Clinical Case Summary

A 48-year-old man with a history of symptomatic hemorrhoids diagnosed a years earlier, complained of new intermitent rectal bleeding in the last month. We decided to do a colonoscopy were we found a pedicled polyp with a head of about 15mm with blackish areas on the anopectineal line and with blackish dots in the arising region (image 1-2). Biopsies gave us the diagnosis of melanoma (immunohistochemistry s-100 and Melan-A positive, cytokeratin AE1/AE3 and CD 117 negative). PET-CT was performed with intense uptake of the radiotracer in the same place, without pathological adenopathies (image 3). This case was discussed in a multidisciplinary session, and taking into account the age of the patient and the doubts of the depth and the existence of satellitosis, we decided to make a surgical treatment (abdominoperineal amputation) with a laparoscopic gamma camera. The pathological anatomy was conclusive with melanoma of the rectal mucosa (tumor thickness 1.5cm) without satellite nodules or affected lymph nodes.
Anorectal melanoma (AM) is a rare neoplasm, accounting for <1% of anorectal malignancies and around 1-2% of all melanomas. The treatment is based on surgery (local or radical), it is resistant to chemotherapy and the role of radiotherapy is highly controversial.
It is a highly lethal disease that reappears in 80% of cases after surgery, with a 5-year survival of 12-15% (30 months if the tumor does not exceed the muscularis propria or 22 months if it exceeds it, even though there is no locoregional lymphadenopathy or distant metastases).
AM, can be pigmented or not, flat, polypoid or ulcerated being easily mistaken with a thrombosed hemorrhoid. The symptoms may also be similar; such as rectal bleeding, pain, pruritus, tenesmus, or change in bowel habits. To mistake AM with hemorrhoids showed a negative impact in survival patients with AM, which reflects the importance of not trivializing the anorectal symptoms and perform a good clinical and endoscopic inspection.

References

-José Donizeti de Meira Júnior, B , C , E , F Lucas Faraco Sobrado, D , E Vivian M. Guzela, et al. Anorectal Mucosal Melanoma: A Case Report and Literature Review. Am J Case Rep. 2021; 22: e933032-1–e933032-5.
-Huang WF, Wang X, Liu W.Primary Malignant Anorectal Melanoma. J Gastrointest Surg. 2022 Jan;26(1):263-265
-Reina A, Errasti J, Espin E. Melanoma anorrectal. Revisión de conjunto. Cir esp. 2014; 92(8):5 1 0 – 5 1 6
-Nigam JS, Nishit, Kumar T, Singh A, et al Tewari P.Anorectal Melanoma-Brownish Black Mass Not Always a Hemorrhoid. J Gastrointest Cancer. 2022 Sep;53(3):825-829

Disclosure

I have no conflicts of interest

Clinical Case Summary

SARS-COV2 infection has accumulated more than 670 million cases since its onset in 2019. Its clinical spectrum varies from asymptomatic patients to bilateral pneumonia with a mortality rate of 1%. Digestive symptoms include nausea, abdominal pain and diarrhea. Multiple complications as hepatitis, pancreatitis, cholecystitis, mesenteric ischemia or venous thrombosis have also been described.
We present the case of a 60-year-old woman who came to ER for abdominal pain. A CT showed acute cholecystitis with a 30mm liver abscess and choledocholithiasis. It was treated with empirical Piperacillin-Tazobactam, thromboprophylaxis and drainage by ERCP. During admission the patient presented bilateral SARS-COV2 pneumonia requiring Dexamethasone and Remdesivir. Due to the reappearance of abdominal discomfort, an US was performed showing a new left portal thrombosis. Given these findings, a coagulation study was performed, with no genetic or cytological alterations. Finally it was decided to maintain antibiotic for 6 weeks and anticoagulation, performing outpatient US control, with deferred surgical treatment.
The portal thrombosis is a complication mostly related to chronic liver diseases and hepatic tumors, being much rarer the septic portal thrombophlebitis associated with abdominal infections or related to proliferative neoplasms. On the other hand, SARS-COV2 infection triggers an inflammatory reaction after binding to ACE-II receptor that leads to a generalized prothrombotic environment. In relation to this process, PTE, DVT and in multiple other locations has been described. One of the the most infrequent locations is abdominal, with very few cases described in the literature.
The scarce clinical repercussion of portal thrombosis and the serious complications derived from it, added to the high prevalence of SARS-COV2, means that we should early rule out this process in patients with abdominal infections with regular evolution and active or recent SARS-COV2 infection.

