Enlarged Para-aortic Lymph Nodes Research Articles

Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen.

Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement.

The Role of Pretreatment FDG-PET in Treating Cervical Cancer Patients With Enlarged Pelvic Lymph Node(s) Shown on MRI: A Phase 3 Randomized Trial With Long-Term Follow-Up

This report is the second analysis of a prospective randomized trial to investigate the impact of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) on cervical cancer patients with enlarged pelvic lymph nodes identified by magnetic resonance imaging. Patients with newly diagnosed cervical cancer with enlarged pelvic lymph nodes but free of enlarged para-aortic lymph nodes (PALN) were eligible. Patients were randomized to receive either pretreatment FDG-PET (PET arm) or not (control arm). The whole pelvis was the standard irradiation field for all patients except those with FDG-avid extrapelvic findings. In all, 129 patients were enrolled. Pretreatment PET detected extrapelvic metastases in 7 patients. No new patient experienced treatment failure during the additional 4-year follow-up period. There were no significant differences between the PET arm and the control arm regarding overall survival, disease-free survival, and freedom from extrapelvic metastasis. In the control arm, 8 of 10 patients with PALN relapse had limited extrapelvic nodal failures; their 5-year disease-specific survival was 34.3%. By contrast, only 1 of 5 patients with PALN relapse in the PET arm experienced such limited failures; their 5-year survival rate was 0%. Although the pretreatment detection of PALN did not translate into survival benefit, it indeed decreased the need for extended-field concurrent chemoradiation therapy.

Multiplelymphomatous Polyposis : A Rare Type of Primary Diffuse Gastrointestinal Non - Hodgkin's Lymphoma = الزوائد اللمفاوية المتعددة : نوع نادر من أنواع السرطانات الأولية و الشاملة الغير هوجكنية للغدد اللمفاوية للجهاز الهضمي

Multiplelymphomatous polyposis (MLP) is a rare form of intestinal mantle cell lymphoma(MCL), few cases were reported in the literature especially female cases. A 58 years old female was thoroughly investigated for her recurrent attacks of bleeding per-rectum associated with anemia, weight loss, low grade fever and mild generalized abdominal pain. Gastroscopy and colonoscopy showed multiple variable sized polyps at the lower esophageal, gastric, duodenal, and colonic mucosa. Ultrasound, computerized tomography of abdomen and diagnostic laparoscopy were done and revealed multiple bilateral pelvic, para-aortic, mesenteric and cecal lymph node enlargement. Histopathology with immunochemical staining were compatible with diagnosis of mantle cell lymphoma with wide spread gastrointestinal involvement (multiple lymphomatous polyposis). On follow up the patient showed good response to remedies with Rituximab-Cyclophosphamide, Doxorubicin, Vincristine, and Prednisolone (R-CHOP). Involvement of nearly entire gastrointestinal tract by MLP is a rare variety of mantle cell lymphoma, the combination therapy of R-CHOP is encouraging and feasible 18 months after initiation of treatment and follows up.

Intra-abdominal Testicular Seminoma

A 49-year-old man married with five children, with no known previous complaint presented to the surgical unit at University Charity Teaching Hospital with complaints of abdominal swelling for 4 months. He had been suffering from anorexia, weight loss during last two months. The patient experienced dragging pain in the hypogastrium during the last two months. On general examination the patient was found to be ill looking and mildly anemic. On local examination an intraabdominal mass was palpable. The abdominal mass was elongated occupying the whole right iliac fossa and extending into the hypogastrium (12 cm x 8cm approximately). The margins were ill defined, surface was irregular and consistency was hard. The lump was fixed with underlying structures and not tender. On examination of the inguinoscrotal region the left testis was found to be in place but the right testis was absent from the left scrotal sac. Our provisional diagnosis was malignant tumor of the right intraabdominal testis. Investigations showed elevated alkaline phosphatase and B-HCG. Sperm analysis and alpha feto protein were within normal ranges. The CT scan showed a huge solid mass arising from the pelvis with calcification, no liver lesions or para-aortic lymph node enlargement (Figure 1A). We went for laparotomy with lower midline incision and found a huge growth occupying the hypogastrium and the right iliac fossa (Figure 1B). The mass was inoperable. The histopathological examination revealed spermatocytic seminoma (Figure 1C). The location of the undescended testis is identified with the probability of carcinogenesis with the intra-abdominal position having the highest risk for malignancy. Painless enlargement of the testis is the common presentation of malignancy in an undescended testis. Rarely, an abdominal testicular tumor can cause abdominal pain, abdominal mass, and haematuria because of adjacent visceral infiltration [1]. Seminomas tumors are extremely sensitive to chemotherapy and radiotherapy [2].

