Resection of T4 hepatocellular carcinomas with adjacent structures,is it justified?

BACKGROUND:T4 hepatocellular carcinoma (HCC) with invasion to adjacent structure(s) may require resection of not only the tumor but also the invaded structure(s).This study aims to assess whether such combined resection for T4 HCC is justifiable.METHODS:Adult patients with T4 HCC were divided into three groups.Group 1:tumors and invaded adjacent structures were resected together if histopathologically confirmed tumor invasion;group 2:same as group 1 but histopathologically confirmed tumor adhesion;group 3:tumor resection only.Group comparisons were made.RESULTS:Totally 144 patients were included in the study.There were 71,14 and 59 patients in groups 1,2 and 3,respectively.The groups were comparable in demographics,complication and survival.Ten hospital deaths occurred (5,0 and 5 in groups 1,2 and 3,respectively;P=0.533).The 5-year overall survival (hospital mortality excluded) was 17.8％ in group 1,14.3％ in group 2,and 28.9％ in group 3 (P=0.191).The 5-year disease-free survival was 10.4％ in group 1 and 14.5％ in group 3 (no data for group 2 yet) (P=0.565).On multivariate analysis,macrovascular invasion and poor differentiation were risk factors for survival whereas combined resection did not impact patients' survival.CONCLUSIONS:Combined resection achieved survival outcomes similar to tumor resection only.Patients with tumor invasion and those with tumor adhesion had comparable survival after combined resection.At centers with the required expertise,combined resection should be attempted to treat T4 HCCs with clinically suspected invasion of adjacent structures.     

Pancreatectomy combined with multivisceral resection for pancreatic malignancies: is it justified? Results of a systematic review

Background

Multivisceral resections combined with pancreatectomy have been proposed in selected patients with tumor invasion into adjacent organs, in order to allow complete tumor resection. Some authors have also reported multivisceral resection combined with metastasectomy in very selected cases. The utility of this practice is debated. The aim of the review is to compare the postoperative results and survival of pancreatectomies combined with multivisceral resections with those of standard pancreatectomies.

Partial hepatic resection for liver metastases of non-colorectal origin, is it justified?

BACKGROUND/AIMS: The liver is a common site of metastases for many solid tumors. Resection of noncolorectal liver metastases is controversial. The aim of this retrospective study is to evaluate partial liver resection as a treatment option for non-colorectal liver metastases. METHODOLOGY: During a 20-year period, 480 patients underwent partial liver resection. Thirty-two patients (17 male, 15 female, median age 55 years) who received partial liver resection for noncolorectal liver metastases were identified. A detailed analysis of these patients was conducted. RESULTS: Primary tumors were: medullary thyroid cancer (n=3), Grawitz tumor (n=2), breast carcinoma (n=2), stomach carcinoma (n=2), neuroendocrine carcinoma (n=10), unknown primary origin (n=9) and various other carcinomas (n=4). Operative morbidity and mortality for partial liver resection were 28 and 6%, respectively. The median overall survival time was 37 months, with an actuarial 5-year survival of 42%. Actuarial 5-year survival rates for patients with neuroendocrine and the non-neuroendocrine carcinomas were 22 and 52% respectively (NS). Median survival for patients with carcinoma of unknown primary origin was 43 months with an actual 5-year survival of 44%. CONCLUSIONS: Partial liver resection for liver metastases of non-colorectal primaries can be performed safely and has survival rates comparable to that of colorectal metastases in carefully selected cases and should therefore be considered.     

Intermittent clamping of the hepatic pedicle in simultaneous ultrasonography-guided liver resection and colorectal resection with intestinal anastomosis: is it safe?

Purpose

In patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) potentially candidates to combined liver (LR) and colorectal resection (CRR), the extent of LR and the need of hepatic pedicle clamping (HPC) in selected cases are considered risk factors for the outcome of the intestinal anastomosis. This study aimed to determine whether intermittent HPC is predictive of anastomotic leakage (AL) and has an adverse effect on the clinical outcome in patients undergoing combined restorative CRR and LR.

Methods

One hundred six LR have been performed for CRLM in our unit from July 2005. Patients who received CRR with anastomosis and simultaneous intraoperative ultrasonography (IOUS)-guided LR/ablation for resectable CRLM were included in this study. CRR was performed first. Intermittent HPC was decided at the discretion of the liver surgeon. The perioperative outcome was evaluated according to occurrence of AL and overall postoperative morbidity and mortality.

