Incidence,Management, and Implications of Visceral Thrombosis in Pancreatic Ductal Adenocarcinoma

Background

Visceral or splanchnic thrombosis is defined as thrombi within the hepatoportal venous system, including portal (PV), mesenteric (MV), and splenic vein (SV), as well as thrombi in renal or gonadal veins. There are limited data to evaluate the prognostic significance, incidence, and clinical management of visceral thromboses in patients with pancreatic ductal adenocarcinoma (PDAC).

C.T. Demonstration of Thrombosis of the Portal Venous System

Thrombosis involving all or part of the portal venous system was demonstrated by C.T. in three patients. Predisposing factors were sigmoid colectomy for adenocarcinoma, appen-diceal abscess and splenectomy for splenic arterio-venous malformation, respectively. Fresh thrombus appeared as high density intraluminal content on noncontrast enhanced scans. Older thrombus appeared as low density intraluminal content surrounded by a high density venous wall on contrast enhanced scans. One patient developed a cavernoma of the portal vein demonstrated by C.T. and porto-graphy. In another patient; bowel infarction with bowel wall thickening and intra-mural gas was demonstrated. Although the diagnosis can be made on non-contrast enhanced scans in the acute phase and by using the bolus intravenous technique for contrast enhanced scans for older thrombus, optimal demonstration of the presence of thrombus and clear definition of the extent of thrombosis requires a dynamic scanning technique during rapid intravenous infusion of contrast.     

Prevalence and Clinical Significance of Incidental and Clinically Suspected Venous Thromboembolism in Lung Cancer Patients

BackgroundIt is unclear what proportion of VTE events in lung cancer patients are incidentally discovered and whether incidental events affect mortality.Patients and MethodsWe conducted a retrospective cohort study of lung cancer patients seen at the University of Rochester between January 1, 2006 and December 31, 2008 with the goal of quantifying and characterizing VTE events. Multiple clinical variables and mortality outcomes were compared using Kaplan-Meier survival analysis and multivariate Cox proportional hazards.ResultsThe study population consisted of 207 subjects with lung cancer. The median age was 66 years and 55% were female (n = 115). Thirty-one patients (14.9%) experienced at least 1 VTE event with 32.2% (10/31) of these incidentally discovered. Incidental events comprised 29.4% (n = 5) of pulmonary embolisms, 11.1% (n = 2) of deep vein thrombosis, and 100% (n = 3) of visceral events. The median survival for patients with incidental VTE was 23.4 months (95% confidence interval [CI], 4.8-32.1) compared with 45.8 months (95% CI, 34.1-56.8) in patients without VTE (HR 2.4; 95% CI, 1.2-4.9; P = .01), but in a subgroup analysis of stage IV patients overall survival was not significantly different (HR, 0.94; P = .33). Patients with clinically suspected VTE had the lowest median survival at 13.1 months (95% CI, 6.4-18.9) which was significantly lower than patients without VTE (HR, 2.7; 95% CI, 1.6-4.5; P = .002), but not significantly different from patients with incidental VTE (HR, 1.2; 95% CI, 0.4-2.0; P = .7). In multivariate analysis, occurrence of VTE (HR, 2.3; 95% CI, 1.3-3.8; P = .002) was significantly associated with mortality when adjusting for age, stage, and histology.ConclusionsOne-third of VTE events in lung cancer patients are incidentally discovered and VTE has negative clinical effect in lung cancer patients.     

Systematic review and meta-analysis of prognostic role of splenic vessels infiltration in resectable pancreatic cancer

Background

Identification of factors associated with dismal survival after surgery in resectable pancreatic ductal adenocarcinoma is important to select patients for neoadjuvant treatment. The present meta-analysis aimed to compare the results of distal pancreatectomy for resectable adenocarcinoma of the pancreatic body-tail with and without splenic vessels infiltration.

Complete remission of advanced hepatocellular carcinoma by sorafenib: A case report

Hepatocellular carcinoma (HCC) is the fifth most common malignant disease worldwide, and curative treatment remains difficult because the majority of cases are diagnosed in the advanced stage. Sorafenib is the only known effective systemic treatment, but patients rarely achieve complete remission (CR). A 66-year-old man with a history of alcoholic liver cirrhosis with a diagnosis of advanced HCC, was initially treated with transarterial chemoembolization on four occasions. However, the disease progressed with portal vein thrombosis. Therefore, sorafenib was started, and 4 mo later, the patient achieved CR. The treatment was continued for 12 mo, and CR was maintained up to 4 mo after sorafenib discontinuation.     