Laparoscopic Left Partial Adrenalectomy in a Child with Von Hippel–Lindau and Recurrent Pheochromocytoma

Introduction: Patients with Von Hippel–Lindau are at high risk of developing recurrent pheochromocytoma. In this 13-year-old patient status post right adrenalectomy with recurrence on the left, we hypothesized that a laparoscopic left partial adrenalectomy would be safe and effective at removing the tumor while preserving native adrenal function.1,2 This video includes a description of the patient's case and illustrates the key portions of his procedure, including complete removal of the tumor and preservation of the renal and adrenal blood supply. Methods: Although asymptomatic, surveillance abdominal ultrasound demonstrated enlarged paraaortic lymph nodes. Follow-up serum catecholamine was elevated, and abdominal computed tomography demonstrated a mass arising from the inferior aspect of the left adrenal gland. Preoperative alpha- and beta-blockade were undertaken. He presented electively on the day of surgery and underwent a laparoscopic left partial adrenalectomy. Key portions of the procedure include mobilization of the splenic flexure, circumferential dissection of the tumor with preservation of the renal vein, renal artery, and the adrenal vein, and separation of the tumor from normal residual adrenal gland.3 Results: Final pathology demonstrated complete resection and was consistent with a 2.6×2.3×1.9 cm pheochromocytoma with intact capsule. Postoperatively, the patient recovered well, with no complications and no requirement for cortisol replacement. He was discharged home on postoperative day 2. He will continue to be followed by his endocrinologist for annual screening. Conclusions: The technique for laparoscopic partial left adrenalectomy described here has utility in the pediatric population to preserve adrenal function during years of growth. Patients with Von Hippel–Lindau are at high risk of recurrence and need continued surveillance.4 This patient will continue to benefit from preserved native adrenal function for months to years before potential recurrence. The authors have nothing to disclose. There are no potential conflicts exist with any of the authors with this publication. Runtime of video: 4 mins 43 secs

Intraoperative diagnosis by frozen section study would prevent unnecessary surgery in ovarian Burkitt′s lymphoma

Sir, Ovarian Burkitt's lymphoma is a rare form of malignant ovarian tumors accounting for 1% of all ovarian neoplasms.[1,2,3] It has been reported as a cause of ovarian torsion.[4] Herein, we briefly report a case of bilateral ovarian Burkitt's lymphoma in a 29-year-old woman presenting with vague suprapubic pain and abdominal distension. On physical examination, a rather large midline pelvic mass with abdominal extension was palpated. Serum beta hCG was negative and serum CA-125 level was within normal limits. Ultrasonography revealed homogenous and slightly echogenic large lobulated masses in both adnexae, each measuring approximately 10 cm in diameter. Pelvic and abdominal computed tomography confirmed the ultrasound findings and also detected enlarged paraaortic lymph nodes. The clinicoradiologic features of the tumor mimicked a primary malignant ovarian epithelial neoplasm despite the normal serum CA-125 level, and the patient became candidate for surgery. At surgery, peritoneal deposits and partial involvement of small intestine were also detected. The patient underwent surgical removal of the ovarian masses, paraaortic lymph node dissection, and peritoneal sampling. Permanent pathology revealed the ovarian masses to be Burkitt's lymphoma with the involvement of paraaortic lymph nodes and peritoneal seedings. The diagnosis was further confirmed by immunohistochemistry showing positive reactivity with leukocyte common antigen (LCA) and CD20 and CD10 markers. Following surgery, the patient underwent chemotherapy for Burkitt's lymphoma. However, an appropriate intraoperative management and diagnosis using tumor sampling and frozen section study would have avoided extensive and unnecessary surgery in this case. In fact, what made us consider extensive surgery was the presence of bilateral ovarian masses with diffuse peritoneal deposits and paraaortic lymphadenopathy, leading to an erroneous impression of primary malignant ovarian tumor originating from the surface epithelium. The main treatment of ovarian lymphoma is chemotherapy, and the overall prognosis of the tumor is good.[5,6] Spontaneous conception with live birth outcome has been reported following gonadotoxic chemotherapy for bilateral Burkitt's lymphoma.[7] The role of surgery is in question and debatable with the present available chemotherapeutic agents.[1] We do emphasize that, although rare, ovarian lymphoma should be considered in the differential diagnosis of advanced ovarian neoplasms, especially bilateral tumors in young women. Appropriate intraoperative management prevents unnecessary surgery in these cases.