Results

Thirty-eight patients underwent simultaneous IOUS-guided LR/ablation and CRR with intestinal anastomosis; 19 underwent intermittent HPC (group ICHPY) while 19 did not (group ICHPN); the mean?±?SD (range) duration of clamping in group ICHPY was 58.6?±?32.2 (10.0–125.0)?min. Postoperative results were similar between groups. One asymptomatic AL occurred in group ICHPY (5.2 %). Major postoperative complications were none in group ICHPY and one (5.2 %) in group ICHPN, respectively. One patient in group ICHPY died postoperatively (5.2 %).

Conclusions

This study suggests that intermittent HPC during LR is not predictive of AL and has no adverse effect on the overall clinical outcome in patients undergoing combined restorative colorectal surgery and hepatectomy for advanced CRC.     

Malignant melanoma of the lung: is it easy to determine its origin?

Malignant melanoma involving the respiratory tract is nearly always metastatic. True primary tumors are very rare, and only approximately 28 cases have been reported in the literature. Extensive clinical and histopathological examinations are needed to ascertain that the lung is the primary site. We present the case of a 67-year-old man with an apparent primary malignant melanoma of the lung in the right lower lobe. We also review the literature.     

Routine histological analysis of resected lung tissue in primary spontaneous pneumothorax -- is it justified?

Surgical management of spontaneous primary pneumothorax consists of pleurectomy together with resection of blebs or bullae. We analysed the utility of routine histological examination of these resected specimens. A consecutive series of 64 resected specimens were reviewed, of which 43 (67%) showed the presence of bullae or blebs. Of the remainder, 20 (31%) specimens showed no evidence of bullae or blebs and 1 specimen showed the presence of pneumatocoeles. Examination of the lung parenchyma revealed inflammation in 34 (53%) cases. In all 64 cases, the histological results did not result in a change in medical therapy. Although resected lung specimens from patients with primary spontaneous pneumothorax show diversity in their histological characteristics, we would question the utility of routine pathological analysis of resected lung specimens in primary spontaneous pneumothorax.     

Infection: is it a cause of bladder cancer?

This article reviews the literature regarding the possible correlation between infection and occurrence of bladder cancer. The PubMed literature database was searched from inception to January 2008. Keywords of bladder, cancer, parasitic, bacterial, viral and infection, were used. Forty studies were included in the review. Several investigators support the idea that schistosomiasis is aetiologically related to the development of bladder cancer in individuals infected with Schistosoma haematobium. Approximately 70% of those with chronic schistosomiasis who have bladder cancer develop squamous cell rather than transitional cell carcinoma. Several investigators suggest that bacteria may play a role in inducing bladder cancer. Clinically, researchers have linked the development of infection, urinary stones and indwelling catheters with bladder cancer. Nevertheless, to date, no prospective study has examined the association between urinary tract infection and bladder cancer risk. The possibility that infection by human papilloma virus (HPV) is a risk factor contributing to bladder cancer has been investigated but no definite conclusions have been drawn. Thus, the debate remains open as to whether there is any direct link between chronic HPV infection and bladder cancer. Only 15 cases of vesical carcinoma have been reported, to date, in the setting of human immunodeficiency virus (HIV). The rare occurrence of bladder cancer during HIV infection and the lack of correlation with the laboratory markers of HIV disease progression may suggest a trivial association between two unrelated disorders. BK virus is oncogenic in newborn hamsters and can transfer to mammalian cells in vitro, but there is little consistent evidence of a link with human bladder cancer. Studies showed no correlation between herpes simplex virus (HSV) and bladder cancer, but bladder cancer becomes infected with HSV much more easily than non-neoplastic urothelium. In conclusion, with the exception of chronic infection with S. haematobium, the association between the occurrence of bladder cancer and chronic bacterial or viral infections could not be confirmed. Prospective studies with large numbers of patients and controls are required to confirm this issue.     

The surgical management of early-stage lung adenocarcinoma: is wedge resection effective?

