Synchronous colorectal liver metastases

Colorectal cancer is one of the most common malignancies worldwide and ranks second in cancer-related deaths in many parts of the Western world. Once in the lymph or blood vessels, colorectal cancer can quickly spread and the liver is known to be a favourable site for metastases. The presence of colorectal liver metastasis (CLM) is associated with a poor outcome. In last centuries new developments in techniques and anatomical knowledge have improved the outcome for this group of patients. Kousnetzoff and Pensky (1896) suggested the use of haemostasis by electrocautery, tourniquet, and suturing with flexible needles for controlling bleeding. The Pringle manoeuvre (1908), a technical advance which established the vascular control of the liver by compressing the portal triad, was a major step in surgery. Different techniques to reduce bleeding followed, including ligation, vascular and aortic clamping. Topographic liver anatomy generally describes the liver in terms of four lobes: right, left, quadrate, and caudate. However, the veins, arteries, and bile ducts of the liver do not conform to this anatomic division. Healey (1953) used the hepatic arteries and bile ducts as the basis of division and Couinaud (1957) the portal and hepatic veins. In 1999 Couinaud described that the portal and hepatic vein segmentation has to be preferred over the arteriobiliary segmentation. Throughout the world, liver surgeons used different terms. In 2000, a group of international liver surgeons proposed a standardized Nomenclature. The use of Brisbane 2000 terminology of hepatic anatomy and resection has led to better communication among surgeons. Many technical tools in the last 20-30 years further refined hepatic surgery: the concept of routine intraoperative ultrasonography for liver surgery, vena portal embolization (VPE) and the introduction of the ultrasonic dissector for division of the hepatic parenchyma. The introduction of low central venous pressure anaesthesia and vascular inflow and outflow control were essential to minimize blood loss during hepatectomy. Today, resection for liver metastasis provides favourable outcomes compared with the natural history

Validation of Six Nomograms for Predicting Non-sentinel Lymph Node Metastases in a Dutch Breast Cancer Population

Background: The usefulness of axillary lymph node dissection (ALND) in patients with positive sentinel nodes (SN) is still an ongoing debate. Several nomograms have been developed for predicting non-sentinel lymph node metastases (NSLNM). We validated six nomograms using data from 10 years of breast cancer surgery in our hospital. Methods: We retrospectively analyzed all patients with a proven breast malignancy and a SN procedure between 2001 and 2011 in our hospital. Results: Data from 1084 patients were reviewed; 260 (24 %) had a positive SN. No patients with isolated tumor cells, 6 patients (8 %) with micrometastases, and 65 patients (41 %) with macrometastases had additional axillary NSLNM. In 2 patients (3 %) with micrometastases, the ALND influenced postoperative treatment. In the group of patients with macrometastases tumor size >2 cm, extranodal growth and having no negative SNs were predictors of NSLNM. The revised MD Anderson Cancer Center and Helsinki nomograms performed the best, with an area under the curve value of 0.78. Conclusions: ALND could probably be safely omitted in most patients with micrometastases but is still indicated in patients with macrometastases, especially in patients with tumor size >2 cm, extranodal growth, and no negative SNs. The revised MD Anderson Cancer Center and Helsinki nomograms were the most predictive in our patient group