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Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits. [ABSTRACT FROM AUTHOR]

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients. [ABSTRACT FROM AUTHOR]

Background. Teratomas are neoplasms that arise from pluripotent germ cells, derived from two or more layers of germ cells. They are classified as mature tumors (cystic or solid), which contain well-differentiated tissues, or as immature tumors, which contain immature and embryonic structures. Its most frequent location is the female and male gonads; the mesenteric location is rare and approximately 40 cases have been described in the world literature. Within the diagnostic and therapeutic approach, computed tomography and magnetic resonance imaging are used to characterize the lesion, assess intra-abdominal extension and the relationship with other structures. The diagnosis must be confirmed by histopathological examination. Clinical case. A 56-year-old female patient with a history of infiltrating ductal carcinoma of the left breast in remission. In follow-up studies, incidental abdominal tomography finding of an abdominopelvic lesion dependent on the mesentery at the level of the mesogastrium, smooth contours with fat-liquid level. Extension studies with negative tumor markers. Results: Due to high clinical and imaging suspicion of teratoma, the patient was taken to resection of the lesion. Histopathological examination confirmed the diagnosis of mature cystic teratoma of the mesentery. Conclusion: Mesenteric teratoma is a rare clinical entity and is considered one of the differential diagnoses of an abdominal mass with a compressive effect. Diagnosis is mainly based on clinical examination and imaging findings. Early surgical excision is the mainstay of treatment; laparoscopic or open approach depends on the clinical characteristics and the experience of the surgeon. [ABSTRACT FROM AUTHOR]

Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits.

Objectives: The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. Material and Methods: This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Results: Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Conclusion: Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory. [ABSTRACT FROM AUTHOR]

Desmoid-type fibromatosis (DF) is a locally aggressive myofibroblastic tumor accounting for approximately 0.03% of all neoplasms and less than 3% of all soft tissue tumors.1 The estimated incidence in the general population is 2 to 4 cases per million per year. In the past, this lesion was considered as an aberrant healing response against local trauma, irritation, or inflammation; however, later a clonal proliferation of the spindle cell was confirmed, and local recurrence as well as distant metastasis was identified.2 DF affects 10%-20% of patients with familial adenomatous polyposis. Sporadic DF predominantly affects young adults, especially women, and it is often related to pregnancy.3 Although it may occur in nearly every body part, it usually involves the extremities and trunk, including the abdominal wall and intra-abdomen. Intra-abdominal desmoid tumors are mainly located within the mesentery or pelvis.4 A bulky desmoid tumor located in the pelvis or lower abdominal wall near the uterus may be preoperatively suspected as a large subserosal uterine leiomyoma. Genetic alterations in theAPCandCTNNB1genes are thought to be vital events resulting in hereditary and sporadic DF. Sporadic DF is associated with a high incidence (85%) of mutations in theCTNNB1gene, which may lead to uninhibited activation of the Wnt pathway and the accumulation of excessive cytoplasmic β-catenin, ultimately resulting in tumor development.5 The early diagnosis of DF is challenging. The findings of computed tomography (CT) and magnetic resonance imaging (MRI) can guide the decisions regarding patient management, but the ultrasound features of DF are non-specific. The relationship between the tumor and the adjacent structures should be carefully evaluated to decide the feasibility of surgery.6 Complete surgical resection is usually the standard treatment in patients with resectable desmoid tumors. However, the local recurrence rate is still high after resection alone due to its infiltrative pattern and positive margins after surgical resection.7 Radiotherapy is another treatment modality for desmoid tumors, but its efficiency is controversial. Recently published meta-analysis and the review suggested the benefit of postoperative radiotherapy over surgery alone in long-term cure and prevention of recurrence.8 Low-dose chemotherapy or systemic therapy (such as hormonal therapy, non-steroidal anti-inflammatory therapy, or targeted therapy) in patients with advanced unresectable tumors or recurrent disease after surgery and/ or radiotherapy is also used.9 A 24-year-old lady presented with gradually progressive pain in the whole abdomen for six months. She had a prior history of lower uterine cesarean section done 3 years back and a history of missed abortion 4 years back. On per-abdominal examination, a 10x8 cm large mass was palpated mainly in the right lower abdomen, with side-to-side mobility. The speculum examination showed a smooth cervix. Per-vaginal examination revealed a large mass felt through the right fornix. Abdominal computed tomography showed bilateral normal ovaries and a large heterogeneous mass measuring 11x9 cm close to the uterus. A possibility of pedunculated subserosal leiomyoma was considered. Given progressive clinical symptoms, laparotomy was performed. On per-operative examination, a large mass was identified as closely adhered to the mesentery of the right colon. The uterus and bilateral adnexa were free of tumor. The tumor was excised in toto with the right colon. Gross examination revealed a rounded mass of size 11x9 cm with a smooth outer surface. The tumor was densely adhered to the cecum and appendix and had engulfed the appendix (Figure 1A). The cut surface shows a solid, whitish, firm lesion with prominent trabeculations (Figure 1B). Figure 1 A - Gross view of the giant globular tumor with a smooth surface and closely adhered to the right colon and appendix;the white arrowhead points towards the tip of the adhered appendix (scale bar= 5 cm); B - Cut surface of the tumor shows a solid, well-circumscribed whitish tumor with areas of trabeculations (scale bar= 5 cm); C - Photomicrograph shows a low-grade spindle cell mesenchymal tumor of low cellularity densely adhered to the serosal surface of the appendix with infiltration of muscularis of the appendix (H&E,40x); D - Photomicrograph shows spindle cell tumor with bland elongated nuclei and moderate cytoplasm disposed over a hyalinized and myxoid stroma interspersed with thin-walled vessels. (H&E, 100x); E - Photomicrograph shows tumor cells positive for smooth muscle actin (SMA) immunohistochemistry (100x); F - Photomicrograph shows tumor cells with nuclear localization of beta-catenin (100x).: Microscopic examination revealed a mesenchymal tumor with low cellularity, composed of bland spindled cells over a densely collagenized matrix interspersed with thin vascular channels (Figure 1D). Mitosis, necrosis, and significant atypia were absent. The tumor was adhered within the serosal surface of the appendix and colon and also showed infiltration of the retroperitoneal skeletal muscle fibers (Figure 1C). On IHC, the tumor cells were positive for Vimentin, Smooth muscle actin (SMA) and showed nuclear localization of beta-catenin with cyclinD1 (Figures 1E and 1F). IHC for h-caldesmon, S-100, CD117, DOG-1, myogenin, ALK, and STAT-6 were negative, ruling out other differential diagnoses, including leiomyoma, nerve sheath tumor, gastrointestinal stromal tumor, spindle cell rhabdomyosarcoma, inflammatory myofibroblastic tumor, and solitary fibrous tumor. Ki-67 labeling was ~2-3%. The DF diagnosis was rendered based on the histology and IHC features. Our patient was advised postoperative close follow-up with clinical and imaging modalities at regular intervals. In summary, awareness about this rare tumor in intra-abdominal locations in young female patients with a prior history of childbirth and surgery and its possible clinical and imaging overlap with leiomyoma prevents aggressive treatment in DF patients. A pre-operative biopsy can confirm the diagnosis. However, in symptomatic patients, surgery is the mainstay of therapy. A search for possible CTNNB1 and APC gene mutation is vital.

Adult intussusception presents a diagnostic challenge given its non-specific symptoms. It is not as common as in infants and young children. Traditionally, diagnostic steps are invariably fit for normal adults, but not in pregnancy which faces certain limitations. A 40-year-old pregnant mother, gravida 9 para 8 at 34-week gestation, complained of intermittent epigastric pain for 2 days, requiring hospitalization. She soon developed minimal per rectal bleeding that was ruled out as hemorrhoid. Imaging was limited due to her pregnancy status. She later developed spontaneous delivery to a premature baby. Computed tomography (CT) revealed an ileocolic intussusception, which was confirmed via exploratory laparotomy. Histology was consistent with inflammatory fibroid polyp. Acute abdomen in pregnancy can be due to various causes, thus a high index of suspicion and early CT abdomen might help in early diagnosis and treatment. The benefit of doing CT on the mother and the risk of CT on the fetus is to be weighed as the timely diagnosis can prevent bowel ischemia and reduce maternal morbidity and mortality. Surgery remains the definite management in adult intussusception and an exact diagnosis can be made during the operation.

