Surgical Therapy of Hepatocellular Carcinoma: State of the Art Liver Resection

Hepatocellular carcinoma (HCC) represents the third most common cause of cancer-related death, showing incremental growth rates throughout the last decades. HCC requires multidisciplinary approach in a group of patients suffering from underlying chronic liver disease, usually in the setting of cirrhosis. The mainstay of treatment in resectable cases is surgery, with anatomic and non-anatomic liver resections widely implemented, as well as liver transplantation in well-selected individuals. Nowadays, there is a variety of liver parenchyma transection devices used by hepatobiliary surgeons in specialized centers, which has significantly improved postoperative outcomes in HCC patients. Therefore, hepatectomy is considered safe and feasible and should be the main therapeutic option for HCC patients, candidates for resection. Liver resection utilizing cavitron ultrasonic aspirator in combination with bipolar radiofrequency ablation is safe and effective for the treatment of HCC with favorable clinical and oncological outcomes

A pathological fracture and a solitary mass in the right clavicle: an unusual first presentation of HCC and the role of immunohistochemistry

<p>Absrtract</p> <p>Hepatocellular carcinoma (HCC) is an aggressive malignant tumor that occurs throughout the world. Μetastases from hepatocellular carcinoma (HCC) were generally considered to be rare in the past, because the carcinoma had an aggressive clinical course. In our era, has been reported that extra-hepatic metastases occur in 13.5%-41.7% of HCC patients and this is considered as terminal-stage cancer. The prognosis for patients at this stage continues to be poor due to limited effective treatment. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals. We present here an extremely infrequent case of a patient, without known liver disease, in which the presenting symptom was a pathological-in retrospect-fracture of his right clavicle which wasn't properly evaluated, until he presented a bulky mass in the region 6 months later. For our patient, the added diagnostic difficulty alongside the unknown liver disease, has been that the clavicular metastases was the first presentation of any metastatic disease, rather than the more common sites of HCC spread to adjacent lung or lymph nodes.</p

Coexistence of a colon carcinoma with two distinct renal cell carcinomas: a case report

<p>Abstract</p> <p>Introduction</p> <p>We present the case of a patient with two tumors in his left kidney and a synchronous colon cancer. While coexisting tumors have been previously described in the same kidney or the kidney and other organs, or the colon and other organs, to the best of our knowledge no such concurrency of three primary tumors has been reported in the literature to date.</p> <p>Case presentation</p> <p>A 72-year-old man of Greek nationality presenting with pain in the right hypochondrium underwent a series of examinations that revealed gallstones, a tumor in the hepatic flexure of the colon and an additional tumor in the upper pole of the left kidney. He was subjected to a right hemicolectomy, left nephrectomy and cholecystectomy, and his postoperative course was uneventful. Histopathology examinations showed a mucinous colon adenocarcinoma, plus two tumors in the left kidney, a papillary renal cell carcinoma and a chromophobe renal cell carcinoma.</p> <p>Conclusion</p> <p>This case underlines the need to routinely scan patients pre-operatively in order to exclude coexisting tumors, especially asymptomatic renal tumors in patients with colorectal cancer, and additionally to screen concurrent tumors genetically in order to detect putative common genetic alterations.</p

Outcomes of elective liver surgery worldwide: a global, prospective, multicenter, cross-sectional study

Background: The outcomes of liver surgery worldwide remain unknown. The true population-based outcomes are likely different to those vastly reported that reflect the activity of highly specialized academic centers. The aim of this study was to measure the true worldwide practice of liver surgery and associated outcomes by recruiting from centers across the globe. The geographic distribution of liver surgery activity and complexity was also evaluated to further understand variations in outcomes. Methods: LiverGroup.org was an international, prospective, multicenter, cross-sectional study following the Global Surgery Collaborative Snapshot Research approach with a 3-month prospective, consecutive patient enrollment within January–December 2019. Each patient was followed up for 90 days postoperatively. All patients undergoing liver surgery at their respective centers were eligible for study inclusion. Basic demographics, patient and operation characteristics were collected. Morbidity was recorded according to the Clavien–Dindo Classification of Surgical Complications. Country-based and hospital-based data were collected, including the Human Development Index (HDI). (NCT03768141). Results: A total of 2159 patients were included from six continents. Surgery was performed for cancer in 1785 (83%) patients. Of all patients, 912 (42%) experienced a postoperative complication of any severity, while the major complication rate was 16% (341/2159). The overall 90-day mortality rate after liver surgery was 3.8% (82/2,159). The overall failure to rescue rate was 11% (82/ 722) ranging from 5 to 35% among the higher and lower HDI groups, respectively. Conclusions: This is the first to our knowledge global surgery study specifically designed and conducted for specialized liver surgery. The authors identified failure to rescue as a significant potentially modifiable factor for mortality after liver surgery, mostly related to lower Human Development Index countries. Members of the LiverGroup.org network could now work together to develop quality improvement collaboratives