Clinical Case Summary

Common variable immunodeficiency (CVID) is the most common symptomatic primary immunodeficiency in clinical practice. These patients have up to 50 times higher risk of developing cancer in comparison to the general population, with gastric adenocarcinoma being the leading cause of death in this population.
We describe a case of a 33-year-old woman with a history of CVID and Addison's disease, who was admitted for upper gastrointestinal hemorrhage with hemodynamic instability refractory to combined endoscopic hemostasis (noradrenaline, hemoclips, thermocoagulation and hemostatic spray) after partial resection of a 40 mm semipediculated gastric polyp (figures 1,2), finally requiring selective arterial embolization to control bleeding. Histological and immunohistochemical studies revealed gastric adenocarcinoma HER2+ with conserved expression of proteins encoded by DNA repair genes.
Multiple studies have demonstrated a dysfunctional immune system at the level of the non-neoplastic gastric mucosa of these patients, characterized by high rates of CD4+, CD8+, Foxp3+, GATA3+, PD-L1 and low numbers of CD20+ B-lymphocytes and CD138+ plasma cells compared to individuals without CVID. In addition, the expression of GATA3+ by cytotoxic T lymphocytes is identified in the literature as a mechanism for tumor escape from immunological surveillance and T-cell depletion. On the other hand, few studies have focused on analyzing the monogenic causes of CVID. This could be an interesting field of study since genes, such as NF-Kb1 deficiency, which is the most common monogenic cause of CVID, have in turn been directly related to the pathogenesis of gastric cancer in individuals without CVID. All this is very important when it comes to being able to stratify our patients according to the risk of developing malignant gastric pathology in order to establish standardized screening recommendations and to be able to carry out individualized follow-ups in order to detect premalignant lesions.

References

Bruns L, Panagiota V, von Hardenberg S, et al. Common Variable Immunodeficiency-Associated Cancers: The Role of Clinical Phenotypes, Immunological and Genetic Factors. Front Immunol. 2022;13:742530. Published 2022 Feb 17.
Pecoraro A, Crescenzi L, Varricchi G, Marone G, Spadaro G. Heterogeneity of Liver Disease in Common Variable Immunodeficiency Disorders. Front Immunol. 2020;11:338. Published 2020 Feb 28. doi:10.3389/fimmu.2020.00338
Pikkarainen S, Martelius T, Ristimäki A, Siitonen S, Seppänen MRJ, Färkkilä M. A High Prevalence of Gastrointestinal Manifestations in Common Variable Immunodeficiency. Am J Gastroenterol. 2019 Apr;114(4):648-655.
Pulvirenti F, Pecoraro A, Cinetto F, et al. Gastric Cancer Is the Leading Cause of Death in Italian Adult Patients With Common Variable Immunodeficiency. Front Immunol. 2018;9:2546. Published 2018 Nov 5.
Gullo I, Costa C, Silva SL, et al. The Dysfunctional Immune System in Common Variable Immunodeficiency Increases the Susceptibility to Gastric Cancer. Cells. 2020;9(6):1498. Published 2020 Jun 19.

Introduction

Endoscopic submucosal dissection (ESD) and transanal minimally invasive surgery (TAMIS) are considered standard of care minimally invasive local en bloc resection techniques for larger benign rectal polyps and early-invasive rectal cancer. To optimize post-procedural care for patients, it is important to obtain more insight in the post-procedural physical recovery of both techniques.

Aims & Methods

This is an ancillary study of the multicenter non-inferiority randomized TRIASSIC-trial (Netherlands Trial Register: NL7083) that compares the outcomes of ESD and TAMIS for large (≥20mm) rectal polyps (1). Patients were 1:1 randomized between ESD or TAMIS and monitored with a smartwatch during a 14-day baseline period prior to resection and a 28-day post-procedural recovery period. A mixed-effects model was fitted for physical activity to describe the recovery period. Recovery was defined as reaching ≥90% of the baseline step-count for 2 consecutive days. If patients did not meet this pre-defined definition of recovery within 28 days post-treatment, a recovery time of 30 days was used in the analyses. This study analyzed subjective time to recovery through an end-of-study questionnaire and post-procedural pain through a self-reported pain diary.