BackgroundThis study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.MethodsThis was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January-October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection.ResultsThis study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P

Objective: Rare disease. Background: Primary adrenal epithelioid angiosarcoma (PAEA) is a very uncommon primary adrenal gland tumor that usually occurs around the age of 60 years and is more common among males. Owing to its rarity and histopathological features, PAEA could be misdiagnosed as adrenal cortical adenoma, adrenal cortical carcinoma, or other metastatic cancers, such as metastatic malignant melanoma and epithelioid hemangioendothelioma. Case Report: A 59-year-old male patient presented to our hospital with a complaint of abdominal bloating that started 2 months prior. His vital signs and the results of his physical and neurological examinations were unremarkable. A computed tomography scan showed a lobulated mass arising from the hepatic limb of the right adrenal gland but no evidence of metastasis to the chest or abdomen. The patient underwent right adrenalectomy, and the macroscopic pathological findings from a right adrenalectomy specimen revealed atypical tumor cells with an epithelioid appearance in the background of an adrenal cortical adenoma. Immunohistochemical staining was performed to confirm the diagnosis. The final diagnosis was epithelioid angiosarcoma involving the right adrenal gland with a background adrenal cortical adenoma. The patient had no postoperative complications, pain in the surgical wound, or fever. Therefore, he was discharged with a schedule for followup appointments. Conclusions: PAEA may be misinterpreted as adrenal cortical carcinoma, metastatic carcinoma, or malignant melanoma radiologically and histologically. Immunohistochemical stains are essential for diagnosing PAEA. Surgery and strict monitoring are the main treatments. In addition, early diagnosis is essential for patient recovery. [ABSTRACT FROM AUTHOR]

Introduction: Surgical palliation of malignancy is defined best as a procedure used with the primary intention of improving Quality of Life (QoL) or relieving symptoms caused by an advanced malignancy. Surgical procedures for palliation include resections, reconstruction, functional repairs, drainage, and biopsy. Primary benefits include QoL improvement through symptom prevention or control, with survival advantage as a secondary benefit. Aim: To evaluate mortality (30 days and 6 months), length of hospital stay and Intensive Care Unit (ICU) stay and QoL among patients undergoing palliative surgery for advanced cancer. Materials and Methods: A retrospective study was conducted at Dr. B. Borooah Cancer Institute, India, from September 2020 to March 2021. The clinicodemographic profile, tumour type and staging, treatment, investigations, surgery, anaesthesia and complications were studied. The outcome was defined by mortality, length of hospital stay and quality of life. Descriptive statistics was used for analysis. A p-value of less than 0.05 was considered significant at 5% level of significance. Results: A total of 86 patients underwent palliative surgeries, out of which 52 (60.5%) were females and 34 (39.5%) were males with the mean age of 49.6±15.9 years. Among them, 8 (9.3%) died within 30 days of surgery and 11 (12.8%) at six months after surgery. There was a significant association of mortality with pallor, deranged Thyroid Stimulating Hormone (TSH), co-morbidities, chemotherapy, type of surgery and anaesthesia but not with age, sex, type and stage of cancer, American Society of Anaesthesiology (ASA) status and General Condition (GC) of the patient. The mean duration of postoperative hospital stay was 15.8 days and mean ICU stay was 0.8 day for all patients. Patients with pallor had longer duration of hospital and ICU stay. Type of surgery was significantly associated with hospital stay but not with ICU stay. On evaluating the quality of life using Eastern Cooperative Oncology Group (ECOG) score, it was seen that the number of patients with poor ECOG scores (3 to 5) increased significantly from 10 (11.63%) to 13 (15.12%) in the immediate postoperative period. Conclusion: Patient factors affected the outcome after palliative surgery more than surgical and anaesthetic factors. The high mortality rate of 12.8% warrants detailed prospective studies in the future. [ABSTRACT FROM AUTHOR]

Methods:Nine patients (seven pancreas, one liver, and one lung) were recruited. 4D-MRI was performed using two prototype k-space sorted techniques, stack-of-stars (SOS) and koosh-ball (KB) acquisitions. Post-processing using MoCoAve was implemented for both methods. Image quality score, apparent SNR (aSNR), sharpness, motion trajectory and standard deviation (σ_GTV) of the gross tumor volumes were compared between original and MoCoAve image sets.Results:All subjects successfully underwent 4D-MRI scans and MoCoAve was performed on all data sets. Significantly higher image quality scores (2.64 ± 0.39 vs 1.18 ± 0.34, p = 0.001) and aSNR (37.6 ± 15.3 vs 18.1 ± 5.7, p = 0.001) was observed in the MoCoAve images when compared to the original images. High correlation in tumor motion trajectories in the superoinferior direction (SI: 0.91 ± 0.08) and weaker in the anteroposterior (AP: 0.51 ± 0.44) and mediolateral (ML: 0.37 ± 0.23) directions, similar image sharpness (0.367 ± 0.068 vs 0.369 ± 0.072, p = 0.805), and minimal average absolute difference (0.47 ± 0.34  mm) of the motion trajectory profiles was found between the two image sets. The σ_GTV in pancreas patients was significantly (p = 0.039) lower in MoCoAve images (1.48 ± 1.35  cm3) than in the original images (2.17 ± 1.31  cm3).Conclusion:MoCoAve using interphase motion correction and averaging has shown promise as a post-processing method for improving k-space sorted (SOS and KB) 4D-MRI image quality in thoracic and abdominal cancer patients.Advances in knowledge:The proposed method is an image based post-processing method that could be applied to many k-space sorted 4D-MRI methods for improved image quality and signal-to-noise ratio while preserving image sharpness and respiratory motion fidelity. It is a useful technique for the radiotherapy planning community who are interested in using 4D-MRI but aren't satisfied with their current MR image quality.

