Most pancreatic adenocarcinoma patients present with locally advanced or metastatic disease at diagnosis. In this retrospective study the authors evaluated the prognostic significance of the CEA and CA-19.9 serum tumor markers in advanced (unresectable) pancreatic cancer in correlation to other prognostic factors (demographic data, clinical parameters, treatment modality) and survival time using univariate and multivariate methods, in 215 patients with locally advanced (unresectable) or metastatic pancreatic adenocarcinoma. Median survival was 29.0 weeks, with 21.9% of patients surviving 36 weeks. Among 24 potential prognostic variables, 19 were associated with shorter survival. Multivariate analysis indicated that ten factors had a significant independent effect on survival: chemotherapy, surgery, tumor localization, elevated C-reactive protein, elevated CEA, CA 19-9 (>30xnl), jaundice at diagnosis, weight loss >10%. distant metastases, and Karnofsky performance status. Patients who had only palliative therapy had a hazard ratio of 8.94 versus those who underwent palliative surgery and chemotherapy. Although certain clinical, biochemical and biological factors remain important predictors of survival in patients with advanced pancreatic cancer, CA-19.9 serum tumor marker levels retain independent prognostic value for poor survival.

Background: Most patients with pancreatic adenocarcinoma are diagnosed with locally advanced (unresectable) or metastatic disease. The aim of this study was to investigate possible prognostic factors of survival in such patients. Patients and Methods: Two hundred and fifteen patients were studied retrospectively. Twenty-four potential prognostic variables (demographics, clinical parameters, biochemical markers, treatment modality) were examined. Results: Mean survival was 29.0 weeks. 21.9% survived more than 36 weeks. On multivariate analysis, 10 factors had an independent effect on survival: tumour localisation, metastasis, performance status, jaundice, weight loss, C reactive protein, CEA, CA 19-9, palliative surgery and chemotherapy. Patients managed only with palliative care had a hazard ratio of 8.94 versus those offered a combination of palliative surgery and chemotherapy. Conclusion: Many factors could be used as predictors of survival in patients with advanced or metastatic pancreatic cancer. Chemotherapy and palliative surgery are associated with increased survival, and should be offered to all eligible patients.

SUMMARY Cecal adenocarcinoma may present with atypic symptoms, mainly in the oldest patients, having a worse prognosis than other colon carcinomas. The most common complication of colorectal carcinoma is obstruction and bleeding,whereas bowel perforation is reported in less than 4% of cases in 1/3 of which it is located in the right colon.1,2 The following study is a case report of a retroperitoneal abscess due to a perforated cecal carcinoma. In the beginning, this abscess was considered to be of tuberculous etiology. In adition, a review of the relevant literature is presented in the following study. The clinical symptoms and signs of a retroperitoneal abscess may be obscure, and despite the large use of image studies, the resulting delay in diagnosis and treatment may lead to a high index of morbidity and mortality.

Pilonidal disease is a common chronic disorder of the sacrococcygeal area affecting young people. Recent reports have advocated different surgical approaches, such as open or closed technique, but recurrence complicates all forms of treatment. We conducted this case review to evaluate the validity of Limberg flap reconstruction method in the treatment of chronic recurrent pilonidal disease. In the period between September 2003 and December 2004, 32 male patients with complicated/recurrent pilonidal disease were operated on using the Limberg flap reconstruction method. The patients' mean age was 26.4 + 1.6 years (range 19-47 years). All patients fared well, had a satisfactory wound healing, had minimal pain and were mobilized immediately after surgery. They stayed at hospital for 6 to 32 hours. No patient had serious wound infection or flap ischemia. They all returned to normal activity within 4 to 12 days. Follow-up ranged between 14 and 28 months. No patient had recurrence during the above period. Limberg flap reconstruction has several advantages compared to the classical surgical methods for the treatment of pilonidal disease. The patients have a short hospital stay, are mobilized soon after surgery and have a minimal morbidity and recurrence rate.