Results

A total of 40 patients were included (20 ESD, 20 TAMIS). The mean age was 66.7 years (SD 7.4), 57.5% was male, and median polyp size was 42.5mm (IQR 25). Histological assessment showed a benign polyp in 82.5% and early-stage T1 rectal cancer in 17.5%. Seventeen patients (85%) in the ESD group and 15 patients (75%) in the TAMIS group were physically recovered within the 28-day post-procedural recovery period (p=0.43). The median time to physical recovery was 6.5 days (IQR 18) after ESD and 14.5 days (IQR 21.3) after TAMIS (p=0.022). Subjective time to recovery was 1-2 weeks in 47.5%, 3-4 weeks in 17.5%, and 32.5% did not feel completely recovered within 28 days. There was a significant correlation (Spearman’s rho = 0.66, p<0.001) between the physical (smartwatch) and subjective (end-of-study questionnaire) time to recovery. Post-procedural pain scores in the first week were similar between ESD and TAMIS (p=0.86) and were significantly associated with patients’ level of physical activity (p<0.01); for each point increase in the pain score total step count compared to baseline decreased by 14% after both ESD (95%CI 4-22%) and TAMIS (95%CI 5-22%). Additionally, higher post-procedural pain scores were significantly associated with a prolonged time to recovery (p=0.001). Other factors that were significantly associated with a prolonged time to physical recovery were polyp diameter ≥4cm (only in the ESD group; p=0.003), polyp located ≤1cm from the dentate line, and female sex (only in the TAMIS group, p=0.02 and p=0.03, respectively)

Conclusion

ESD-treated patients have a shorter physical recovery time of ~1 week as compared to ~2 weeks for TAMIS-treated patients. Post-procedural pain is a potentially modifiable factor that significantly influences physical activity and time to physical recovery after ESD and TAMIS.

References

1. Dekkers N, Boonstra JJ, Moons LMG, Hompes R, Bastiaansen BA, Tuynman JB, et al. Transanal minimally invasive surgery (TAMIS) versus endoscopic submucosal dissection (ESD) for resection of non-pedunculated rectal lesions (TRIASSIC study): study protocol of a European multicenter randomised controlled trial. BMC Gastroenterology. 2020;20(1):225.

Disclosure

The TRIASSIC trial is funded by ZonMW (Efficiency program: 852001926) and Applied Medical. Funding bodies had no role in the study design, data collection and analyses, decision to publish, or preparation of this abstract.

Introduction

Little is known on the outcomes of endoscopic submucosal dissection (ESD) in patients with recurrent lesions after surgical local excision (transanal endoscopic surgery TES, transanal endoscopic microsurgery TEM, transanal minimally invasive surgery TAMIS) of superficial rectal neoplasms (1). We aimed to evaluate the feasibility, safety and efficacy of ESD for incomplete or recurrent rectal neoplastic lesions after transanal surgery.

Aims & Methods

This multicenter retrospective study assessed 38 patients who underwent ESD between June 2016 and February 2022 for recurrent or incompletely resected after TES or TEM. Treatment outcomes were evaluated. Primary outcome was the non-recurrence tumoral lesion at first endoscopic follow-up control. Secondary outcome were En bloc resection, R0 resection, curative resection.

Results

Main results are given in Table 1. There were 16 male and 22 female patients. Median age (range) was 68.7 (44–88) years. Seventy-four percent of lesions were located in the lower rectum, and 55% reached the pectineal line. Sixty-one percent of lesions were laterally spreading tumor granular type (LST-G), and 34% were polyps. Forty-four percent of lesions were 0-IIa, and 23% were 0-Is according to the Paris classification. Seventy-one of lesions were Sano II, and 45% of lesions were Kudo IV. The median size of lesions (range) was 44 mm (10-100). Sixty-six percent of ESD were performed starting with full circumferential incision. Median operation time (range) was 79 (10–270) minutes. Thirty-nine percent of lesions has low vascular supply. Severe fibrosis was present in 78%of lesions. Ninety-two percent of lesions were successfully resected en bloc. R0 resection and curative resection rates were both 68%. Rectal fat is visualized in eleven patients, none of them requiring a surgery. Four post-operative bleeding and two stenosis occurred. Median (range) hospital length of stay after ESD was 1.8 days (0-4). Pathological examination revealed 32 adenomas (23 with low-grade dysplasia, 9 with high-grade dysplasia) and 3 adenocarcinomas (3 T2; there was no Tis or T1). All patients were followed up with endoscopic control after ESD, with biopsy samples if residual or recurrent tumor.Median (range) of follow-up period until first endoscopy control was 6.2 (1-13) months. « Only one residual lesion (one of three non-en bloc resections) actually showed low-grade dysplasia adenoma at follow-up.

Conclusion

ESD for incomplete or recurrent superficial rectal neoplastic lesions after transanal surgery (TEM,TES, TAMIS) is highly feasible and safe, and allows curative resection in a vast majority of cases.

References

1) Ikezawa N, et al. Digestion. 2021;102(3):446‑52.

Introduction

The Updated Sydney System recommends reporting the severity of both glandular atrophy (GA) and intestinal metaplasia (IM) as two independent parameters. However, the OLGA system assesses both GA and IM together as part of the same entity which should be reported as an average severity. The OLGIM system is based on the IM severity recommended by the updated Sydney system. Thus, the final OLGIM score can be estimated by any clinician. Currently, no system addresses the severity of both GA and IM as they are reported following the updated Sydney recommendation.