A combination therapy with transarterial chemo-lipiodolization and systemic chemo-infusion for large extensive hepatocellular carcinoma invading portal vein in comparison with conservative management

PURPOSE: Hepatocellular carcinoma (HCC) invading the portal vein is a medical challenge. We evaluated the therapeutic efficacy of a combination of transarterial and systemic chemo-infusion for large HCC with portal vein thrombosis (PVT) compared with conservative management. PATIENTS AND METHODS: This was a case-control cohort study of 103 consecutive patients with Child-Pugh class A who had a large (>10 cm) HCC with PVT. The patients were assigned to receive either combined transarterial epirubicin (50 mg/m(2)) plus cisplatin (60 mg/m(2)) chemo-lipiodolization and systemic 5-fluorouracil (200 mg/m(2)) chemo-infusion (ECF regimen) at monthly intervals (n=80) or conservative management (n=23). RESULTS: The objective tumor response (21.3 vs. 0%, P=0.011) and overall survival (8.7 vs. 3.5 months, P<0.001) were significantly better in the treatment group than in the conservative group. The prognostic factors for survival were tumor type (P=0.007), bilobar involvement (P=0.001), distant metastasis (P=0.009) and objective tumor response (P<0.001) for the treatment group. Survival benefits with the treatment were also maintained in each subgroup after stratification of these variables. CONCLUSIONS: This study suggests that when the hepatic function is preserved, a therapeutic strategy could be more beneficial than conservative management for such a large extensive HCC. As a therapeutic option, a combination therapy using ECF regimen may provide a significantly better tumor response and survival benefit in patients with large HCC invading the portal vein.     

Prophylactic Versus Therapeutic Mastectomy: A Contemporary Analysis of the ACS-NSQIP Database

IntroductionThe objective of the study was to evaluate the morbidity, mortality, and postoperative outcomes associated with simple or subcutaneous mastectomy in the management of prophylactic versus therapeutic resection. In this study we aimed to assess if simple or subcutaneous mastectomy for prophylaxis affects perioperative outcomes compared with resection performed for biopsy proven malignancy.Materials and MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried for subjects who underwent simple or subcutaneous mastectomy between 2007 and 2012. Patient demographic characteristics, comorbid conditions, and postoperative complications were analyzed.ResultsOf the 30,803 patients, 30,644 (99.5%) underwent therapeutic mastectomy and 159 (0.5%) underwent prophylactic mastectomy. Subjects who underwent prophylactic surgery were more likely to be younger (45 vs. 58 years; P < .01) and white (134 [84%] vs. 20,647 [67%]; P < .01). Surgery time was significantly greater in the prophylactic group (265 vs. 166 minutes; P < .01). There was no significant difference in mortality between groups. There was a trend toward greater 30-day morbidity (15 [9%] vs. 1835 [6%]; P = .09) and occurrence of deep venous thrombosis (DVT; 2 [1%] vs. 74 [0.2%]; P = .06) in those who underwent prophylactic mastectomy. After age adjustment, the prophylactic group showed a nearly sixfold increase in DVT (odds ratio [OR], 5.77; 95% confidence interval [CI], 1.37-24.22), which persisted when controlling for surgery time (OR, 4.95; 95% CI, 1.18-20.86).ConclusionProphylactic simple or subcutaneous mastectomy incurs significant additional 30-day postoperative morbidity related to perioperative DVT. Risk-mitigating strategies should be considered in the perioperative care of this patient population.     

Risk of venous thromboembolism in people with lung cancer: a cohort study using linked UK healthcare data

Background:

Venous thromboembolism (VTE) is a potentially preventable cause of death in people with lung cancer. Identification of those most at risk and high-risk periods may provide the opportunity for better targeted intervention.

Methods:

We conducted a cohort study using the Clinical Practice Research Datalink linked to Hospital Episode Statistics and Cancer Registry data. Our cohort comprises 10 598 people with lung cancer diagnosed between 1997 and 2006 with follow-up continuing to the end of 2010. Cox regression analysis was performed to determine which demographic, tumour and treatment-related factors (time-varying effects of chemotherapy and surgery) independently affected VTE risk. We also determined the effect of a VTE diagnosis on the survival of people with lung cancer.

