigated. A tendency toward more complications after laparoscopic repair was found compared to open repair.

Treatment of temporal artery pseudoaneurysms.

PURPOSE: To give an overview of the etiology and diagnostic process of superficial temporal artery pseudoaneurysms and to evaluate different treatment modalities. BASIC METHODS: PubMed was used for searching multiple databases for relevant clinical studies. PRINCIPAL FINDINGS: A total of 62 studies were included, harboring 82 patients. Surgical excision is the most frequently described treatment, but less invasive treatment modalities as coiling and thrombin injections are gaining popularity. Surgical treatment was successful in all cases (67/67). Endovascular treatment was successful in 69% (9/13); the five cases treated with thrombin injection were all successful. Complementary, a description of our experience with thrombin injection is given. CONCLUSIONS: Limited evidence of minimal invasive treatment for superficial temporal artery pseudoaneurysm is available. Based on this review combined with our limited experience, we suggest thrombin injections to be considered as the future primary treatment modality. In the case of unsuccessful exclusion of the aneurysm, surgical excision can be performed.

Small bowel perforation caused by advanced melanoma.

The incidence of melanoma has been increasing over the years and it remains, despite the heterogeneous survival for different stages, a disease with high mortality. Dissemination occurs primarily by the lymphatic route, followed by the hematogenous route. Gastrointestinal metastases do occur, but they are mainly intraluminal mucosal melanomas. Peritoneal or primary mucosal melanomas are rare. Only a few cases have been described of patients presenting with acute abdominal pain due to a melanoma. In this report we present a young patient with no prior health problems. Due to silent progression of disease at first, and secondarily avoidance of medical consultation, she finally presented to our emergency department with signs of intestinal perforation. In the operating theater a massive metastasis in the intestines with perforation was seen, as well as many smaller intra-abdominal and cutaneous lesions. Approximately 35 cm of jejunum had to be resected. Furthermore, the primary melanoma on the left forearm was excised and turned out to be in almost complete regression. Although initial recovery after surgery was good, the patient died only one month after presentation due to the advanced nature of her disease, which points to the devastating effect of undiagnosed melanoma and gastrointestinal metastasis. Since the melanoma incidence is rising, similar cases may present in the near future. This emphasizes the importance of proper full physical examination in patients with atypical abdominal symptoms.

Population-based incidence, treatment and survival of patients with peritoneal metastases of unknown origin.

AIM: Until recently, peritoneal metastases (PM) were regarded as an untreatable condition, regardless of the organ of origin. Currently, promising treatment options are available for selected patients with PM from colorectal, appendiceal, ovarian or gastric carcinoma. The aim of this study was to investigate the incidence, treatment and survival of patients presenting with PM in whom the origin of PM remains unknown. METHODS: Data from patients diagnosed with PM of unknown origin during 1984-2010 were extracted from the Eindhoven Cancer Registry. European age-standardised incidence rates were calculated and data on treatment and survival were analysed. RESULTS: In total 1051 patients were diagnosed with PM of unknown origin. In 606 patients (58%) the peritoneum was the only site of metastasis, and 445 patients also had other metastases. Chemotherapy usage has increased from 8% in the earliest period to 16% in most recent years (p=.016). Median survival was extremely poor with only 42days (95% confidence interval (CI) 39-47days) and did not change over time. Median survival of patients not receiving chemotherapy was significantly worse than of those receiving chemotherapy (36 versus 218days, p<.0001). CONCLUSION: The prognosis of PM of unknown origin is extremely poor and did not improve over time. Given the recent progress that has been achieved in selected patients presenting with PM, maximum efforts should be undertaken in order to diagnose the origin of PM as accurately as possible. Potentially effective treatment strategies should be further explored for patients in whom the organ of origin remains unknown.

[A man with a bump on his forehead after a fall]. / Een man met een bult op zijn voorhoofd na een val.

UNLABELLED: An 84-year-old male patient presented with a swelling on his forehead which had developed gradually over a period of three weeks after a fall. Ultrasound examination revealed a complex fluid collection with a yin-yang flow pattern (revealed by colour Doppler imaging), which was suggestive of a pseudoaneurysm of the frontal branch of the superficial temporal artery. This was successfully treated with an injection of thrombin. DIAGNOSIS: traumatic pseudoaneurysm of the superficial temporal artery.

Incidence, prognosis, and possible treatment strategies of peritoneal carcinomatosis of pancreatic origin: a population-based study.

OBJECTIVES: Peritoneal carcinomatosis (PC) is an important cause of morbidity and mortality among patients with pancreatic cancer. In an era where therapeutic options for PC of multiple origins are emerging, our aim was to provide population-based data on incidence, treatment, and prognosis of PC of pancreatic origin. METHODS: All patients with a condition diagnosed as nonendocrine pancreatic cancer between 1995 and 2009 in the area of the Eindhoven Cancer Registry were included. RESULTS: In total, 2924 patients had a diagnosis of pancreatic cancer of which 265 patients (9%) presented with synchronous PC. An increasing trend could be noted in patients treated with chemotherapy in more recent years (11% in 1995-1999 and 22% in 2005-2009; P = 0.060). Median survival in patients presenting with PC was only 6 weeks (95% confidence interval, 5-7 weeks) and did not improve over time, contrasting improvements among patients with nonmetastasized disease (19-30 weeks) and patients with metastasized disease confined to the liver (8-12 weeks). CONCLUSION: Prognosis of patients with pancreatic cancer presenting with PC remains extremely poor. Treatment options are scarce and, given the magnitude of the problem, efforts should be undertaken to develop effective treatments in experimental and clinical studies.

[13-Year old boy with abdominal pain]. / Een jongen met pijn rechts in de onderbuik.

A 13-year old boy presents with pain in the lower right abdomen, showing clinical signs of appendicitis. During McBurney' incision an appendix sana was seen. Histologic examination showed penetrating enterobiasis. This was treated with mebendazol.

Steroid use is associated with clinically irrelevant biopsies in patients with suspected giant cell arteritis.

Temporal artery biopsy (TAB) is the diagnostic gold standard for giant cell arteritis (GCA). GCA is treated by high-dose corticosteroids. In cases of high clinical suspicion, steroids may be administrated despite negative TAB, making TAB clinically irrelevant. We assessed the role of TAB in clinical decision-making in patients with suspected GCA and to identify factors associated with clinically irrelevant TAB. Charts of patients who underwent TAB from 2005 to 2010 were reviewed for clinical parameters potentially associated with GCA and clinically irrelevant TAB. We studied 143 patients with 99 negative (69%), 34 positive (24%), and 10 undefined (7%) TABs. Eventually 26 patients (18% of the entire cohort and 26% of the patients with a negative TAB) received steroid treatment for GCA despite negative TAB. The start of steroid treatment before TAB was associated with clinically irrelevant TABs. If clinical suspicion of GCA is high, a TAB can be considered clinically irrelevant.