Malignant melanoma of the lung: is it easy to determine its origin?

Malignant melanoma involving the respiratory tract is nearly always metastatic. True primary tumors are very rare, and only approximately 28 cases have been reported in the literature. Extensive clinical and histopathological examinations are needed to ascertain that the lung is the primary site. We present the case of a 67-year-old man with an apparent primary malignant melanoma of the lung in the right lower lobe. We also review the literature.     

Is autoimmunity a component of natural immunity to HIV?

Antibody neutralization would be a major way to prevent HIV infection and disease progression, but the complex relationship between host and pathogen makes tough to achieve this target through immunogens based on viral envelope proteins. Autoimmunity has been associated to bacterial and viral diseases, as a consequence of inflammatory response to pathogens; it may eventually lead to harm host cells and organs. However, autoimmune-like responses have also been observed in HIV-infected patients, raising many questions about their clinical significance. Recent studies have elucidated both similarities and differences between anti-self responses in HIV infection and autoimmune diseases, identifying new molecular players that might enhance immune protection to HIV and/or modulate the clinical progression of the established infection. This paper will present the current knowledge on auto-antibodies observed in HIV infection, their putative mechanisms of generation and their possible implications for immune therapy.     

Does tumor size influence the outcome of laparoscopic distal pancreatectomy?

BackgroundLaparoscopic distal pancreatectomy (LDP) is a safe procedure, but its role in resection of large pancreatic lesions has been questioned.MethodsPatients who underwent LDP for pancreatic solitary tumors in 1997–2017 were included in this study. The patients were divided into three groups in accordance with tumor size: <3.5 cm (group I); from 3.5 cm to 7.0 cm (group II), and ≥7 cm (group III).Results218, 146 and 58 patients were identified in the groups I, II and III. Median tumor size in the groups I, II and III was 20, 47 and 81.5 mm (p < 0.001). Nine procedures (2.1%) were converted including 1(0.5%), 5(3.4%) and 3(5.2%) in the groups I, II and III (p = 0.036). Median operative time was longer in the group III compared with the groups I and II – 195 vs 158 and 159 min (p = 0.005). Median blood loss did not differ. Regression analysis revealed correlation between tumor size and operative time (R = 0.103; P = 0.035) and no correlation between tumor size and blood loss (R = 0.075; P = 0.125). Hospital stay was 5 days, similar in all groups.Postoperative morbidity was similar – 38.5, 32 and 34% in the group I, II and III.ConclusionLDP can be safely performed laparoscopically with outcomes similar to those for smaller tumors.     

Is decrease of tumor volume correlated with stage change after preoperative concurrent chemoradiotherapy?

BACKGROUND/AIMS: The significance of tumor volume and its change after concurrent chemoradiotherapy (CCRT) was evaluated. METHODOLOGY: Standard-dose external radiation and oral UFUR plus leucovorin were used to treat 30 middle and lower rectal adenocarcinoma patients. Volume of tumor calculated from images obtained by dynamic MRI of the rectum before and after CCRT was compared to pathological results after definite resection and other clinical data. RESULTS: The T-stage in 15 patients (50%), the N-stage in 13 (72.2%), and overall, the TNM stage in 18 (60%), were downstaged, including 7 (23.3%) with complete responses (CR). Volume of tumor before CCRT (Vpre) and after CCRT (VPost) was 10.3+/-6.1cm3 and 4.2+/-2.2cm3, respectively, and VPre correlated with initial T stage, N stage, age, and location. The net decrease ratio (NDR) of tumor volume was related to Vpre and initial T stage. As to the downstaging effect, VPre was related to incidence of CR; NDR was related to the downstaging of the N stage. CONCLUSIONS: All tumors showed volume reduction after CCRT, but the downstaging benefits were not in proportion to the size change. Initially larger tumors had higher ratios of volume reduction, and smaller tumors had higher chance of CR.     

Is there a qualitative interaction between adjuvant trastuzumab and size of the primary tumor in breast cancer?