Aims & Methods

This study aimed to assess the utility of a new system, OLGIMA (Operative Link on Gastric IM and GA assessment), as a tool to identify patients at higher risk for GC in daily practice.
Consecutive diagnostic UGI endoscopies performed for any indications in patients older than 18 years old were recorded prospectively in 21 Spanish hospitals between April 2021 and July 2023. Protocolized gastric biopsies were taken according to the Updated Sydney consensus. We excluded patients with dysplasia, any malignancy, suspicion of autoimmune chronic atrophic gastritis, and lack of histological data. The severity of both GA and IM was assessed in the antrum (including incisura) and corpus following the updated Sydney system. After that, we considered the most advanced severity (none:0; mild:1; moderate:2; marked:3) provided for any of them in each of the two topographical areas. Then, the OLGIMA staging was done according to the same methodology used by the OLGA and OLGIM systems.

Results

A total of 998 patients were included. The median age was 57 (IQR 46 - 67), and 64% were women. Hp infection was identified in 334 (35%) patients (19% active infection and 16% eradicated). GA was identified in 192 (19.2%) patients which was limited to the antrum in 113 (11.3%) cases and extensive in 79 (7.9%). IM was identified in 159 (15.9%) patients which was limited to the antrum in 114 (11.4%) cases and extensive in 45 (4.5%). According to IM severity, 27 (2.7%) patients were OLGIM III/IV. According to GA severity, 22 (2.2%) patients were significantly extensive. The OLGIM system would have missed 12 (1.2%) patients with GA at higher risk. Considering both criteria, we would have detected 39 (3.9%) patients at higher risk in total (17 OLGIM III-IV, 12 extensive significative GA, and 10 both OLGIM III-IV and extensive significative GA). The new OLGIMA system categorized all 39 (3.9%) patients, OLGIM III-IV and significantly extensive GA, in the high-risk group (OLGIMA III/IV).

Conclusion

The new OLGIMA system (based on the severity of IM and GA recommended by the updated Sydney system) was able to detect patients at higher risk including all cases of OLGIM III/IV and also with advanced GA. The OLGIMA staging is much simpler and it can be estimated by any clinician regardless of whether the biopsy from incisura was taken.

References

Rugge M, Meggio A, Pennelli G et al. Gastritis staging in clinical practice: the OLGA staging system. Gut. 2007;56:631-6
Capelle LG, de Vries AC, Haringsma J et al. The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc. 2010;71:1150-8
Pimentel-Nunes P, Libânio D, Marcos-Pinto R et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy. 2019;51:365-388.

Clinical Case Summary

An hemoperitoneum may be the initial presentation of a liver tumour. A good differential diagnosis is critical, including trauma, vascular rupture and tumours.
A 79-year-old male, retired welder and painter, consulted for weight loss, abdominal pain and distension of 3 months of evolution. Ascitic semiology led to do a paracentesis with hematic debit. An urgent computerized tomography (CT) reported hemoperitoneum secondary to multicentric liver tumor with active bleeding (Figure 1) and intratumoral pseudoaneurysms compatible with angiosarcoma, performing an urgent transarterial embolization (Figure 2). Extension CT ruled out distant disease, magnetic resonance imaging (MRI) was realized (Figure 3) and fine needle aspiration (FNA) showed atypical cellular with CD31 expression (Figure 4), consistent with primary hepatic angiosarcoma (PHA). Given the bilobar involvement, surgery was dismissed and he was treated with chemotherapy (CTX), dying at 10 months of diagnosis.
PHA is a rare entity (2% of primary liver tumor) with an annual prevalence of 200 worldwide cases and a male predominance (3:1) at 60 years. It has been associated to exposure to vinyl chloride, arsenic or thoracotrast, but currently 75% of diagnoses have unknown aetiology.
Diagnosis is based on anatomopathology and inmunohistochemistry, including atypical cellularity in FNA and expression of vascular markers as ERG (100%), CD34 (87%) and CD31 (79%). Imaging tests are non-specific, with hypodense lesions in CT and T2-weighted hyperintense sequence in MRI.
Due to its aggressiveness, around 60% of PHA presents lymph nodes or lung, bones or spleen metastases at diagnosis. Liver resection is the only potentially curative treatment because it is a radioresistent tumour. Transplantation is not recommended due to its high recurrence rate. PHA has less than 6 months of overall survival (OS) without treatment. Otherwise, patients with CTX treatment has a OS of 3% at 2 years of diagnosis.