Analysis of 30 patients with persistent or recurrent squamous cell carcinoma of the cervix within one year after concurrent chemoradiotherapy.

ObjectiveTo investigate the recurrence sites, risk factors, and prognosis of patients with persistent or recurrent squamous cell carcinoma (SCC) of the cervix within one year after undergoing concurrent chemoradiotherapy (CCRT).MethodsClinical data of 30 patients with persistent or recurrent SCC of the cervix within one year after CCRT between July 2006 and July 2011 were analyzed retrospectively. These data were compared with those of 35 SCC cases with no signs of recurrence after complete remission. These 35 patients were treated during the same period (between 2006 and 2011) and selected randomly.ResultsAmong these 30 patients, 25 exhibited distant metastases of which 14 were observed within 6 months after CCRT. Univariate analysis showed higher incidence of pelvic or para-aortic lymphadenectasis and SCC-ag >10 ng/mL in the group with persistent or recurrent disease before treatment (P<0.01). Multivariate analysis by logistic regression revealed that the pre-therapeutic pelvic or para-aortic lymph node enlargement and SCC-ag >10 ng/mL were the independent risk factors. Palliative chemotherapy was the main treatment option for patients with persistent or recurrent disease. The 2-year survival rate was 21.7%, and the median survival time was 17 months.ConclusionPatients with persistent or recurrent SCC of the cervix after CCRT exhibited a high rate of distant metastasis with poor prognosis. The pre-therapeutic pelvic or para-aortic lymph node enlargement and SCC-ag >10 ng/mL were identified as the independent risk factors for persistent or recurrent SCC within 1 year after CCRT.

Anti-HER2 combination chemotherapy for advanced gastric cancer associated with the Peutz-Jeghers syndrome: a case report and literature review

Peutz-Jeghers syndrome (PJS) is an autosomal dominant genetic syndrome characterized by gastrointestinal hamartomatous polyposis. Malignant transformation of the polyp is rare, but the incidence of various cancers, including digestive organ cancers, is high in affected patients. A 26-year-old male who had been diagnosed with PJS in infancy developed abdominal pain and was diagnosed with gastric cancer. Computed tomography revealed enlarged para-aortic lymph nodes and lung metastasis. HER2 overexpression was confirmed by immunohistochemistry. Combination chemotherapy, consisting of capecitabine, cisplatin and trastuzumab, was administered. The patient had stable disease for 7 months but died of the gastric cancer 14 months after diagnosis. Trastuzumab might inhibit mTOR by blocking HER2 signaling, but PJS often has a germ-line genetic alteration of LKB1 (also called STK11), causing mTOR activation. Analysis of the clinical efficacy and safety of trastuzumab for patients with gastric cancer and PJS traits would be of benefit.