BackgroundThe aim of the study was to explore the outcomes of wedge resection on patients with early-stage lung adenocarcinoma (LUAD) and further identify potential prognostic factors for these patients.MethodsA retrospective cohort of 190 patients (99 solitary LUAD and 91 multifocal LUAD) undergone wedge resection from October 2014 to September 2015 was established. Cox proportional-hazards model was used to evaluate the significant clinical prognostic factors. Further, data on patients with multifocal adenocarcinoma after segmentectomy were retrieved and propensity score matching was used to compare the outcomes of patients with multiple pulmonary nodules (MPNs) after wedge resection and segmentectomy.ResultsThe 5-year overall survival (OS), progression-free survival (PFS), and lung cancer specific survival of the 190 patients after wedge resection were 95.5%, 87.9%, and 97.7%, respectively. Multivariable analysis showed that MPN [hazard ratio (HR) 3.07; 95% confidence interval (CI), 1.05–8.98] and solid-dominant lesions (HR 15.87; 95% CI, 2.38–105.84) were independently associated with worse PFS. Further, propensity score matching analysis showed that MPN patients had better PFS after segmentectomy compared with wedge resection (94% vs. 80.9%, P=0.008). MPN patients were more likely to perform systematic mediastinal nodal sampling (95.6% vs. 59.3%, P<0.001) after segmentectomy compared to patients who underwent wedge resection.ConclusionsWedge resection is a practical option for appropriately selected early-stage LUAD where tumor size is less than 2 cm and has a consolidation-to-tumor ratio ≤0.5. However, for MPNs, wedge resection may be not reliable and alternative procedures such as segmentectomy should be used.     

What is the role of tests of lung function in the management of infants with lung disease?

This review considers whether there is a role for lung function tests in the clinical management of infants with lung disease. The purpose of testing lung function in older subjects, the tests available for infants, and the practical problems of testing lung function in infants are considered. After reviewing all the facts, we suggest that there are four situations in which lung function testing should be recommended for infants, as follows: (1) the infant who presents with unexplained tachypnea, hypoxia, cough, or respiratory distress in whom a definitive diagnosis is not apparent from physical examination and other, less difficult investigations; (2) the infant with severe, continuous, chronic obstructive lung disease who does not respond to an adequate clinical trial of combined corticosteroid and bronchodilator therapy; (3) the infant with known respiratory disease of uncertain severity in whom there is need to justify management decisions; and (4) research and development. A review of 62 recent publications to determine how lung function tests are being used at the present time showed that they are being used overwhelmingly for research. The role of lung function testing in the clinical management of infants has not been established, and research is needed to clarify this situation. We suggest that such studies should explore the role of lung function tests in infants with specific symptoms, signs, or diagnoses, taking into account information from other types of investigation and the cost/benefit/risk ratios.     

Open lung biopsy in diffuse infiltrative lung disease with progressive dyspnoea: is it useful?

Eleven subjects, aged between 15 and 60 years, presenting with diffuse infiltrative lung disease (DILD) and progressive dyspnoea, underwent an open lung biopsy (OLB). The authors feel that OLB does give a confidence to the treating physician to begin with a specific therapy in the form of steroids. But, as a matter of fact, at most health care delivery centres in the country, facilities for OLB are not available. Hence, the specific therapy should be instituted presumptively following an overall suggestion of disease based upon the clinical, physiological (chiefly comprising the pulmonary function test or PFT) and the radiological criteria, so that progression of disease could be arrested at an early stage.     

Ultrasonography: is it useful in the diagnosis of cancer in thyroid nodules?

The role of ultrasonography (US) in the diagnosis of cancer in thyroid nodules is not well-established. The aim of the present study was to evaluate US performance in predicting cancer in thyroid nodules using a novel approach. Two hundred and eighty-nine patients with thyroid nodular disease were evaluated with clinical, biochemical and cytopathological examinations. Eighty patients with palpable solitary thyroid nodules or multinodular goiters who were to undergo surgery were included, and had a US exam performed by one of us. Some US characteristics of thyroid nodules were associated to cancer: absent halo, hypoechogenicity and microcalcifications, with sensitivity, respectively, of 56, 44 and 56%, and specificity of, respectively, 80, 83 and 94%. These findings were considered positive and were studied in two different combinations: simultaneous, when two or more were positive, and parallel, when any positive finding was present. When positive findings were studied simultaneously, sensitivity ranged 25 to 38% and specificity ranged 89 to 97%. Microcalcifications, associated or not to other findings, were highly specific for thyroid cancer, but they were only present in half of the malignancies. When positive findings were studied in parallel, sensitivity ranged 69 to 81% and specificity ranged 70 to 81%. The parallel combination of hypoechogenicity or microcalcifications or absent halo improved US sensitivity to 81% with an acceptable specificity (70%). This method is potentially useful to help us select patients for surgery when fine-needle aspiration biopsy is repetitively non-diagnostic or select for biopsy incidentally discovered non-palpable nodules.     

