Gallbladder carcinoma fortuitously discovered on specimen after cholecystectomy: should re-operation be advocated?

Le cancer de la vésicule biliaire est rare, de pronostic sévère et souvent diagnostiqué de manière fortuite sur pièce de cholécystectomie. La survie des cancers découverts fortuitement est cependant meilleure que lorsque le diagnostic est fait en pré-opératoire, car il s’agit le plus souvent de « petits cancers ». Le compte-rendu opératoire détaillé, l’analyse complète du compte-rendu anatomo-pathologique de la pièce de cholécystectomie, complétés d’un bilan d’extension, permettent de classer la lésion selon le stade TNM qui sera déterminant pour décider de la prise en charge ultérieure et notamment de l’indication d’une réintervention chirurgicale carcinologique. Seuls les adénocarcinomes n’envahissant pas la musculeuse (T1a) et avec des marges de résections chirurgicales saines peuvent être considérés comme ayant eu une résection satisfaisante. Toutes les autres lésions nécessiteront une réintervention comportant une résection hépatique, un curage ganglionnaire, une recoupe du canal cystique (plus ou moins associée à une résection de la voie biliaire principale) ainsi qu’une exérèse des orifices de trocarts lorsque la cholécystectomie avait été réalisée par laparoscopie. La réintervention ne doit laisser aucun résidu tumoral si l’on veut espérer un bénéfice en termes de survie pour le patient.Cancer of the gallbladder cancer is rare and associated with a poor prognosis. It is frequently fortuitously discovered on a specimen after cholecystectomy. Survival with such cancers fortuitously discovered is often better than when diagnosed pre-operatively, as they are often of small size.A detailed operative report, the whole analysis of the pathological report of the surgical specimen, followed with a staging of the lesion according to the TNM classification will be of utmost importance to decide of the further management and especially if surgical re-operation is indicated. Resection can be considered as satisfactory only if the adenocarcinoma is not invading the musculosa (T1a) and shows safe resection margins. All other lesions should be re-operated with hepatic resection, lymphnode dissection, resection of the cystic duct (more or less associated to the resection of the main biliary tract) as well as the exeresis of the trocar orifices if cholecystectomy has been performed by laparoscopy. Surgical re-operation should not leave any tumoral residue if a benefit in terms of survival is expected for the patient

The accuracy of Multi-detector row CT for the assessment of tumor invasion of the mesorectal fascia in primary rectal cancer

PURPOSE: To evaluate the accuracy of Multi-detector row CT (MDCT) for the prediction of tumor invasion of the mesorectal fascia (MRF). MATERIALS AND METHODS: A total of 35 patients with primary rectal cancer underwent preoperative staging magnetic resonance imaging (MRI) and MDCT. The tumor relationship to the MRF, expressed in 3 categories (1--tumor free MRF = tumor distance > or = 1 mm; 2--threatened = distance < 1 mm; 3--invasion = distance 0 mm) was determined on CT by two observers at patient level and at different anatomical locations. A third expert reader evaluated the MRF tumor relationship on MRI, which served as reference standard. Receiver operating characteristic curves (ROC-curves) and areas under these curves (AUC) were calculated. The inter-observer agreement of CT was determined by using linear weighted kappa statistics. RESULTS: The AUC of CT for MRF invasion was 0.71 for observer 1 and 0.62 for observer 2. The inter-observer agreement was kappa = 0.34. The performance of CT at mid-high rectal levels was statistically significant better compared to low anterior (obs.1: AUC = 0.88 vs. 0.50; obs 2: AUC = 0.84 vs. 0.31; P < or = 0.040). CONCLUSION: Multi-detector row CT has a poor accuracy for predicting MRF invasion in low-anterior located tumors.The accuracy of CT significantly improves for tumors in the mid-high rectum. There is a high inconsistency among readers

Open versus laparoscopically-assisted oesophagectomy for cancer: a multicentre randomised controlled phase III trial - the MIRO trial

<p>Abstract</p> <p>Background</p> <p>Open transthoracic oesophagectomy is the standard treatment for infracarinal resectable oesophageal carcinomas, although it is associated with high mortality and morbidity rates of 2 to 10% and 30 to 50%, respectively, for both the abdominal and thoracic approaches. The worldwide popularity of laparoscopic techniques is based on promising results, including lower postoperative morbidity rates, which are related to the reduced postoperative trauma. We hypothesise that the laparoscopic abdominal approach (laparoscopic gastric mobilisation) in oesophageal cancer surgery will decrease the major postoperative complication rate due to the reduced surgical trauma.</p> <p>Methods/Design</p> <p>The MIRO trial is an open, controlled, prospective, randomised multicentre phase III trial. Patients in study arm A will receive laparoscopic-assisted oesophagectomy, i.e., a transthoracic oesophagectomy with two-field lymphadenectomy and laparoscopic gastric mobilisation. Patients in study arm B will receive the same procedure, but with the conventional open abdominal approach. The primary objective of the study is to evaluate the major postoperative 30-day morbidity. Secondary objectives are to assess the overall 30-day morbidity, 30-day mortality, 30-day pulmonary morbidity, disease-free survival, overall survival as well as quality of life and to perform medico-economic analysis. A total of 200 patients will be enrolled, and two safety analyses will be performed using 25 and 50 patients included in arm A.</p> <p>Discussion</p> <p>Postoperative morbidity remains high after oesophageal cancer surgery, especially due to major pulmonary complications, which are responsible for 50% of the postoperative deaths. This study represents the first randomised controlled phase III trial to evaluate the benefits of the minimally invasive approach with respect to the postoperative course and oncological outcomes in oesophageal cancer surgery.</p> <p>Trial Registration</p> <p><a href="http://www.clinicaltrials.gov/ct2/show/NCT00937456">NCT00937456</a> (ClinicalTrials.gov)</p

Magnetic resonance imaging (MRI) in rectal cancer: a comprehensive review

Magnetic resonance imaging (MRI) has established itself as the primary method for local staging in patients with rectal cancer. This is due to several factors, most importantly because of the ability to assess the status of circumferential resection margin. There are several newer developments being introduced continuously, such as diffusion-weighted imaging and imaging with 3 T. Assessment of loco-regional lymph nodes has also been investigated extensively using different approaches, but more work needs to be done. Finally, evaluation of tumours during or after preoperative treatment is becoming an everyday reality. All these new aspects prompt a review of the most recent advances and opinions. In this review, a comprehensive overview of the current status of MRI in the loco-regional assessment and management of rectal cancer is presented. The findings on MRI and their accuracy are reviewed based on the most up-to-date evidence. Optimisation of MRI acquisition and relevant regional anatomy are also presented, based on published literature and our own experience