Metastatic prostate cancer with elevated serum levels of CEA and CA19-9

Prostate-specific antigen (PSA) is well known as a specific tumor marker for prostate cancer, but carcinoembryonic antigen (CEA)- and carbohydrate antigen 19-9 (CA19-9)-elevating adenocarcinomas originating in the prostate gland are rare. We report a case of metastatic adenocarcinoma of the prostate gland with a high serum level of CEA and CA19-9 in a 78-year-old man in whom prostate cancer (T3N1M1) had been diagnosed 2 years ago and who was treated with androgen deprivation therapy. He visited the emergency department because of a loss of appetite and abdominal pain. The serum CEA and CA19-9 levels were increased to 218.9ng/mL (normal, <5ng/mL) and 212ng/mL (normal, <27ng/mL), respectively. The serum PSA level was slightly elevated (4.41ng/mL). Computed tomography demonstrated multiple liver metastases, para-aortic lymph node enlargement, and lung metastases. A liver biopsy was performed and the specimen showed high-grade adenocarcinoma with focal positive staining for PSA. Despite chemotherapy with docetaxel, the patient died 3 months after treatment. Based on this case and a review of the literature, an aggressive variant of prostatic carcinoma with a high serum level of CEA and CA19-9 and a low PSA level was shown to progress rapidly with a poor prognosis.

Unremitting pyrexia, pancytopenia, hepatosplenomegaly, and extreme hyperferritinemia

Unremitting pyrexia, pancytopenia, hepatosplenomegaly, and extreme hyperferritinemia

Perihepatic lymph node enlargement observed at a general health examination: A cross‐sectional study

Although perihepatic lymph node enlargement (PLNE) is known as a common finding in chronic liver disease, it can be found occasionally at a general health examination. We aimed to clarify the clinical significance of PLNE in general. Between January 2008 and December 2011, 4234 subjects were enrolled, who underwent a general health examination at the University of Tokyo Hospital. PLNE was observed in 69 (1.6%) subjects, among whom 17 (0.4%) had liver disorders and 13 (0.3%) had malignancy, one of whom had both. No disorders were determined in the remaining 40 subjects (0.9%). Among 17 subjects with liver disorder-associated PLNE, anti-hepatitis C virus (HCV) antibody was determined in 11 and serum alanine aminotransferase levels were less than 40 U/L in eight. Among 13 subjects with malignancy-associated PLNE, para-aortic lymph nodes were also enlarged in eight. Among 40 subjects with PLNE of unknown etiology, 27 could be followed up for the mean period of 2.08 years, where no underlying disorders were newly determined with largely unaltered size of PLNE. The incidence of PLNE in the general population may vary with the prevalence of chronic liver disease, especially HCV infection. When PLNE is observed, liver disorders should be first surveyed including HCV infection even with normal serum alanine aminotransferase levels. PLNE with para-aortic lymph node enlargement may be suggestive of a malignant lesion. The incidence of PLNE of unknown etiology may be approximately 1% in the general population, which may be just followed up without further change.

A CASE OF TUBERCULOUS PSOAS ABSCESS SUCCESSFULLY TREATED WITH SURGERY DURING ANTITUBERCULOSIS THERAPY FOR MILIARY TUBERCULOSIS

A case of tuberculous psoas abscess complicated during antituberculosis therapy for miliary tuberculosis and successfully treated with surgery was reported. A 20-year-old man visited our hospital because of fever lasting for 3 months. Chest radiography showed miliary nodules in both lungs and transbronchial lung biopsy revealed granuloma. Magnetic resonance imaging of the head showed small lesions in the brain. Computed tomography of the abdomen showed an enlarged paraaortic lymph node and a nodule in the spleen. Needle biopsy of the lymph node revealed necrotic tissue. Mycobacterium tuberculosis was not isolated; however, miliary tuberculosis was highly suspected based on clinical and radiographic findings. Once antituberculosis therapy was initiated with isoniazid, rifampicin, streptomycin, and pyrazinamide, the fever subsided. In spite of improvement of general radiographic findings, a new abscess was found in the right psoas major muscle after 8 months of therapy by computed tomography. A sample of the abscess showed a positive smear, negative culture, and positive PCR test for M. tuberculosis. Although antituberculosis therapy continued for another 6 months, the abscess enlarged to 7 cm and new retroperitoneal lymph nodes also appeared. Surgical drainage and curettage of the abscess was performed. Intra- and post-operative specimens were negative for bacteria, fungi, and M. tuberculosis. The patient was treated with isoniazid, rifampicin, and ethambutol for one year postoperatively. The disease disappeared without any evidence of relapse for 2.5 years after surgery.

Endometriosis in para-aortic lymph nodes during pregnancy: case report and review of literature

To report a case of endometriosis in para-aortic lymph nodes during pregnancy. Case report. Tertiary care center. A 25-year-old multipara pregnant woman with a history of chronic pelvic pain and ovarian cystectomies for bilateral endometriomas. The patient was admitted with a placenta previa and a subchorionic hemorrhage at 24 weeks 5 days' gestation, and subsequently developed uterine contractions. Magnetic resonance imaging revealed a large complex adnexal mass adherent to the uterus and pelvic and para-aortic lymphadenopathy. Tocolysis could not be achieved and the patient underwent cesarean delivery at 26 weeks 3 days. An implant on the uterus and an enlarged para-aortic lymph node were removed surgically at that time. Involvement of lymph node by endometriosis and presence of a recurrent endometrioma. Endometriosis was confirmed pathologically in para-aortic lymph nodes. Uterine serosal biopsy demonstrated endometriosis, and the large adnexal cyst was grossly consistent with endometrioma. The patient delivered a viable male infant at 26 weeks 3 days. To our knowledge, this is the first reported case of endometriosis in para-aortic lymph nodes. Its presence supports the hypothesis that endometriosis travels lymphatically, and not simply via locoregional spread. Lymphatic spread also further supports the theory that endometriosis is an aggressive chronic systemic disease.

Lymph Node Staging by Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in Patients With Small Cell Lung Cancer

Surgical treatment of small cell lung cancer (SCLC) is limited to stage I disease. Therefore, accurate lymph node staging is mandatory in SCLC patients. The purpose of this study was to evaluate the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for the evaluation of mediastinal and hilar lymph node metastasis in patients with SCLC. Forty patients with untreated SCLC who underwent EBUS-TBNA for lymph node staging between November 2002 and September 2008 were retrospectively analyzed. The convex probe endobronchial ultrasonography was used for EBUS-TBNA. Lymph nodes assessed by the convex probe endobronchial ultrasonography were aspirated until EBUS-TBNA revealed malignant cells by rapid on-site cytology. Endobronchial ultrasound-guided transbronchial needle aspiration was successfully performed in all patients, and revealed lymph node status as follows: N0, 13 cases; N1, 5 cases; and N2, 22 cases. Among the 13 N0 cases, 9 patients underwent surgery, whereas 4 patients did not undergo surgical intervention because of enlargement of subaortic or paraaortic lymph nodes (stations 5 and 6) that precluded EBUS-TBNA assessment (n = 3) or poor performance status (n = 1). Pathologic examination of dissected nodes confirmed an N0 diagnosis in 8 patients, whereas 1 patient had hilar lymph node metastasis (N1). The sensitivity, specificity, and diagnostic accuracy rate of EBUS-TBNA were 96.4%, 100%, and 97.2%, respectively. The overall 5-year survival rate for the 9 patients who underwent surgery was 77.8%. Endobronchial ultrasound-guided transbronchial needle aspiration has a high diagnostic yield for the evaluation of mediastinal and hilar lymph node metastasis in SCLC and has a high impact on patient management.

Retroperitoneoscopic para-aortic lymph node sampling in bladder rhabdomyosarcoma

Determining lymph node involvement is an important step in the pre-treatment evaluation of non-metastatic rhabdomyosarcoma. We describe retroperitoneoscopy for para-aortic lymph node biopsy in a 4-year-old boy with embryonal rhabdomyosarcoma of the bladder with pelvic and para-aortic lymph node enlargement on magnetic resonance imaging. This technique affords access to the para-aortic region with minimal dissection, permitting quick recovery and early commencement of chemotherapy.

Primary renal lymphoma

A 55-year-old woman presented with low grade fever and frequent night sweating of one month’s duration. Laboratory data showed severe anaemia (haemoglobin: 74 g/l) with low reticulocyte count 67AE54 · 10/l (2AE2%) and elevated lactate dehydrogenase (1174 U/l) without leukocytosis (white blood cell count: 6AE56 · 10/l). There was no history or evidence of recent blood loss. Microbiological studies and immunological profiles were unremarkable. Abdominal computed tomography with contrast enhancement (left figure) demonstrated a heterogenous hypodense renal tumour occupying the right renal sinus. In addition, right renal vein encasement and inferior vena cava invasion (arrow) were noted, accompanied by multiple enlarged para-aortic lymph nodes (arrow heads). Doppler sonography (right figure) showed a hypovascular mass (arrow heads) with surrounding hydrocalyces (arrows). Tissue sampling was achieved by open laparotomy. Histopathology with immunochemical staining revealed a diffuse large B-cell lymphoma with positive CD20 expression, confirming the diagnosis of primary renal lymphoma. One month after rituximab-based chemotherapy, the patient became apyrexial with concurrent regression of the renal tumour. Primary renal lymphoma is rare and may present with acute renal failure of flank pain or as an incidental renal mass. Typical image findings on a colour Doppler ultrasound consist of a hypoechoic mass with hypovascularity, in contrast to the hypervascular pattern of most renal cell carcinomas. Most primary renal lymphomas are highly chemo-sensitive as demonstrated in this case.

Diagnostic value of intraoperative ultrasonography to assess para‐aortic lymph nodes in women with ovarian and uterine corpus malignancy

To examine the ability of intraoperative ultrasonography to detect enlarged para-aortic lymph nodes, and to assess its potential use in reducing the number of unnecessary para-aortic lymphadenectomies performed in women with ovarian and uterine corpus malignancies. Computed tomography (CT), palpation during surgery, and intraoperative ultrasonography were used to assess whether para-aortic lymph nodes were enlarged in 163 women with ovarian and uterine corpus malignancy. All the women underwent para-aortic lymphadenectomy, and nodes were assessed for metastasis. Thirty-five women had pathological para-aortic node metastasis. The sensitivity, specificity, and positive and negative predictive values of CT for the diagnosis of metastasis were 42.9, 96.1, 75.0 and 86.0%, respectively. These values were 60.0, 82.0, 47.7 and 88.2% for palpation, and 91.4, 69.5, 45.1 and 96.7% for intraoperative ultrasonography, respectively. If para-aortic lymphadenectomy had been performed only when enlarged lymph nodes were detected on CT then the number performed would have been reduced from 163 to 20 (12.3%); however, node metastasis would have been missed in 20 out of 35 women. On the same basis, the number of lymphadenectomies performed would have been 44 (27.0%) and metastasis would have been missed in 14 women on palpation during surgery, and 71 lymphadenectomies (43.6%) would have been performed and metastasis would have been missed in three women on intraoperative ultrasonography. Intraoperative ultrasonography is a highly sensitive tool with which to diagnose lymph node metastasis. Its high negative predictive value allows avoidance of unnecessary para-aortic lymphadenectomy in women with ovarian and uterine corpus malignancy.

Ulcerative Jejunoileitis – An Uncommon Cause of Gastrointestinal Bleeding and Adenopathy

A 66 year old man presented for unexplained gastrointestinal bleeding. He had noticed bright red blood per rectum and had a syncopal event upon getting up from the toilet. His initial evaluation included an EGD and a colonoscopy without any significant findings. He required 5 units of blood and was discharged and sent to Boston University Medical Center for a small intestinal evaluation. Of note, he was noticed to have a 45 pound weight loss over the prior months and he had an albumin of 2.7 g/dl. His past medical history was significant for hypertension, coronary artery disease and diabetes, and he was not taking any NSAIDs. On exam, he was tender at a site of fullness in the right lower quadrant. His laboratory evaluation revealed an elevated WBC of 11.6 and ESR of 87 with a normal tTG and IgA level and HIV negative. A CT enterography was performed showing multiple enlarged paraaortic lymph nodes up to 2.6 cm. Additional prominent less than one centimeter lymph nodes were noted within a region of swirling mesentery anterior to the pancreas. Concentric wall thickening was noted in multiple loops of the distal ileum and less so in some loops of jejunum. The patient underwent a CT-guided lymph node biopsy. The pathology, flow cytometry and PCR of the lymph node biopsy were inconclusive (non-specific inflammation). All other laboratory cell-typing evaluations for lymphoma were negative. Without a definitive diagnosis, a capsule endoscopy was performed and demonstrated multiple ulcerations scattered throughout the small intestine. The proximal ulcerations were within the reach of a push enteroscope and were biopsied. The pathology was inconclusive (normal small bowel mucosa). The patient underwent a CT/PET scan that was essentially negative except for a mild uptake presumed to be from the jejunal biopsies. After another bleeding episode, the patient was taken to the operating room. An area of significant ileal inflammation and adjacent adenopathy was easily identified and was resected laparoscopically. Pathology demonstrated mucosal ulcerations with reactive adenopathy without granulomata, lymphproliferative disease or carcinoma, suggestive of primary ulcerative jejunoileitis. Ulcerative jejunoileitis is a rare disease entity and can be seen without the presence of associated celiac disease. The significance of the adenopathy, weight loss, and hypoalbuminemia suggested a neoplastic process that required an operation to make a definitive diagnosis.

