Gastric melanoma of unknown primary

We describe a case of a patient with anemia referring to our Digestive Endoscopy Unit. Upper GI endoscopy revealed a polypoid lesion with an ulcerated central depression. Histopathological examination of the biopsy specimen taken during endoscopy revealed a gastric metastatic melanoma. The dermatologic inspection failed in finding the primary melanoma. The importance of endoscopic examination in the diagnostic process of metastatic patients with unknown primaries is highlited by this case

Die Behandlungspraxis bei Patienten mit isolierter stumpfer Milzverletzung: Eine Befragung der Schweizer Traumatologen

Zusammenfassung: Hintergrund: Das nicht-operative Management (NOM) des stumpfen Milztraumas hat sich in den vergangenen Jahren als Therapiekonzept etabliert. Es bestehen jedoch zahlreiche Kontroversen bezüglich der Überwachung und Nachsorge dieser Patienten. Ziel dieser Studie war es, mittels einer Umfrage bei Mitgliedern der Schweizerischen Gesellschaft für Allgemeine und Unfallchirurgie (SGAUC) die aktuelle Praxis bezüglich NOM beim isolierten Milztrauma zu erfassen und mögliche Diskrepanzen zur aktuellen Literatur zu eruieren. Studiendesign und Untersuchungsmethode: Sämtliche praktizierende Mitglieder der SGAUC wurden mittels schriftlichem Umfragebogen adressiert. Dieser enthielt Fragen zu Person und Klinik des Chirurgen, Fragen zu Diagnostik und Management während der Hospitalisation sowie zu radiologischen Verlaufskontrollen und zur stufenweisen Wiederaufnahme von Alltagsaktivitäten. Ergebnisse: An der Umfrage nahmen 52 von 165 (31,5%) praktizierenden Mitgliedern der SGAUC teil. Diese deckten 62,8% aller Schweizer Traumazentren ab. Vierzehn Befragte (26,9%) verfügen an ihrer Klinik über ein Protokoll zur Behandlung des Milztraumas. Als initiale Bildgebung beim hämodynamisch stabilen Patienten mit stumpfem Abdomaninaltrauma gaben 82,7% der Befragten die Sonographie an. Bei sonographischem Verdacht auf Milztrauma verzichteten allerdings 19,2% der Befragten auf eine weitergehende Diagnostik. Die Hälfte der Chirurgen gab außerdem an, bei sichtbarem Kontrastmittelextravasat aus der Milz keine weiteren therapeutischen Maßnahmen einzuleiten. 86,5% der Befragten würden Patienten mit niedriggradigem Milztrauma für durchschnittlich 1,6 (0-4Tage) in einem kontinuierlich-monitorisierten Bett überwachen. Keine Unterschiede wurden hinsichtlich der Aktivitätsrestriktion zwischen mittel- und hochgradigen Milztraumata gemacht. Schlussfolgerung: Aufgrund eines Mangels an evidenzbasierten Richtlinien zum NOM des Milztraumas gibt es eine beträchtliche Variabilität in der klinischen Praxis selbst unter erfahrenen Chirurgen. Die größten Diskrepanzen zu den Empfehlungen in der aktuellen Literatur waren zum einen der Verzicht auf eine Computertomographie bei Verdacht auf Milztrauma, zum anderen das konservative Vorgehen trotz nachgewiesenem Kontrastmittelaustrit

Hepatocellular adenoma: An unsolved diagnostic enigma

Hepatocellular adenoma (HCA) is a rare benign liver tumour associated with the use of oral contraceptives or other steroid medications which occurs predominantly in young and middle-aged women. Unlike other benign liver tumours, an HCA may be complicated by bleeding and malignant transformation. HCAs have been divided into four subtypes based on molecular and pathological features: hepatocyte nuclear factor 1\u3b1-mutated HCA, inflammatory HCA, \u3b2-catenin-mutated HCA, and unclassified HCA. \u3b2-catenin-mutated HCA has the highest risk of haemorrhage or malignant transformation. In the latest upgrade of the guidelines regarding the management of benign liver tumours published in 2016 by the European Association for the Study of the Liver, magnetic resonance imaging (MRI) was recognized to be superior to all other imaging modalities in detecting HCAs and in being able to subtype HCAs up to 80%, with positive identification of 1\u3b1-mutated HCA or inflammatory HCA achievable with > 90% specificity. This review analyzed the imaging features of HCA using MRI with hepato-specific contrast agents, focusing on the limitations in the HCA characterization