Simultaneous evaluation of maspin and CXCR-4 in patients with breast cancer

AIMS: Maspin and CXCR4 share several similar pathways in cancer, including apoptosis and angiogenesis, but their action has not been studied simultaneously. METHODS: Our material consisted of 151 invasive breast carcinomas arranged in a Tissue Microarray Setting. Maspin and CXCR4 expression was evaluated by immunochemistry. We also assessed microvessel density by CD34 immunodetection and apoptosis by the Tdt-mediated dUTP nick end labeling assay (TUNEL). RESULTS: Maspin expression was related with CXCR4 expression, apoptosis, patient age and the Nottingham Prognostic Index. The expression of both maspin and CXCR4 progressively increased in high-grade tumors. In lymph node negative patients, maspin overexpression was associated with increased risk of death. High expression of CXCR4 was associated with prolongation of survival in patients with high maspin expression. CONCLUSIONS: Our results show that maspin overexpression is a potentially useful marker, especially for the clinically important group of lymph node negative patients. The expression of CXCR4 is of less significance in our study but may be informative for specific patient subsets or in a longer timeframe.ΣΚΟΠΟΣ: Η μασπίνη και ο CXCR4 μοιράζονται κοινούς μηχανισμούς στον καρκίνο, συμπεριλαμβανομένης της απόπτωσης και της αγγειογένεσης, αλλά η δράση τους δεν έχει μελετηθεί ταυτόχρονα. ΜΕΘΟΔΟΣ: Το υλικό μας αποτελούνταν από 151 διηθητικά καρκινώματα του μαστού, τα οποία μελετήθηκαν με ιστικές μικροσυστοιχίες (Tissue Microarrays). Η έκφραση της μασπίνης και του CXCR4 μελετήθηκαν με ανοσοϊστοχημική μέθοδο. Επίσης, μελετήθηκε η μικροαγγειακή πυκνότητα με ανοσοϊστοχημική εντόπιση με CD34 και η απόπτωση με τη μέθοδο TUNEL. ΑΠΟΤΕΛΕΣΜΑΤΑ: Η έκφραση της μασπίνης συσχετίσθηκε με την έκφραση του CXCR4, την απόπτωση, την ηλικία των ασθενών και το Nottingham Prognostic Index. Τόσο η έκφραση της μασπίνης, όσο και η έκφραση του CXCR4 προοδευτικά αυξάνει σε όγκους υψηλής κακοήθειας. Σε ασθενείς με αρνητική λεμφαδενική διήθηση, η υπερέκφραση της μασπίνης σχετίσθηκε με αυξημένο κίνδυνο θανάτου. Αυξημένη έκφραση του CXCR4 σχετίσθηκε με παρατεινόμενη επιβίωση σε ασθενείς με αυξημένη έκφραση της μασπίνης. ΣΥΜΠΕΡΑΣΜΑΤΑ: Τα αποτελέσματά μας δείχνουν πως η υπερέκφραση της μασπίνης είναι ένας πιθανά χρήσιμος δείκτης, ιδιαίτερα για την κλινικά σημαντική ομάδα των ασθενών με αρνητική λεμφαδενική διήθηση. Η έκφραση του CXCR4 είναι μικρότερης σημασίας στη μελέτη μας, μπορεί όμως να παρέχει πληροφορίες μακροπρόθεσμα και για συγκεκριμένες κατηγορίες ασθενών

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients

Seatbelt sign in a case of blunt abdominal trauma; what lies beneath it?

Background: The reported incidence of hollow viscus injuries (HVI) in blunt trauma patients is approximately 1 %. The most common site of injury to the intestine in blunt abdominal trauma (BAT) is the small bowel followed by colon, with mesenteric injuries occurring three times more commonly than bowel injuries. Isolated colon injury is a rarely encountered condition. Clinical assessment alone in patients with suspected intestinal or mesenteric injury after blunt trauma is associated with unacceptable diagnostic delays. Case presentation: This is a case of a 31-year-old man, admitted to the emergency department after being the restrained driver, involved in a car accident. After initial resuscitation, focused assessment with sonography for trauma examination (FAST) was performed revealing a subhepatic mass, suspicious for intraperitoneal hematoma. A computed tomography scan (CT) that followed showed a hematoma of the mesocolon of the ascending colon with active extravasation of intravenous contrast material. An exploratory laparotomy was performed, hemoperitomeum was evacuated, and a subserosal hematoma of the cecum and ascending colon with areas of totally disrupted serosal wall was found. Hematoma of the adjacent mesocolon expanding to the root of mesenteric vessels was also noted. A right hemicolectomy along with primary ileocolonic anastomosis was performed. Patient’s recovery progressed uneventfully. Conclusion: Identifying an isolated traumatic injury to the bowel or mesentery after BAT can be a clinical challenge because of its subtle and nonspecific clinical findings; meeting that challenge may eventually lead to a delay in diagnosis and treatment with subsequent increase in associated morbidity and mortality. Isolated colon injury is a rare finding after blunt trauma and usually accompanied by other intra-abdominal organ injuries. Abdominal ‘seatbelt’ sign, ecchymosis of the abdominal wall, increasing abdominal pain and distension are all associated with HVI. However, the accuracy of these findings remains low. Diagnostic peritoneal lavage, ultrasound, CT and diagnostic laparoscopy are used to evaluate BAT. Although CT has become the main diagnostic tool for this type of injuries, there are few pathognomonic signs of colon injury on CT. Given the potential for devastating outcomes, prompt diagnosis and treatment is necessary and high clinical suspicion is required

The Hepaticojejunostomy Technique with Intra-Anastomotic Stent in Biliary Diseases and Its Evolution throughout the Years: A Technical Analysis

Roux-en-Y hepaticojejunostomy (RYHJ) is currently considered as the definitive treatment for iatrogenic bile duct injuries and the principal representative of biliary diversion procedures. This technique has met many milestones of extensive evolution, particularly the last years of concomitant technological evolution (laparoscopic/robotic approach). Anastomotic strictures and leaks, which may have deleterious effects on the survival and quality of life of a patient with biliary obstruction of any cause, made the need of the development of a safe and efficient RYHJ compulsory. The aim of this technical analysis and the juxtaposed discussions is to elucidate with the most important milestones and technical tips and tricks all aspects of a feasible and reliable RYHJ technique that is performed in our center for the last 25 years in around 400 patients