Introduction: Surgical palliation of malignancy is defined best as a procedure used with the primary intention of improving Quality of Life (QoL) or relieving symptoms caused by an advanced malignancy. Surgical procedures for palliation include resections, reconstruction, functional repairs, drainage, and biopsy. Primary benefits include QoL improvement through symptom prevention or control, with survival advantage as a secondary benefit. Aim: To evaluate mortality (30 days and 6 months), length of hospital stay and Intensive Care Unit (ICU) stay and QoL among patients undergoing palliative surgery for advanced cancer. Materials and Methods: A retrospective study was conducted at Dr. B. Borooah Cancer Institute, India, from September 2020 to March 2021. The clinicodemographic profile, tumour type and staging, treatment, investigations, surgery, anaesthesia and complications were studied. The outcome was defined by mortality, length of hospital stay and quality of life. Descriptive statistics was used for analysis. A p-value of less than 0.05 was considered significant at 5% level of significance. Results: A total of 86 patients underwent palliative surgeries, out of which 52 (60.5%) were females and 34 (39.5%) were males with the mean age of 49.6±15.9 years. Among them, 8 (9.3%) died within 30 days of surgery and 11 (12.8%) at six months after surgery. There was a significant association of mortality with pallor, deranged Thyroid Stimulating Hormone (TSH), co-morbidities, chemotherapy, type of surgery and anaesthesia but not with age, sex, type and stage of cancer, American Society of Anaesthesiology (ASA) status and General Condition (GC) of the patient. The mean duration of postoperative hospital stay was 15.8 days and mean ICU stay was 0.8 day for all patients. Patients with pallor had longer duration of hospital and ICU stay. Type of surgery was significantly associated with hospital stay but not with ICU stay. On evaluating the quality of life using Eastern Cooperative Oncology Group (ECOG) score, it was seen that the number of patients with poor ECOG scores (3 to 5) increased significantly from 10 (11.63%) to 13 (15.12%) in the immediate postoperative period. Conclusion: Patient factors affected the outcome after palliative surgery more than surgical and anaesthetic factors. The high mortality rate of 12.8% warrants detailed prospective studies in the future.

Objective To explore the safety, feasibility and short-term outcomes of hyperthermic intraperitoneal chemotherapy (HIPEC) for abdominal cancer in children. Methods From December 2019 to May 2021,16 patients with abdominal malignant tumor underwent surgical resection (cytoreductive surgery or tumorectomy) plus HIPEC.The median age was 68(8-167) months. Clinical characteristics, therapies and short-term outcomes were retrospectively analyzed. Results The histologic types included wilms tumor (n=5),rhabdomyosarcoma (n=4),malignant renal rhabdoid (n=1),undifferentiated sarcoma (n=1),immature teratoma (n=1),neuroblastoma (n=2),serous peritoneal carcinoma (n=1) and malignant ovarian germ cell tumor (n=1).Six cases underwent the initial operation and ten cases were re-operated for tumor recurrences. The median peritoneal carcinomatosis index (PCI) was 2.5(0-21) and the completeness of cytoreduction (CC) score (0-1) post-resection. There was no perioperative mortality or life-threatening complication. Four children had grade 3 adverse events within 30 days after surgery and HIPEC. The median follow-up period was 8(3.3-20) months. After surgery and HIPEC, six cases recurred. Three children died due to recurrence. One case had chemotherapy, surgery and radiotherapy after recurrence and survived without disease while another two cases received chemotherapy after recurrence and survived with disease. The remainders had no evidence of disease. The median disease-free survival (DFS) was 7.4(2-20) months. Conclusion HIPEC is both safe and feasible for pediatric abdominal malignant tumors. There is no onset of serious perioperative complications and adverse events are tolerable. The short-term outcomes are decent while long-term effectiveness requires more cases and extended follow-ups. [ABSTRACT FROM AUTHOR]