Primary splenic cyst is a relatively rare disease, and the majority of cases are classified as epithelial cysts. Three cases with nonparasitic splenic cysts are presented: two epithelial and one pseudocyst. All cases had an atypical symptomatology, consisted mainly of fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computerized tomography. Two cases with large cysts located in the splenic hilum were treated with open complete splenectomy. The most recent case, a pseudocyst, was managed laparoscopically with partial cystectomy. All cases did not have any problems or recurrence during follow-up. Laparoscopic partial cystectomy is an acceptable procedure for the treatment of splenic cysts, because it cures the disease preserving the splenic tissue. Complete splenectomy is reserved for cases in which cyst excision cannot be done otherwise.

Adult granulosa cell tumours (GCTs) are rare ovarian neoplasms characterised by an indolent course and a propensity for late recurrence. Due to frequent endocrine manifestations most GCTs are diagnosed at an early stage. However, clinical behaviour can not be safely predicted on the basis of conventional clinicopathologic parameters. Surgery remains the cornerstone of therapeutic management. We report on a rare case of a Stage IA GCT twice recurring ten and 11 years after initial surgical treatment. The first recurrence presented as an acute abdomen due to haemoperitoneum after tumour rupture. The second recurrence presented as a subhepatic mass. This case emphasises the need for extended, lifelong follow-up even for patients with early stage, apparently completely removed GCTs. Prognostic parameters and therapeutic options especially for patients with recurrent disease are discussed.

PURPOSE To evaluate the effectiveness of 6-month therapy with leucovorin (LV)+5-fluorouracil (5-FU) versus 12-month therapy with levamisole (LVS)+5-FU, as adjuvant chemotherapy in patients with completely resected Aster-Coller stage B(2) or C(1)/C(2) rectal cancer (RC). PATIENTS AND METHODS One hundred and fifty patients with surgically resected RC were enrolled. Seventy patients with stage B(2) and 80 with stage C were randomly assigned to adjuvant chemotherapy with 5-FU+LXx6 months or 5-FU+LVSx12 months. Patient characteristics were equally balanced between the examined groups. Adjuvant chemotherapy consisted of LV 20 mg/m(2) intravenously (i.v.) plus 5-FU 450 mg/m(2) i.v. bolus every week plus LVS tablets 50 mg t.i.dx3 days every 2 weeks for 1 year. RESULTS After a median follow up for survivors of 8.7 years (range 1.8-10.5), all of the patients were evaluable. There were no significant differences between the two treatment groups with respect to the recurrence rates (p=0.821). Moreover, there were no significant differences between the two tratment groups in disease-free survival (DFS) (p=0.84) [B(2)(p=0.805) and C (p=0.978)] and overall survival (OS) rates for patients of either stage B(2) or C (p=0.78). Toxicities were more frequent in the 5-FU+LVS versus 5-FU+LV group: myelosuppression (grade 3 leucopenia, 12 versus 4%, p<0.04), diarrhea (grade 0, 60 versus 76%, p<0.02), and liver toxicity (increase of transaminases >3-fold, 12 patients versus 2, p<0.03.). No patient stopped chemotherapy because of toxicity, and there were no treatment-related deaths. CONCLUSION Adjuvant chemotherapy in RC with LV+5-FU for 6 months is equally effective and less toxic than LVS+5-FU for 12 months.