A phase II study of neoadjuvant chemotherapy with docetaxel, capecitabine and cisplatin (DXP) in patients with advanced unresectable or intra-abdominal metastatic gastric cancer

4640 Background: The prognosis of gastric cancer is dismal once R0 resection is impossible due to local invasion or distant metastasis. Previous studies have suggested the possible efficacy of neoadjuvant chemotherapy for the patients with locally advanced gastric cancer (AGC). The aim of the present study was to evaluate the feasibility, the impact on R0 resection of neoadjuvant chemotherapy in locally advanced, unresectable or intra-abdominal metastatic gastric cancer Methods: Patients with advanced gastric cancer, clinically unresectable because of local invasion or intra-abdominal metastasis in paraaortic lymph nodes and/or peritoneum based on CT scan were entered into this study. Preoperative chemotherapy consisted of docetaxel 60 mg/m2 IV on day 1, cisplatin 60 mg/m2 IV on day 1, and capecitabine 1,875 mg/m2/day PO on days 1 - 14 every 21 days. After 2 cycles of chemotherapy, the tumors were evaluated. Unless disease progression was encountered, surgery was performed after total 3 - 6 cycles of chemotherapy and followed by two cycle of adjuvant therapy with the same regimen if R0 resection was done. Results: Total 49 patients were accrued. Among them, 36 (74%) could undergo surgery, and 31 (63%) had R0 resection. R0 resection was possible in 15 (71%) of 21 patients with initially unresectable T4 lesions and in 12 (70%) of 17 patients with paraaortic lymph node enlargement, while only in 3 (42%) of 7 patients with suspicious peritoneal seeding. After a median follow up of 18.2 months for the surviving patients, median overall survival and progression free survival of total enrolled patients were 19 months (95% C.I, 10.5 - 27.4) and 11.6 months (95% C.I, 9.6 - 13.7), respectively. Among 31 patients who underwent R0 resection, median OS was 33.4 months and median PFS was 18.2 months. Major toxicity was neutropenia and grade 3/4 neutropenia occurred in 77% of patients, but there was only 4% of neutropenic fever and no treatment related mortality. Postoperative morbidities were observed in 4 patients. Conclusions: These data suggested that neoadjuvant DXP chemotherapy could offer a reasonable chance for curative surgery in AGC patients with local invasion or paraaortic lymph node enlargement. No significant financial relationships to disclose.

Bladder paraganglioma with a calculus: A case report

A 2×1.5 cm tumor was found at the left wall 2 cm above left ureteric orifice during cystoscopy. The patient then received a partial cystectomy under general anaesthesia. No other tumors or paraaortic lymph node enlargement were found. The post-operative period was uneventful and her blood pressure recovered to normal after operation (123/76 mmHg). Histological examination: small round cells showed a solid proliferation. The tumor cells were multilateral or round, full of hobby red Iraq graininess in the cytoplasm, a vacuole like nucleus and less nuclear disruption. There was a large number of capillary vessels in the mesenchyme. Immunohistochemical results showed that vimentin and keratin staining were negative. However, chromogranin A、synaptophysin and NSE were positive. Paraganglioma, pheochromocytoma or chromo-receptor tumors, originate from the paraganglion and have a high hereditary component. They usually occur in the neuroendocrine system from the