Experience with regorafenib in the treatment of hepatocellular carcinoma

Regorafenib is a diphenylurea oral multikinase inhibitor, structurally comparable to sorafenib, which targets a variety of kinases implicated in angiogenic and tumor growth-promoting pathways. Regorafenib was the first agent to positively show significant survival advantage as a second-line therapy in patients with unresectable hepatocellular carcinoma (HCC) who had previously failed first-line treatment with sorafenib. Recent evidence has shown that its antitumor efficacy is due to a comprehensive spectrum of tumor neo-angiogenesis and proliferation inhibition and immunomodulatory effects on the tumor microenvironment, which plays a crucial role in tumor development. This review addresses the rationale and supporting evidence for regorafenib’s efficacy in HCC that led to regorafenib’s approval as a second-line therapy. In addition, we review proof from clinical practice studies that validate the RESORCE trial results. We discuss regorafenib’s potential role in the newly emerging therapeutic strategy based on combination with immune checkpoint blockade and its possible extensibility to patient categories not enrolled in the registrative study

Surveillance for Hepatocellular Carcinoma Also Improves Survival of Incidentally Detected Intrahepatic Cholangiocarcinoma Arisen in Liver Cirrhosis

Background: Due to its poor survival, intrahepatic cholangiocarcinoma (ICC) is held to be a much more aggressive cancer than hepatocellular carcinoma (HCC). In most published series, patients were diagnosed when symptomatic. However, ICC is now increasingly being discovered during the surveillance for HCC in cirrhosis. Whether this earlier detection of ICC is associated with an equally dismal prognosis or not is unknown. Methods: This is amulticenter retrospective study of consecutive ICC patients. Patients were stratified into subgroups according to the absence/presence of cirrhosis. A propensity score matching was performed to reduce the potential biases. Cirrhotic patients were further stratified according to their surveillance status. The lead-time bias and its potential effects were also estimated. Results: We gathered 184 patients. Eighty-five patients (46.2%) were cirrhotic. Liver cirrhosis was not related to a worse overall survival (33.0 vs. 32.0 months, p = 0.800) even after the propensity score analysis (43.0 in vs. 44.0 months in 54 pairs of patients, p = 0.878). Among the cirrhotic population, 47 (55.3%) patients had received a diagnosis of ICC during a surveillance programme. The 2 subgroups differed in maximum tumour dimensions (30 vs. 48 mm in surveyed and non-surveyed patients, respectively). Surveyed patients were more likely to receive surgical treatments (59.8 vs. 28.9%, p = 0.003). Overall survival was higher in surveyed patients (51.0 vs. 21.0 months, p 0.001). These benefits were confirmed after correcting for the lead-time bias. Conclusions: Cirrhotic patients have different clinical presentation and outcomes of ICC according to their surveillance status. In our series, ICC in cirrhosis was not associated with worse OS. Cirrhosis itself should not discourage either surgical or non-surgical treatments