Results:

People with lung cancer had an overall VTE incidence of 39.2 per 1000 person-years (95% confidence interval (CI), 35.4–43.5), though rates varied depending on the patient group and treatment course. Independent factors associated with increased VTE risk were metastatic disease (hazard ratio (HR)=1.9, CI 1.2–3.0 vs local disease); adenocarcinoma subtype (HR=2.0, CI 1.5–2.7, vs squamous cell; chemotherapy administration (HR=2.1, CI 1.4–3.0 vs outside chemotherapy courses); and diagnosis via emergency hospital admission (HR=1.7, CI 1.2–2.3 vs other routes to diagnosis). Patients with VTE had an approximately 50% higher risk of mortality than those without VTE.

Conclusions:

People with lung cancer have especially high risk of VTE if they have advanced disease, adenocarcinoma or are undergoing chemotherapy. The presence of VTE is an independent risk factor for death.     

Portal vein embolization failure: Current strategies and future perspectives to improve liver hypertrophy before major oncological liver resection

Portal vein embolization (PVE) is currently considered the standard of care to improve the volume of an inadequate future remnant liver (FRL) and decrease the risk of post-hepatectomy liver failure (PHLF). PHLF remains a significant limitation in performing major liver surgery and is the main cause of mortality after resection. The degree of hypertrophy obtained after PVE is variable and depends on multiple factors. Up to 20% of patients fail to undergo the planned surgery because of either an inadequate FRL growth or tumor progression after the PVE procedure (usually 6-8 wk are needed before surgery). The management of PVE failure is still debated, with a lack of consensus regarding the best clinical strategy. Different additional techniques have been proposed, such as sequential transarterial chemoembolization followed by PVE, segment 4 PVE, intra-portal administration of stem cells, dietary supplementation, and hepatic vein embolization. The aim of this review is to summarize the up-to-date strategies to overcome such difficult situations and discuss future perspectives on improving FRL hypertrophy.     

Adenocarcinoma of the Lung in Childhood and Adolescence: A Systematic Review

Primary lung cancer is extremely rare in children. It often presents with metastatic disease and carries a poor prognosis. Adenocarcinoma is the most common type of bronchogenic carcinoma in children and adults. Our aim was to systematically review the presenting features, approach to diagnosis and management, as well as the outcomes of primary pediatric adenocarcinoma of the lung. This systematic review was prospectively registered with PROSPERO. The following databases were searched: Medline, Embase, Web of Science, and Scopus for English language cases of primary pediatric adenocarcinoma of the lung. Forty-eight studies were included, comprising 62 patients with adenocarcinoma and 21 cases of adenocarcinoma in situ. Presenting features were nonspecific, with cough and dyspnea the main symptoms at diagnosis. The majority of patients with adenocarcinoma had metastatic disease at diagnosis. Surgery was the most common form of management. More than half the patients with adenocarcinoma had died at final follow-up, whereas 5 of 21 with adenocarcinoma in situ died. Medical management did not improve outcomes, except for two ALK receptor tyrosine kinase (ALK)–rearranged adenocarcinomas that responded to ALK inhibitor therapy alone. Primary pediatric adenocarcinoma of the lung is a rare entity which often presents with metastatic disease and portends a poor prognosis. Surgery is associated with disease-free status, although new agents such as ALK-inhibitors are able to prolong life without surgical management.     

Internal Jugular Vein Tumor Thrombus: A Tricky Question for the Thyroid Surgeon

Internal jugular vein tumor thrombus is an extremely rare condition in thyroid carcinoma, but it does exist. Correlated with greater aggressiveness with a higher incidence of distant metastases at diagnosis and a higher recurrence rate, this important prognostic element should be systematically investigated by ultrasound operators in all patients presenting with thyroid carcinoma. The patient’s follow-up must be careful. This can be a trap that surgeons must look for in their preoperative checklist. We report the case of a 58-year-old woman with an IJV thrombus associated with multiple bone metastases. She underwent successful surgical treatment, and postoperative pathology showed a poorly differentiated follicular carcinoma of the thyroid and a tumor thrombus in the internal jugular vein.     