Screening for lung cancer with chest computerized tomography: Is it cost efficient?

Despite lung cancer (LC) screening by low-dose computerized tomography (LDCT) gaining many proponents worldwide, for many years it was not recognized as a life-prolonging and cost-effective procedure, until recently. Prospective observational studies had not been able to prove that this screening prolongs survival, but they helped to specify the inclusion and exclusion criteria. Long-awaited results of a prospective, randomized trial finally provided the evidence that LC screening with LDCT can prolong survival of the screened population. Several cost-effectiveness analyses were performed to justify mass introduction of this screening. Results of these analyses are equivocal, although conclusions highly depend upon inclusion and exclusion criteria, methods of analysis and prices of medical procedures which differ between countries as well as the incidence of other pulmonary nodules, especially tuberculosis. Therefore, cost-effectiveness analysis should be performed separately for every country. Cost-effectiveness depends especially upon the rate of false-positive results and the rate of unnecessary diagnostic, screening and treatment procedures. To ensure high cost-effectiveness, LC screening should be performed in accordance with screening protocol, in dedicated screening centers equipped with nodule volume change analysis, or as a prospective non-randomized trial, to ensure compliance with the inclusion and exclusion criteria. To ensure high cost-effectiveness of LC screening, future research should concentrate on determination of high-risk groups and further specifying the inclusion and exclusion criteria.     

Principles of biopsy in suspected lung cancer: priority still based on invasion in the era of targeted therapy?

There are multiple ways to obtain a biopsy for patients with suspected lung cancer under clinical circumstances. Diagnostic goals described previously in literature should be achieved preferably by using the safest, least invasive, and least costly biopsies. Insight into molecular profile and era of targeted therapy challenged the previous concepts on tumor biopsy. Distinct principles of biopsy should be revisited to adopt the advances in clinical research. A 53-year-old gentleman with 10-year history of dust exposure consulted to our hospital because of bloody sputum. PET/CT scanning revealed a 3.2-centimeter mass with an increased ¹⁸F-FDG uptake in right upper lung lobe, metabolically active lesions in multiple stations of mediastinal or bilateral hilar lymph nodes and an intramuscular nodule in the left gluteus maximus. He underwent transthoracic core needle biopsy of the lung mass, resection of intramuscular nodule, bronchoscopy and right upper lung lobectomy in sequence. The final diagnosis was considered as systemic lipid deposition. Principles of biopsy in suspected lung cancer should be prioritized in sequence based on weight in clinical management, acquisition of tissue, invasion, efficiency and cost.KEY WORDS : Lung cancer, biopsy, principle, management     

Surgery without preoperative histological confirmation of lung cancer: what is the current clinical practice?

BackgroundThere are discordances in the guidelines regarding the need to acquire histological diagnosis before surgical treatment of (presumed) lung cancer. Preoperative histological confirmation is always encouraged in this setting to prevent unnecessary surgery or when sublobar resection for small-sized tumors is considered. The aim of this retrospective cohort study was to assess the proportion of patients undergoing lung cancer resection in the Netherlands without preoperative pathological confirmation, based on the intraoperative pathological diagnosis (IOD) rate, and to determine characteristics that may influence IOD frequency.MethodsData on 10,226 patients, who underwent surgical treatment for lung cancer from 2010 to 2015, were retrieved from the Netherlands National Cancer Registry. We registered an IOD when the date of diagnosis equaled the date of the first surgical intervention. Tabulations and multivariable logistic regression were used to identify predictive parameters for IOD.Results36% of surgical procedures were classified as IOD, and decreased with increasing tumor size and extent of surgery (57% for segmentectomy, 39% for lobectomy and 11% for pneumonectomy). IOD was more frequently observed in adenocarcinoma (41%), varied between hospitals from 13% to 66% and was less common when patients were referred from a hospital where thoracic surgery was not performed. Previous history of cancer did not affect IOD.ConclusionsMore than one-third of patients with suspected lung cancer in the Netherlands was operated without preoperative histological confirmation. There was significant variation in IOD rates between different hospitals, which deserves further detailed analysis when striving for uniform surgical quality of care for patients with lung cancer.