The aim of this study was to evaluate the effectiveness of 6-month therapy with leucovorin (LV) + 5-fluorouracil (5-FU) vs 12 months of therapy with levamisole (LVZ) + 5-FU, as adjuvant chemotherapy in patients with completely resected Dukes' stage B2 or C rectal cancer. One hundred and fifty patients with surgically resected rectal carcinoma, were enrolled in the present study; Dukes' stage B2 (n=70) or C (n=80), were randomly assigned to chemotherapy with 5-FU + LV x 6 months or 5-FU + LVZ x 12 months. Patient characteristics were equally balanced between the examined groups. Adjuvant CT consisted of LV 20 mg/m(2) intravenously (i.v.) plus 5-FU 450 mg/m(2) i.v., on days 1-5 every 4 weeks for 6 cycles or 5-FU 450 mg/m(2) i.v. every week plus LVZ 50 mg t.i.d x 3 days for 1 year. All patients received radiotherapy with a three-field technique to a total dose of 45 Gy, over 5 weeks. After a median follow-up of 7.4 years there were no significant differences between the two treatment groups with respect to the recurrence rates (P=0.821). Moreover, there was no difference in disease-free survival for patients stage Dukes' B2 (log-rank p=0.73); median for LV group 90 (8-131) months, and for LVZ group 86.5 (3-129) months. No difference was noted in disease-free survival for patients stage Dukes' C (log-rank p=0.73); median for LV group 60 (17-128) months, and for LVZ group 64 (2-123) months. There was no difference in overall survival for patients stage Dukes' B2 (log-rank p=0.75); median for LV group 90 (22-131) months, and for LVZ group 86 (10-129) months. For stage Dukes' C (log-rank p=0.73); median for LV group 67 (17-128) months, and for LVZ group 64 (5-123) months. Toxicities were as follows in the 5-FU + LVZ vs 5-FU + LV group; myelosuppression (leucopenia grade 3, 12% vs 4%, p<0.04), diarrhea (grade 0, 60% vs 76%, p<0.02), and liver toxicity (increase of transaminases >3-fold, 12 patients vs 2, p<0.03), were more frequent in LVZ group. None of the patients stopped chemotherapy because of the toxicity, and there were no toxicity-related deaths. In conclusion, adjuvant chemotherapy in RC with LV + 5-FU for 6 months is equally effective and less toxic than LVZ + 5-FU for 12 months.

The aim of this study is to present an unusual site of renal cell carcinoma metastasis. A 60-year old man presented to our clinic with massive rectal bleeding. A large small intestine metastasis from renal cell carcinoma was evidenced by an elective angiography of the superior mesenteric artery. This metastasis was surgically excised.

Gastrointestinal (GI) carcinoids are rare neuroendocrine tumors of great interest because of the multitude of the peptide hormones they produce, their clinical manifestations, the carcinoid syndrome they cause, their biologic behavior, and the methods of their surgical and adjuvant treatment. In this retrospective study, 25 patients with carcinoid tumors admitted and surgically treated in our department during the last 10 years are presented. Most of the cases were located in the ileum (n = 8) and appendix (n = 12). The remaining cases were located in the rectum (n = 2), stomach (n = 1), duodenum (n = 1), and ileocecal valve (n = 1). After tumor resection and postoperative treatment, mainly with somatostatin analogs, our patients had a good recovery, and only five deaths were reported during follow-up. Carcinoids, despite the fact that they are usually silent and diagnosed with advanced stage, have good prognosis and offer, after effective treatment, long survival.

Recurrent incisional hernia remains a major problem for the general surgeon. The high recurrence rate of incisional hernias after primary closure by tissue approximation led to the development of tension-free procedures using prosthetic materials. The goal of this study is to present the results of an extraperitoneal tension-free technique using a polyester mesh (Mersilene). A total of 43 patients with incisional hernias were surgically treated during a 9-year period in our department. Twenty-four patients (56%) had recurrent incisional hernias, 21 had primary repair by tissue approximation, and 3 had prolene mesh tension-free repair with wound infection. Patients' mean age was 68.2 years, and the mean postoperative follow-up was 54.4 months. Immediate postoperative complications were noticed in 9 patients (21%) subcutaneous seroma in 6 (14%) and wound infection in 3 (7%). Recurrence was noticed in 4 patients (9%) during the first 9 postoperative months. Late minor complications such as restriction of abdominal wall motility and chronic pain was noticed in 3 (7%) patients. In conclusion, the extraperitoneal onlay tension-free incisional hernia repair using polyester mesh is an easy and safe procedure with no major morbidity or recurrence rate.

This phase II trial studied the efficacy and toxicity of docetaxel-epirubicin, supported by granulocyte colony-stimulating factor, as first-line chemotherapy in metastatic breast cancer. Patients received epirubicin (60 mg/m2) followed 1 hour later by docetaxel (80 mg/m2) every 3 weeks for a maximum of 8 cycles or until disease progression. Prophylactic granulocyte colony-stimulating factor (5 micrograms/kg) was administered daily for 5 days. Sixty-nine patients were evaluable for efficacy and toxicity. Objective responses occurred in 45 patients (65%; 95% confidence interval: 53-76%), with 11 (16%) complete responses and 34 (49%) partial responses. Responses were observed at all metastatic sites. The median response duration was 8 months (range 4-68), median time to progression was 10 months (range 4-68) and median overall survival was 24 months (range 7-68): neutropenia was dose limiting (46% grade 3-4 toxicity). The left ventricular ejection, fraction measured in 50 patients, fell below normal in 14 patients (28%), 8 patients had grade 1 and 6 grade 2 cardiotoxicity, but none developed congestive cardiac failure. The docetaxel-epirubicin regimen is extremely effective in poor prognosis breast cancer patients with visceral metastases, with significant overall and complete responses, followed by prolonged survival in responders. Although myelosuppression remains the major toxicity, prophylactic GCSF administration was associated with a small percentage of neutropenic fever.

BACKGROUND: To study whether Pseudomonas aeruginosa may directly trigger peroxidation of polyunsaturated fatty acids, since lipid peroxidation is a mechanism involved in the pathogenesis of sepsis. METHODS: Gamma-linolenic acid (GLA) was administered intravenously at a dose of 25mg/kg in an infusion time of 10 minutes to seven male rabbits. Blood samples were collected from the hepatic veins and from the carotid artery at regular time intervals. One clinical isolate was ex vivo incubated with the serum derived from the latter samples and concentrations of malondialdehyde (MDA) were determined during incubation in the growth medium by the thiobarbiturate assay. RESULTS: Elevated concentrations of MDA compared to their basal levels were found over the first three hours of incubation in the presence of samples collected 30 to 60 minutes after the end of the infusion of GLA. After infusion of GLA concentrations of arachidonic acid in the serum increased to concentrations comparable to those detected in sepsis. CONCLUSION: Direct triggering of lipid peroxidation by nosocomial isolates might be proposed as a pathogenetic mechanism of sepsis.

OBJECTIVE:To evaluate the clinical usefulness of serum vascular endothelial growth factor (VEGF) levels in gastric cancer patients.SUMMARY BACKGROUND DATA:Vascular endothelial growth factor plays an important role in the formation of new blood vessels involved in the growth and metastatic spread of solid tumors, but there is limited information regarding the clinical significance of serum VEGF levels in cancer patients.METHODS:Serum VEGF concentrations were measured by an enzyme linked immunosorbent assay in 61 healthy controls and in 58 gastric cancer patients before surgery, and then again at 7 and 30 days after surgery. The association between preoperative serum VEGF levels, clinicopathological features and patient survival, and their changes following surgery were evaluated.RESULTS:Serum VEGF levels in gastric cancer patients were significantly higher than those in controls. There was a significant association between serum VEGF levels and disease stage, as well as invasion depth of the tumor and the presence of distant metastases. Serum VEGF levels decreased significantly after radical resection of the primary tumor and increased in patients with unresectable tumors. Multivariate regression analysis showed that serum VEGF level is an independent prognostic factor for survival.CONCLUSIONS:Serum VEGF levels in gastric patients are significantly higher compared with normal controls and correlate with local tumor extent, disease stage, and the presence of distant metastases. Preoperative serum VEGF concentration decreases significantly after radical resection of the primary tumor and is an independent prognostic factor for patient survival suggesting that determination of serum VEGF levels may be clinically useful.

Background: Elevated serum levels of the cell adhesion molecule E-cadherin have been associated with the presence of tissue injury and inflammation. We compared soluble E-cadherin response during laparoscopic and open cholecystectomy. Methods: The E-cadherin response to surgery was studied in 16 patients undergoing laparoscopic cholecystectomy and 12 patients undergoing open cholecystectomy. Serum E-cadherin levels were measured by an enzyme immunoassay (ELISA) preoperatively, 10 and 30 min after the commencement of surgery, and at 6 and 24 h following the operation. Results: Serum E-cadherin levels decreased progressively during laparoscopic cholecystectomy; their concentrations at 24 h after surgery were significantly lower when compared with preoperative values. In the open cholecystectomy group, serum E-cadherin levels did not differ from preoperative values at any time point. Serum E-cadherin concentrations at 24 h after surgery and the cumulative E-cadherin response were significantly higher in the open cholecystectomy group than in the laparoscopic group. Conclusion: Compared with open cholecystectomy, the cumulative E-cadherin response is significantly reduced following laparoscopic cholecystectomy.

BACKGROUND:Vascular endothelial growth factor (VEGF) is an angiogenic cytokine involved in the progression of solid tumors. In this study we evaluated the clinical usefulness of preoperative serum VEGF concentrations in patients with colorectal cancer. The changes in serum VEGF levels after tumor surgery were also evaluated.METHODS:Serum VEGF levels were determined by an enzyme-linked immunosorbent assay in the sera of 61 healthy control subjects and 67 patients with colorectal cancer preoperatively and 7 and 30 days after surgery.RESULTS:Serum VEGF levels in patients with colorectal cancer (median, 492 pg/mL; interquartile range, 281 to 737 pg/mL) were higher (P <.0001) than in control subjects (median, 186 pg/mL; interquartile range, 100 to 273 pg/mL). There was a significant association between serum VEGF levels and disease stage, invasion depth of the tumor, the presence of lymph node and distant metastases, and the degree of differentiation. Curative but not palliative resection of the primary tumor resulted in a significant decrease of preoperative serum VEGF levels but normalized in only 72% of patients. Failure of a return of VEGF to normal after resection for cure was associated with an increased although not statistically significant risk of metastasis during follow-up. Univariate analysis showed a lower survival rate for patients with increased preoperative serum VEGF levels (P <.002). Multivariate regression analysis showed that the prognostic value of serum VEGF level was not independent of tumor stage.CONCLUSIONS:These findings suggest that VEGF plays an important role in tumor progression and the formation of distant metastases in colorectal cancer. It is at present unclear whether serial estimation of serum VEGF is clinically useful in the prediction of tumor relapse.

BACKGROUND:Small bowel diverticula are usually asymptomatic and rare. Their importance is based on the fact that they carry the risk of serious complications.OBJECTIVE:To study the implications and the therapeutic approach regarding small bowel diverticulosis.METHODS:The medical records of 54 patients with diverticular disease of the small bowel, including Meckel's and duodenum diverticula, were retrospectively reviewed. The mean age of the 32 male and 22 female patients was 53.2 years.RESULTS:Diverticula were found in the duodenum in 11 cases, in the jejunum and ileum in 21 cases, and with Meckel's diverticula in 22 cases. In 24% of the patients the diverticula were multiple. The most common clinical symptom was abdominal pain, in 44.4%. Most of the duodenum diverticula were asymptomatic; 47.6% of the patients with diverticular disease located in the jejunum and ileum presented with chronic symptoms. The overall diagnostic rate for symptomatic diverticula before surgery was 52.7%; in 33.3% diverticula were found incidentally during other diagnostic or therapeutic procedures. Forty-one patients were managed surgically. 15 patients were operated on urgently because of infection or rupture, 4 patients for bleeding, 5 patients for intestinal obstruction, and one patient for jaundice.CONCLUSIONS:The incidence of asymptomatic small bowel diverticula is difficult to ascertain. Patients with Meckel's and duodenal diverticula are usually asymptomatic, while the majority of jejunal and ileal diverticula patients present with chronic symptoms. The pre-operative diagnostic rate is higher for duodenal diverticula. Small bowel diverticula do not require surgical treatment unless refractory symptoms or complications occur.