恶性肿瘤伴发下肢深静脉血栓形成的机制及治疗对策探讨

 目的　探讨恶性肿瘤伴发下肢深静脉血栓形成的机制及其治疗对策。方法　对 2 5例恶性肿瘤伴发下肢深静脉血栓形成的患者与随机选取的 2 5例健康成人进行血液流变学比较 ,并对此类患者的治疗过程进行回顾分析。结果　恶性肿瘤组的 ηb、ηp、Fib、HCT、ESR等五项指标均高于对照组 ,具有显著的统计学差异 (P <0 .0 1或 0 .0 5 ) ;在近期疗效上 ,经抗凝、溶栓、祛聚集治疗 3天后 ,病情好转率为 6 0 %。病情加重或无变化的患者 ,立即给予化疗 ,病情得到明显改善者占 90 %。结论　恶性肿瘤患者存在血液流变学变化 ,所导致的高凝状态易诱发下肢深静脉血栓的形成 ;在通过常规溶栓、抗凝、祛聚集等治疗无明显效果时 ,应考虑有癌栓的可能 ,应果断给予化疗。     

回生口服液对中晚期非小细胞肺癌患者化疗后血凝状态及疗效的影响

目的评价回生口服液对中晚期非小细胞肺癌（NSCLC）患者化疗后血凝状态及疗效的影响。方法将69例首次确诊且可接受化疗的中晚期NSCLC随机分为实验组35例和对照组34例,两组皆采用含铂三代一线方案（吉西他滨+顺铂,或多烯紫杉醇+顺铂）化疗,21天为一周期。其中实验组在化疗同时配合使用回生口服液,10毫升/次,3次/日,从化疗当天开始口服,全程使用直至化疗终止。所有患者至少接受2周期化疗并评价临床客观疗效,在化疗前和第二周期化疗结束后一周检测血小板（PLT）、D-二聚体（D-dimer）、纤维蛋白水平（FIB）。结果实验组总有效率74.3%（26/35）,临床受益率（CBR）为80.0%（28/35）,疾病进展时间（TTP）为(5.5±2.8)月,平均生存期为(11.1±5.8)月。对照组总有效率47.1%（16/34）,CBR为55.9%（20/34）,TTP为(4.2±2.5)月,平均生存期为(8.4±5.3)月,两组总有效率、CBR、TTP与平均生存期比较差异均有统计学意义（P<0.05）;化疗后实验组PLT(157±89)×109/L、D-dimer(2078±770)μg/ml、FIB(3.8±1.4)g/L,与对照组PLT(208±118)×109/L、D-dimer(2680±980) μg/ml、FIB(4.6±1.8)g/L比较差异均有统计学意义（P<0.05、P<0.01、P<0.05）,且对照组化疗后有3例（8.8%）发生深静脉血栓,实验组无1例发生。结论回生口服液配合化疗提高了NSCLC患者近期疗效,并在一定程度上改善了血液高凝状态,可预防深静脉血栓的发生,并能延长TTP和平均生存期,值得临床推广。     

肺癌患者围手术期高凝状态的实验室指标特征及对深静脉血栓形成的诊断价值

目的 探讨肺癌患者围手术期高凝状态的实验室指标特征及对深静脉血栓形成（DVT）的诊断价值。方法 143例围手术期患者均接受双下肢深静脉加压超声检查和实验室指标检测。对DVT（+）与（-）组围手术期水平变化有明显差异的实验室指标进行ROC曲线下面积分析（AUC）及找出诊断界值。结果 术后第3~7天下肢DVT者33例。全组患者术后纤维蛋白原降解产物（FDP）、D-二聚体（D-Dimer）、脑钠肽和C反应蛋白水平在术后第1~7天均明显升高（P<0.05）。DVT（+）与DVT（-）组围手术期FDP和D-Dimer水平的变化差异有统计学意义（P<0.05）,POD1（术后第1天）-FDP、POD3-FDP和POD3-D-Dimer的AUC和诊断界值分别为（0.726、4.65 μg/ml）、（0.811、4.85 μg/ml）和（0.772、1.55 μg/ml）,其联合诊断的串联试验敏感度为46.5%,特异度为94.9%。结论 术后第1天及第3天FDP和术后第3天D-Dimmer水平增高对DVT的诊断价值中等,串联试验联合诊断可明显提高特异度。