Benefit of adjuvant trastuzumab in breast cancer has been reported in four randomized trials of phase III, and these results are consistent in showing improvement in disease-free survival (DFS). Current evidence for homogeneity of this DFS benefit in subgroups of patients with the different size of the primary HER2-positive tumor treated according to the HERA trial is reviewed. It is evident that current published evidence is insufficient to rule out that there is a cohort of patients with HER2-positive disease who do not achieve a reduction in the risk of recurrence by adjuvant treatment with trastuzumab after completion of previous adjuvant chemo- and radiotherapy. An alternative interpretation of results of the HERA trial currently available in two primary reports (1-year, and 2-year median follow- up, respectively) is discussed. The risk factors of central nervous system (CNS) metastases in breast cancer and problem of CNS metastases in HER2-positive tumors are briefly reviewed. A hypothesis on the relations between brain metastases, their risk factors, the size of the primary tumor, and their impact on the DFS in patients with HER2-positive tumors treated with adjuvant trastuzumab is proposed based on the results of the HERA trial. Altogether, some direct evidence is presented here based on the published results of the HERA trial, and still more indirect evidence based on the information on related topics in literature, to show that current clinical practice of adjuvant trastuzumab in mono-therapy, which is based on assumption that there is a homogeneous benefit as for disease-free survival for all sizes of primary HER2-positive tumors above 1 cm, may not be based on such firm evidence as is commonly presented. Key words: breast cancer; trastuzumab; adjuvant; brain metastases.     

Is endoscopic submucosal dissection safe for papillary adenocarcinoma of the stomach?

AIM: To identify the clinicopathological predictors of lymph node(LN) metastasis and evaluate the outcomes of endoscopic submucosal dissection(ESD) in papillary adenocarcinoma-type early gastric cancers(EGCs).METHODS: From January 2005 to May 2013, 49 patients who underwent surgical operation and 24 patients who underwent ESD for papillary adenocarcinomatype EGC were enrolled to identify clinicopathological characteristics and predictive factors of LN metastasis and to evaluate the outcomes of ESD for papillary adenocarcinoma-type EGC.RESULTS: Most papillary adenocarcinoma-type EGCs were located in the lower third of the stomach and had an elevated macroscopic shape. The overall prevalence of LN metastasis was 18.3%(9/49). The presence of lymphovascular invasion was found to be a predictor of LN metastasis(P = 0.016). According to current indication criteria of ESD, 6 and 11 of the 49 patients had absolute and expanded indications for ESD, respectively. Two patients(11.8%) with expanded indication for ESD had LN metastasis. Of the 24 patients who underwent ESD, 13(54%) achieved out-of-ESD indication, with 9 of those 13 patients undergoing surgical operation due to non-curative resection. CONCLUSION: The use of ESD should be carefully considered for papillary adenocarcinoma-type EGC with suspected ESD indication after pre-treatment work-up because of the higher frequency of LN metastasis and additional surgeries.     

How to determine the diagnosis of Helicobacter pylori infection in the elderly?

PURPOSE: The real prevalence of Helicobacter pylori (H. pylori) infection is difficult to determine in the elderly because of the frequency of drug intake (antibiotics or anti-secretory drugs). The aim of this study was to evaluate the diagnostic performance of five tests in the elderly. METHODS: The study population consisted of consecutive patients undergoing a routine endoscopy between August 1998 and December 1999. We evaluated the diagnostic performance of four tests in all of the included patients: culture and histology of biopsy specimens, serology (ELISA) and urea breath test (13C-UBT). Detection of H. pylori antigens in stool samples (HpSA) was realized in a subgroup. Patients were considered H. pylori + when result for culture was positive or when two tests were positive. RESULTS: One hundred and sixty-seven patients were included in this study (55 men, 112 women; mean age: 85.6 +/- 5.1 years). Only 38 (22.8%) patients were H. pylori+. Test performances showed the following results: serology sensitivity: 90.9% (IC 95%: 75.6-98.1) versus 86.9% (IC 95%: 63.6-96.9) for culture versus 77.8% (IC 95%: 60.8-89.9) for histology and 74.3% (IC 95%: 56.7-87.5) for 13C-UBT. Eighty-nine (53.3%) took antibiotics or anti-secretory drugs, only 13C-UBT performances decreased significantly (sensitivity: 94.4% [72.7-99.8] versus 52.9% [27.8-77]; P < 10(-6)). When gastric or duodenal ulcer were endoscopically diagnosed in older patients, both histology and 13C-UBT could not improve the diagnosis of H. pylori infection. HpSA was realized in 107 patients (sensitivity: 74.1%, specificity: 98.7%). We showed no statistical difference between HpSA performances and drug intake. CONCLUSION: Diagnostic performances decreased in older patients especially because of drug intake.     

Collision tumor of the rectum： A case report of metastatic gastric adenocarcinoma plus primary rectal adenocarcinoma

INTRODUCTION The term collision tumor refers to two coexisting, but independent tumors[1]. Malignant neoplasms originating from two or more distinct topographic organs may form a collision tumor. A possible explanation for this is field cancerization, whi…     

Should we try to determine the specific cause of cardiac tamponade?

INTRODUCTION: The causes of cardiac tamponade vary and it has been suggested that underlying causes should be sought in all cases. The purpose of this study was to determine the causes of cardiac tamponade in our environment, distinguishing between specific and idiopathic causes, and analyzing the proportion and causes in the subgroup of patients with relapsing tamponade. PATIENTS AND METHOD: We retrospectively studied all patients who underwent therapeutic pericardiocentesis between 1985 and 2001. The clinical and radiographic features and macroscopic characteristics of the pericardial fluid were analyzed. The final diagnosis in each patient was based on the clinical history, follow-up, pericardial fluid cytology, and pericardial biopsy, if available. RESULTS: Ninety-six patients were included (52 men/44 women), mean age 56.1 16.1 years. The cause of pericardial effusion was neoplasm in 50 patients (52.1%), 14 idiopathic pericarditis (14.6%), 12 renal failure (12.5%), 7 iatrogenic cases (7.3%), 4 mechanical tamponades (4.2%), 2 tuberculosis (2.1%), and 7 other causes (7.3%). Thirty-five patients had relapsing tamponade; only 2 of them had idiopathic pericarditis (5.7%). We found no significant differences in age, development time, extracted volume or fluid features between tamponade of specific or idiopathic origin. CONCLUSIONS: Most of the cardiac tamponades in our series had a specific cause. This made it necessary to identify a specific underlying cause in each case, especially in relapsing effusions. However, we did not find any variable suggestive of the cause of the disease.     

Is hypertension related to the number of nephrons?

The kidney has a key role in blood pressure control, and an abnormal regulation of sodium balance is involved in essential hypertension. It has been suggested that a reduced nephron number at birth could be one possible mechanism. Indeed various strains of hypertensive animals exhibit a reduced nephron number. In human beings, two autopsy studies have clearly shown a lower (about 50%) nephron number in hypertensive subjects. The glomeruli are also enlarged, indicating hyperfiltration. This could be the cause of both high blood pressure and later nephrosclerosis. A low number of nephrons is part of the perinatal programming which occurs together with fetal growth retardation, and this has been reproduced experimentally. There is a negative correlation between birth weight and glomerular number. Such a situation is associated with a largely increased risk of cardiovascular complications in adulthood.     

Is the severity of gastroesophageal reflux dependent on hiatus hernia size?

AIM: To determine if the severity of gastroesophageal reflux disease is dependent on the size of a hiatus hernia. METHODS: Seventy-five patients with either a small(n = 25), medium(n = 25) or large(n = 25) hiatus hernia(assessed by high resolution esophageal manometry) were investigated using 24-h esophageal monitoring and a self-assessed symptom questionnaire. The questionnaire comprised the following items, each graded from 0 to 3 according to severity: heartburn; pharyngeal burning sensation; acid regurgitation; and chest pain. RESULTS: The percentage total reflux time was significantly longer in the group with hernia of 5 cm or more compared with the group with a hernia of < 3 cm(P < 0.002), and the group with a hernia of 3 to < 5 cm(P < 0.04). Pharyngeal burning sensation, heartburn and acid regurgitation were more common with large hernias than small hernias, but the frequency of chest pain was similar in all three hernia groups. CONCLUSION: Patients with a large hiatus hernia are more prone to have pathological gastroesophageal reflux and to have more acid symptoms than patients with a small hiatus hernia. However, it is unlikely that patients with an absence of acid symptoms will have pathological reflux regardless of hernia size.     

Gastrointestinal stromal tumor of the stomach: How to manage?

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the stomach. Prognosis of this disease is related to tumor size and mitotic activity and early diagnosis is the only way to improve it. Diagnosis of GIST always requires histological and immunohistochemical confirmation as no imaging modalities can diagnose it conclusively. Endoscopic forceps biopsy results are frequently negative. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a technique which allows tissue samples to be obtained with minimal risks and is accurate in the diagnosis of GIST. From the point of view of the endoscopist, aggressive use of EUS-FNA is the only promising way to allow early diagnosis and early treatment of this disease.