Unexpected discovery of massive liver echinococcosis. A clinical, morphological, and functional diagnosis

We report a case of symptomatic massive liver echinococcosis due to Echinococcus granulosus, unexpectedly found in a 34 year old woman living in Apulia, Italy. Based on size (max diameter 18 cm), clinical presentation, geographical area, and natural history of echinococcosis, we estimate that the initial infection should have occurred 9-20 yrs before. Presenting symptoms were those of typical mass effect with RUQ pain, pruritus, malaise, and recent weight loss. Abdominal ultrasound diagnosis of probable echinococcal cyst was subsequentely confirmed by positive serology and further detailed by radiological imaging. The cyst was massively occupying subdiaphragmatic liver segments and extending to the omentum and the stomach. The characteristics of the lesion were compatible with the WHO 2003 classification type CE2l, indicating a large active fertile cyst with daughter cysts. The cyst was successfully treated with medical therapy followed by surgery. The prevalence, diagnostic workup, management, and costs of echinococcosis are discussed in this case presentation

ASO Author Reflections: The Liver-First Approach: A New Standard for Patients with Multiple Bilobar Colorectal Metastases?

The best surgical strategy for patients with colorectal cancer and synchronous liver metastases is a matter of endless debate. Technical and oncological issues must be considered but have often been confounded. In 2006, Mentha et al.1 proposed an innovative and convincing oncosurgical approach, whereby they reversed the strategy, focusing attention on the prognostically most relevant target, i.e. the liver. Even if appealing, the liver-first approach struggled to find its role and failed to demonstrate a benefit, except for the inclusion of chemoradiotherapy in the treatment schedule of patients with locally advanced rectal tumors. The proposers themselves reported non-inferiority (and not superiority) of the reverse strategy in comparison with the standard primary-first approach.2 A recent network meta-analysis ranked the liver-first approach as the best treatment option for its relative efficacy based on 5-year overall survival outcomes,3 but the evidence is too weak to impact current clinical practice

The FXR agonist obeticholic acid inhibits the cancerogenic potential of human cholangiocarcinoma

Cholangiocarcinoma (CCA) is an aggressive cancer with high resistance to chemotherapeutics. CCA is enriched in cancer stem cells, which correlate with aggressiveness and prognosis. FXR, a member of the metabolic nuclear receptor family, is markedly down-regulated in human CCA. Our aim was to evaluate, in primary cultures of human intrahepatic CCA (iCCA), the effects of the FXR agonist obeticholic acid (OCA), a semisynthetic bile acid derivative, on their cancerogenic potential. Primary human iCCA cell cultures were prepared from surgical specimens of mucinous or mixed iCCA subtypes. Increasing concentrations (0–2.5 μM) of OCA were added to culture media and, after 3–10 days, effects on proliferation (MTS assay, cell population doubling time), apoptosis (annexin V-FITC/propidium iodide), cell migration and invasion (wound healing response and Matrigel invasion assay), and cancerogenic potential (spheroid formation, clonogenic assay, colony formation capacity) were evaluated. Results: FXR gene expression was downregulated (RT-qPCR) in iCCA cells vs normal human biliary tree stem cells (p < 0.05) and in mucinous iCCA vs mixed iCCA cells (p < 0.05) but was upregulated by addition of OCA. OCA significantly (p < 0.05) inhibited proliferation of both mucinous and mixed iCCA cells, starting at a concentration as low as 0.05 μM. Also, CDCA (but not UDCA) inhibited cell proliferation, although to a much lower extent than OCA, consistent with its different affinity for FXR. OCA significantly induced apoptosis of both iCCA subtypes and decreased their in vitro cancerogenic potential, as evaluated by impairment of colony and spheroid formation capacity and delayed wound healing and Matrigel invasion. In general, these effects were more evident in mixed than mucinous iCCA cells. When tested together with Gemcitabine and Cisplatin, OCA potentiated the anti-proliferative and pro-apoptotic effects of these chemotherapeutics, but mainly in mixed iCCA cells. OCA abolished the capacity of both mucinous and mixed iCCA cells to form colonies when administered together with Gemcitabine and Cisplatin. In subcutaneous xenografts of mixed iCCA cells, OCA alone or combined with Gemcitabine or Cisplatin markedly reduced the tumor size after 5 weeks of treatment by inducing necrosis of tumor mass and inhibiting cell proliferation. In conclusion, FXR is down-regulated in iCCA cells, and its activation by OCA results in anti-cancerogenic effects against mucinous and mixed iCCA cells, both in vitro and in vivo. The effects of OCA predominated in mixed iCCA cells, consistent with the lower aggressiveness and the higher FXR expression in this CCA subtype. These results, showing the FXR-mediated capacity of OCA to inhibit cholangiocarcinogenesis, represent the basis for testing OCA in clinical trials of CCA patients

Final analysis of colorectal cancer patients treated with irinotecan and 5-fluorouracil plus folinic acid neoadjuvant chemotherapy for unresectable liver metastases

We have previously reported that neoadjuvant therapy with modified FOLFIRI enabled nearly a third of patients with metastatic colorectal cancer (mCRC) to undergo surgical resection of liver metastases. Here, we present data from the long-term follow-up of these patients. Forty patients received modified FOLFIRI: irinotecan 180 mg m−2, day 1; folinic acid, 200 mg m−2; and 5-fluorouracil: as a 400 mg m−2 bolus, days 1 and 2, and a 48-h continuous infusion 1200 mg m−2, from day 1. Treatment was repeated every 2 weeks, with response assessed every six cycles. Resected patients received six further cycles of chemotherapy postoperatively. Nineteen (47.5%) of 40 patients achieved an objective response; 13 (33%) underwent resection. After a median follow-up of 56 months, median survival for all patients was 31.5 months: for non-resected patients, median survival was 24 months and was not reached for resected patients. Median time to progression was 14.3 and 5.2 months for all and non-resected patients, respectively. Median disease-free (DF) survival in resected patients was 52.5 months. At 2 years, all patients were alive (8 DF), and at last follow-up, eight were alive (6 DF). Surgical resection of liver metastases after neoadjuvant treatment with modified FOLFIRI in CRC patients achieved favourable survival times

Splenic artery transposition for hepatic arterial reconstruction in a locally advanced pancreatic cancer: A case report and literature review

OBJECTIVE: During pancreatic surgery for malignancies, hepatic revascularization is needed in case of en bloc resection with hepatic artery involvement. In these cases, the use of the splenic artery is described in the literature, including transposition and interposition techniques. PATIENTS AND METHODS: We report the case of pancreatic cancer resection with involvement of the right hepatic artery, anomalous arising from the superior mesenteric artery, and hepatic revascularization with splenic artery reconstruction. A literature review to analyze the use of splenic artery in hepatic revascularization during pancreatic cancer surgery was performed. RESULTS: A 61-year-old man with a 55-mm hypovascular tumor in the pancreatic head, in wide contact with the right hepatic artery, underwent total pancreatectomy and splenectomy. Right hepatic artery was resected, and the distal part of the splenic artery was transposed to the right hepatic artery with a termino-terminal anastomosis. Histopathological examination revealed R0 resection. CONCLUSIONS: Hepatic revascularization with splenic artery should be considered in patients suitable to extend resectability in pancreatic cancer surgery. A multidisciplinary approach and careful pre-operative planning are essential

Primum Non Nocere in interventional oncology for liver cancer: How to reduce the risk for complications?

: Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments

Correction to: Diffusion, outcomes and implementation of minimally invasive liver surgery: a snapshot from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry

A technical error led to incorrect rendering of the author group in this article. The correct authorship is as follows: Luca Aldrighetti, Francesca Ratti, Umberto Cillo, Alessandro Ferrero, Giuseppe Maria Ettorre, Alfredo Guglielmi, Felice Giuliante, Fulvio Calise on behalf of the Italian Group of Minimally Invasive Liver Surgery (I GO MILS) The collaborators are: Raffaele Dalla Valle, AOU Parma, Parma; Vincenzo Mazzaferro, Istituto Nazionale Tumori, Milano; Elio Jovine, Ospedale Maggiore, Bologna; Luciano Gregorio De Carlis, Ospedale Niguarda Ca\u2019 Granda, Milano; Ugo Boggi, AOU Pisana, Pisa; Salvatore Gruttadauria, ISMETT, Palermo; Fabrizio Di Benedetto, AOU Policlinico di Modena, Modena; Paolo Reggiani, Ospedale Maggiore Policlinico, Milano; Stefano Berti, Ospedale Civile S.Andrea, La Spezia; Graziano Ceccarelli, Ospedale San Donato, Arezzo; Leonardo Vincenti, AOU Consorziale Policlinico, Bari; Giulio Belli, Ospedale SM Loreto Nuovo, Napoli; Guido Torzilli, Istituto Clinico Humanitas, Rozzano; Fausto Zamboni, Ospedale Brotzu, Cagliari; Andrea Coratti, AOU Careggi, Firenze; Pietro Mezzatesta, Casa di Cura La Maddalena, Palermo; Roberto Santambrogio, AO San Paolo, Milano; Giuseppe Navarra, AOU Policlinico G. Martino, Messina; Antonio Giuliani, AO R.N. Cardarelli, Napoli; Antonio Daniele Pinna, Policlinico Sant\u2019Orsola Malpighi, Bologna; Amilcare Parisi, AO Santa Maria di Terni, Terni; Michele Colledan, AO Papa Giovanni XXIII, Bergamo; Abdallah Slim, AO Desio e Vimercate, Vimercate; Adelmo Antonucci, Policlinico di Monza, Monza; Gian Luca Grazi, Istituto Nazionale Tumori Regina Elena, Roma; Antonio Frena, Ospedale Centrale, Bolzano; Giovanni Sgroi, AO Treviglio-Caravaggio, Treviglio; Alberto Brolese, Ospedale S.Chiara, Trento; Luca Morelli, AOU Pisana, Pisa; Antonio Floridi, AO Ospedale Maggiore, Crema; Alberto Patriti, Ospedale San Matteo degli Infermi, Spoleto; Luigi Veneroni, Ospedale Infermi AUSL Romagna, Rimini; Giorgio Ercolani, Ospedale Morgagni Pierantoni, Forl\uec; Luigi Boni, AOU Fondazione Macchi, Varese; Pietro Maida, Ospedale Villa Betania, Napoli; Guido Griseri, Ospedale San Paolo, Savona; Andrea Percivale, Ospedale Santa Corona, Pietraligure; Marco Filauro, AO Galliera, Genova; Silvio Guerriero, Ospedale San Martino, Belluno; Giuseppe Tisone, Policlinico Tor Vergata, Roma; Raffaele Romito, AOU Maggiore della Carit\ue0, Novara; Umberto Tedeschi, AOU Integrata Verona, Verona; Giuseppe Zimmitti, Fondazione Poliambulanza, Brescia

411 Ovarian cancer metastases in the liver area: proposal of a standardized anatomo-surgical classification

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Effectiveness of Direct Bite Raiser Onlays in Patients Affected By Temporomandibular Disorders: A Retrospective Observational Study

This retrospective observational study aims to assess the effectiveness of direct bite raiser onlays (DBRO) on pain and dysfunctional symptoms in patients affected by pain-related temporomandibular disorders (TMD). Furthermore, it wants to provide descriptive information about the clinical performance of the treatment. We screened the electronic medical records of male and female patients with a diagnosis of pain-related temporomandibular disorders treated with DBRO. A data collection was performed from patients routinely gathered clinical records. A final sample of 43 patients was included in the analysis. At the beginning of treatment all patients (100%) referred having pain and 12 patients (27.9%) complained about both pain and functional limitation. At the end of the treatment, 36 patients (83.7%) were symptom-free. In 5 subjects (11.6%), pain was still present but reduced in intensity. In 2 subjects (16.6%) functional limitations were improved but not completely resolved. During the treatment that lasted on average 8 months a mean of 7 checks have been carried out; the occlusal changes made on the DBRO had been on average 3. In 23 patients (53.5%) initial discomfort occurred after the beginning of treatment. The first beneficial effect was obtained on average on the fifth week of therapy. The results of this retrospective observational study should be treated cautiously because of the limitations of the study design but suggest that patients with a diagnosis of pain-related temporomandibular disorders who are treated with direct bite raiser onlays experience a reduction in pain and dysfunctional symptoms

Gene Expression Profiling of Pancreas Neuroendocrine Tumors with Different Ki67-Based Grades.

Pancreatic neuroendocrine tumors (PanNETs) display variable aggressive behavior. A major predictor of survival is tumor grade based on the Ki67 proliferation index. As information on transcriptomic profiles of PanNETs with different tumor grades is limited, we investigated 29 PanNETs (17 G1, 7 G2, 5 G3) for their expression profiles, mutations in 16 PanNET relevant genes and LINE-1 DNA methylation profiles. A total of 3050 genes were differentially expressed between tumors with different grades (p &lt; 0.05): 1279 in G3 vs. G2; 2757 in G3 vs. G1; and 203 in G2 vs. G1. Mutational analysis showed 57 alterations in 11 genes, the most frequent being MEN1 (18/29), DAXX (7/29), ATRX (6/29) and MUTYH (5/29). The presence and type of mutations did not correlate with the specific expression profiles associated with different grades. LINE-1 showed significantly lower methylation in G2/G3 versus G1 tumors (p = 0.007). The expression profiles of matched primaries and metastasis (nodal, hepatic and colorectal wall) of three cases confirmed the role of Ki67 in defining specific expression profiles, which clustered according to tumor grades, independently from anatomic location or patient of origin. Such data call for future exploration of the role of Ki67 in tumor progression, given its involvement in chromosomal stability