MANAJEMEN PEMBINAAN PERPUSTAKAAN KELURAHAN DI KOTA BANDUNG

Dinas Perpustakaan dan Kearsipan (Dispusip) Kota Bandung merupakan suatu bentuk dari perpustakaan umum yang memiliki fungsi membina perpustakaan. Pemberdayaan perpustakaan kelurahan di Kota Bandung saat ini belum terealisasi sesuai dengan jumlah kelurahan yang terdapat di kota Bandung sebanyak 151 kelurahan. Perpustakaan kelurahan dapat menjalankan fungsinya dengan baik sesuai dengan fungsi perpustakaan dengan penerapan fungsi manajemen perpustakaan. Masalah yang menjadi kajian pada penelitian ini bagaimana implementasi manajemen pembinaan perpustakaan kelurahan di Kota Bandung oleh Dispusip Kota Bandung. Tujuan penelitian ini yaitu untuk mendeskripsikan mengenai perencanaan, pengorganisasian, penggerakan dan pengawasan pembinaan perpustakaan kelurahan oleh Dispusip Kota Bandung. Metode yang digunakan pada penelitian ini adalah metode kualitatif dengan pendekatan studi kasus. Partisipan dalam penelitian ini terdiri atas tiga informan yang bertindak sebagai pustakawan dan key informan sebagai Kepala Bidang Pengembangan Perpustakaan dan Kearsipan menggunakan teknik purposive sampling. Instrumen penelitian yang digunakan adalah wawancara, observasi dan studi dokumentasi. Teknik analisis data yang digunakan adalah data reduction, data display, dan conclusion drawing (verification). Berdasarkan hasil penelitian yaitu sebuah konstuksi model manajemen pembinaan perpustakaan kelurahan yang menunjukkan bahwa kegiatan pembinaan perpustakaan kelurahan oleh Dispusip Kota Bandung relevan dengan fungsi manajemen. Fungsi perencanaan, pengorganisasian, penggerakan kegiatan manajemen pembinaan perpustakaan kelurahan di Kota Bandung terealisasi cukup baik. Namun pada fungsi pengawasan belum berjalan secara optimal, hal ini dikarenakan oleh keterbatasan sumber daya manusia yang dimiliki oleh Dispusip Kota Bandung. Program pembinaan ini diharapkan dapat mewujudkan penyelenggaraan perpustakaan kelurahan dan dapat memberikan kontribusi terhadap perbaikan/ penyempurnaan manajemen pembinaan perpustakaan oleh Dispusip Kota Bandung. ;--- Dinas Perpustakaan dan Kearsipan (Dispusip) Kota Bandung is a form of public library, which function is to develop urban village libraries. Currently, the empowerment of urban village libraries in 151 village in Bandung City is not realized yet. Urban village libraries can perform its functions properly in accordance with the implementation of library management functions. The problem of this study is how Dispusip Kota Bandung manages the implementation of urban village libraries coaching in Bandung City. The purpose of this study is to describe the planning, organizing, actuating, and controlling of urban village libraries coaching by Dispusip Kota Bandung. The research method used in this study is qualitative method with a case study approach. The subjects of this study consist of three informants who act as a librarian and a key informant as a Head of Library and Archive Development by using purposive sampling technique. The research instruments used in this study are interviews, observations, and documentation studies. This study uses data analysis technique of data reduction, data display, and conclusion drawing (verification). Based on the study of a model construction of urban village libraries coaching, the result is that the coaching activities of urban village libraries done by Dispusip Kota Bandung is relevant to the management functions. The functions of planning, organizing, and actuating of village libraries coaching activities in Bandung City are realized quite well. However, the function of controlling has not run optimally. This is due to the limitations of human resources owned by Dispusip Kota Bandung. This coaching program is expected to be able to realize the enforcement of urban village libraries and to give contribution to the improvement of library coaching management done by Dispusip Kota Bandung

Radiological Features of Microvascular Invasion of Hepatocellular Carcinoma in Patients with Non-Alcoholic Fatty Liver Disease

Background: The aim of the present study was to evaluate the presence and the prognostic value of the radiological signs of microvascular invasion (MVI) of hepatocellular carcinoma (HCC) in patients with non-alcoholic fatty liver disease (NAFLD). Methods: Between January 2015 and December 2017, all patients (91 patients) with de novo HCC or HCC recurrence occurring at least 2 years after the last treatment in NAFLD (36 patients) or with hepatitis C virus (HCV) liver disease (55 patients) were included. Each HCC was treated with liver resection and transplantation to obtain the anatomopathological confirmation of MVI. All patients had at least one available computed tomography (CT) scan or magnetic resonance imaging (MRI) performed no more than one month prior to the treatment. The clinical data of each patient, tumor burden (diameter, margins, two-trait predictor of venous invasion (TTPVI), and peritumoral enhancement), the recurrence rate (RR) after a 1-year follow-up, and the time to recurrence (TTR) were collected. Results: The NAFLD–HCC nodules were larger as compared to HCV–HCC (51 mm vs. 36 mm, p = 0.004) and showed a higher prevalence of TTPVI (38.9 vs. 20.0%, p = 0.058). At multivariate analysis, nodule diameter >50 mm was found to be the only independent prognostic factor of TTPVI (hazard ratio: 21.3, 95% confidence interval: 4.2–107.7, p < 0.001), and the presence of TTPVI was confirmed to be the only independent prognostic factors of recurrence (hazard ratio: 2.349, 95% confidence interval: 1.369–4.032, p = 0.002). No correlations were found between TTR and irregular tumor margins or peritumoral enhancement. Conclusion: The NAFLD–HCC patients had larger tumors at diagnosis and showed a more frequent presence of radiological signs of MVI as compared to the HCV–HCC patients. The MVI was related to a more rapid recurrence after curative treatments, demonstrating the prognostic value of this radiological diagnosis

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoa-neurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible