原发性肝细胞肝癌组织分化程度与超声造影的关系

目的探讨原发性肝细胞肝癌（HCC）超声造影与组织学分化程度的关系。方法回顾术前应用SonoVue超声造影剂的47例HCC患者超声造影表现,将所获得曲线形态和灌注参数与术后标本的组织分化程度进行对照分析。结果9例高分化HCC均为快上慢下型;24例中分化HCC,15例呈快上慢下型（20.80%）,19例（79.20%）呈快上快下型;14例低分化HCC,8例（57.10%）呈快上慢下型、6例（42.90%）呈快上快下型;不同分化程度HCC病灶始增时间、增强时间、峰值强度组间差异无统计学意义（P〉0.05）,始消时间差异有统计学意义（P〈0.05）。结论不同分化程度HCC超声造影TIC形态和声学定量参数变化特征不同,有助于术前无创性了解肿瘤分化程度。     

Contrast-enhanced ultrasound appearances of enhancement patterns of intrahepatic cholangiocarcinoma: correlation with pathological findings

The aim of this study was to investigate the correlation between enhancement patterns of intrahepatic cholangiocarcinoma (ICC) on contrast-enhanced ultrasound (CEUS) and pathological findings. The CEUS enhancement patterns of 40 pathologically proven ICC lesions were retrospectively analysed. Pathologically, the degree of tumour cell and fibrosis distribution in the lesion was semi-quantitatively evaluated. Four enhancement patterns were observed in the arterial phase for 32 mass-forming ICCs: peripheral rim-like hyperenhancement (n = 19); heterogeneous hyperenhancement (n = 6); homogeneous hyperenhancement (n = 3); and heterogeneous hypo-enhancement (n = 4). Among the four enhancement patterns, the differences in tumour cell distribution were statistically significant (p < 0.05). The hyperenhancing area on CEUS corresponded to more tumour cells for mass-forming ICCs. Heterogeneous hyperenhancement (n = 2) and heterogeneous hypo-enhancement (n = 2) were observed in the arterial phase for four periductal-infiltrating ICCs. In this subtype, fibrosis was more commonly found in the lesions. Heterogeneous hyperenhancement (n = 1) and homogeneous hyperenhancement (n = 3) were observed in the arterial phase for four intraductal-growing ICCs. This subtype tended to have abundant tumour cells. The CEUS findings of ICC relate to the degree of carcinoma cell proliferation at pathological examination. Hyperenhancing areas in the tumour always indicated increased density of cancer cells.     

不同组织病理学类型肝细胞癌超声造影定量血流灌注参数的差异

目的探讨不同组织病理学类型肝细胞癌（HCC）CEUS定量血流灌注参数的差异。方法选择36例经手术治疗并有病理结果的HCC患者。术前利用CEUS软件绘制病灶区时间-强度曲线,分析不同组织病理学类型HCC造影时间-强度曲线各参数的差异。结果 36例中,小梁状型14例,假腺样型9例,实性型11例,硬化型2例。小梁状型HCC的曲线峰值降半时间、下降斜率与假腺样型及实性型比较差异有统计学意义（P均〈0.05）。结论不同组织学结构类型HCC之间CEUS曲线参数存在差异;CEUS曲线参数对于判断HCC分化程度及组织学类型具有一定价值。     

超声造影在肝细胞肝癌射频治疗中的应用

目的探讨超声造影（CEUS）在肝细胞肝癌（HCC）射频消融（RFA）治疗中的应用价值。方法对接受RFA治疗的84例HCC患者共105个病灶,于治疗前、后行CEUS检查,与常规超声、增强CT比较,分析CEUS在治疗前、治疗后、随访中的作用。结果 RFA治疗前：CEUS清晰显示95.24%（100/105）病灶的边界,优于常规超声[47.62%（50/105）];CEUS测量病灶平均最大直径、面积较常规超声测值大,差异有统计学意义（P〈0.01）;CEUS对荷瘤动脉血管的显示率为60.95%（64/105）,高于彩色多普勒（25.71%）和增强CT（42.86%）。RFA治疗后：CEUS与增强CT评价疗效符合率为96.15%;3个病灶CEUS发现残留,CEUS引导下完成补充治疗。随访：CEUS评价RFA治疗后病灶残留或复发的敏感度、特异度和准确率分别为84.62%、95.40%和94.00%,与同期增强CT比较,差异无统计学意义（P〉0.05）。结论 RFA治疗HCC中,CEUS可有效辅助,具有重要价值。     

Laparoscopic and robotic partial nephrectomy without renal ischaemia for tumours larger than 4?cm: perioperative and functional outcomes

Purpose

To evaluate the technical feasibility, safety and functional outcomes of zero ischaemia laparoscopic and robotic partial nephrectomy with controlled hypotension for renal tumours larger than 4?cm.

Methods

We evaluated 121 consecutive patients with American Society of Anaesthesiologists (ASA) scores 1–2 who underwent laparoscopic (n?=?70) or robotic (n?=?51) partial nephrectomy with controlled hypotension with either tumour size ≤4?cm (group 1, n?=?78) or tumour size >4 cm (group 2, n?=?43) performed by a single surgeon from December 2010 to December 2011. Operative data, complications, serum creatinine, estimated glomerular filtration rates and effective renal plasma flow calculated from 99mTc-mercaptoacetyltriglycine renal scintigraphy were compared. Differences between groups were evaluated by the Chi-square test and the Student’s t test.

Results

A significant difference in mean intraoperative blood loss and postoperative complications was found between the two groups: 168?ml (range: 10–600?ml in group 1) and 205?ml (range: 90–700?ml in group 2); p?=?0.005, and 6.4?% versus 18.6?%; p?=?0.004, respectively. The mean percentage decrease of ERPF of the operated kidney was 1.8?% in group 1 and 4.1?% in group 2.

Conclusions

Laparoscopic and robotic partial nephrectomy with controlled hypotension for tumours >4?cm in ASA 1–2 patients was feasible with significant higher intraoperative blood loss and postoperative complications compared to smaller renal masses. The benefits of avoiding hilar clamping to preserve kidney function seem excellent.     

Role of Portal Vein Embolization in Hepatocellular Carcinoma Management and Its Effect on Recurrence: A Case-control Study

Background

Liver regeneration that occurs after portal vein embolization (PVE) may have adverse effects on the microscopic tumor foci in the residual liver mass in patients with hepatocellular carcinoma (HCC).

Methods

Fifty-four HCC patients with inadequate functional residual liver volume were offered PVE during a seven-year period. Among them, 34 (63%) patients underwent curative resection. They were compared with a matched control group (n?=?102) who underwent surgery without PVE. Postoperative complications, pattern of recurrence, and survival were compared between groups.

Results

In the PVE group, a pre-embolization functional residual liver volume of 23% (12–33.5%) improved to 34% (20–54%) (p?=?0.005) at the time of surgery. When the two groups were compared, minor (PVE, 24%; control, 29%; p?=?0.651) and major (PVE, 18%; control, 15%; p?=?0.784) complications were similar. After a follow-up period of 35?months (standard deviation 25?months), extrahepatic recurrences were detected in 10 PVE patients (29%) and 41 control patients (40%) (p?=?0.310). Intrahepatic recurrences were seen in 10 (29%) and 47 (46%) cases (p?=?0.109) in the PVE and control groups, respectively. In the PVE group, 41% (n?=?14) of the recurrences were detected before one year, compared with 42% (n?=?43) in the control group (p?=?1). Disease-free survival rates at 1, 3, and 5?years were 57, 29, and 26% in the control group and 60, 42, and 42% in the PVE group (log-rank, p?=?0.335). On multivariate analysis, PVE was not a factor affecting survival (p?=?0.821).

Conclusions

Portal vein embolization increases the resectability of initially unresectable HCC due to inadequate functional residual liver volume, and it has no deleterious oncological effect after major resection of HCC.     

Surgical treatment of extrahepatic recurrence of hepatocellular carcinoma

Purpose

The purpose of this study was to clarify the clinicopathological features of extrahepatic hepatocellular carcinoma (HCC) recurrence after hepatectomy in order to schedule optimal treatment strategies for better long-term outcomes.

Methods

A cohort of 206 patients who had undergone curative hepatectomy for HCC was analysed; 133 patients had developed relapse. Among them, 101 patients had intrahepatic recurrence only (IHR), and 32 patients had extrahepatic recurrence (EHR). Clinicopathological and survival data were compared between the two groups.

Results

The overall survival rate after hepatectomy was better in the IHR than in the EHR group (p?p?p?=?0.0295). Patients with more than two risk factors for EHR showed poor prognosis in comparison with patients without any risk factors (p?p?=?0.0098). Furthermore, among EHR patients with concomitant IHR, patients with controllable IHR had significantly better survival than those with uncontrollable IHR (524 vs. 147 days, p?=?0.0131).

Conclusions

EHR of HCC was associated with early recurrence, and risk factors for the occurrence of EHR included the presence of high PIVKA II, large tumours, and microscopic portal vein invasion. Resection of recurrent tumour and local control of concomitant IHR may improve the prognosis of EHR patients.     

Diffuse Infiltrative Hepatocellular Carcinoma: Assessment of Presentation, Treatment, and Outcomes

Background

Data on infiltrating hepatocellular carcinoma (HCC) are limited. We sought to define treatment and outcome of patients treated with infiltrating HCC compared with patients who had advanced multifocal HCC.

Methods

Between January 2000 and July 2011, a total of 147 patients with advanced HCC were identified from the Johns Hopkins Hospital database (infiltrative, n?=?75; multifocal, n?=?72). Clinicopathologic data were compared by HCC subtype.

Results

Patients with infiltrating HCC had higher alfa-fetoprotein levels (median infiltrative, 326.5?ng/mL vs. multifocal, 27.0?ng/mL) and larger tumors (median size, infiltrating, 9.2?cm vs. multifocal, 5.5?cm) (P?P?=?0.001). Survival after IAT was similar among patients treated with infiltrating HCC versus multifocal HCC (hazard ratio 1.29, 95?% confidence interval 0.82?C2.03; P?=?0.27). Among infiltrating HCC patients, pretreatment bilirubin >2?mg/dL and alfa-fetoprotein >400?ng/mL were associated with worse survival after IAT (P?P?=?0.004).

Conclusions

Patients with infiltrative HCC often present without a discrete lesion on imaging. IAT for infiltrative HCC was safe and was associated with survival comparable to IAT outcomes for patients with multifocal HCC. Infiltrative HCC morphology is not a contraindication to IAT therapy in select patients.     

Clinical features and surgical outcomes of primary cauda equina tumours

Background

To identify clinical features, radiological findings and surgical outcomes of primary cauda equina tumours.

Methods

A consecutive series of 64 operations in 60 patients with primary cauda equina tumours from April 1999 to May 2009 at one institution comprised the study. The cases were divided into tumours of neural sheath origin (TNS, n?=?48) and tumours of non-neural sheath origin (TNNS, n?=?22). We analysed pain intensity, neurological abnormalities, MRI findings, surgical extent and functional outcome.

Results

The TNS group showed more leg pain (76 % vs. 44 %, p?=?0.019) with higher intensity (6.1?±?1.5 vs. 4.6?±?1.9, p?=?0.04). Motor weakness and bladder dysfunction were more common in the TNNS group (p?=?0.028 and p?=?0.00 in each). Flow voids of MRI were more frequently observed in TNNS (50 % vs. 4 %, p?=?0.01). The TNS group achieved total removal in all operations compared with total removal in 77 % in the TNNS group (p?=?0.001). The TNNS group showed higher recurrence rates (18 % vs. 0 %, p?=?0.009). The TNS group showed higher improvement of JOA scores postoperatively (p?=?0.049). Surgical complications were observed less frequently in the TNS group (19 % vs. 78 %, p?=?0.000).

Conclusions

TNS differs from TNNS by causing more frequent leg pain, higher pain intensity and more frequent flow voids. TNS has better surgical outcomes than TNNS in terms of higher rates of total removal, fewer surgical complications, better functional outcomes and less recurrence.     

CEUS评价肝癌射频治疗后的局部进展:与初发肝癌的自身对比

目的探讨原发性肝细胞癌(HCC)射频消融(RFA)治疗后局部进展病灶的CEUS灌注特征,并与初发HCC的CEUS灌注模式进行自身对照比较。方法收集本院RFA治疗后,经随访发现局部进展病灶并于治疗前后均接受CEUS检查的HCC患者33例。比较初发病灶与RFA治疗后局部进展病灶CEUS灌注特征,包括增强时相、荷瘤血管、增强形态、增强边界、增强过程、廓清时相、内部坏死等。结果 RFA治疗后局部进展病灶100%(33/33)呈动脉期或门静脉期增强,96.97%(32/33)呈实质或延迟期廓清,与初发病灶差异无统计学意义(P0.05)。灌注特征比较:HCC初发病灶多见荷瘤血管(29/33,87.88%)、增强形态规整(27/33,81.82%)、边界清(26/33,78.79%);增强过程以周边至中心多见(18/33,54.55%),部分病灶出现内部坏死(9/33,27.27%)。RFA后局部进展病灶多见无荷瘤血管(20/33,60.61%)病灶、增强形态不规则(31/33,93.94%)、边界不清(27/33,81.82%);增强模式以整体增强多见(19/33,57.58%),内部坏死相对少见(2/33,6.06%)。结论 RFA后局部进展病灶造影灌注特征具有特殊表现,有助于其早期诊断及生物学行为检测。     

Contrast-enhanced ultrasonography of the prostate: various imaging findings that indicate prostate cancer

Study Type – Diagnostic (non‐consecutive case series)
Level of Evidence 3b What’s known on the subject? and What does the study add? Contrast‐enhanced ultrasonography (CEUS) can visualize some prostate cancer lesions. Findings suggestive of cancer have been defined as rapid contrast enhancement; increased contrast enhancement. CEUS could be useful for targeted biopsy in patients with a PSA level <10 ng/mL. The CEUS findings suggestive of prostate cancer are more varied than previously reported. Low‐echogenicity areas containing abnormal blood vessels were also found to represent cancer.

OBJECTIVES

• ? To perform transrectal ultrasonography (TRUS) with an ultrasonography (US) contrast agent to visualize prostate cancer.
• ? To explore the possibility of targeted biopsy by studying the findings obtained by different cancerous tissue imaging modalities and evaluating needle biopsies from prostate cancer using contrast‐enhanced ultrasonography (CEUS).

PATIENTS AND METHODS

• ? In all, 41 patients undergoing prostate biopsy and 13 patients undergoing prostatectomy received i.v. injection of the US contrast agent (Sonazoid®).
• ? We evaluated pre‐contrast and contrast‐enhanced US images, and then compared ultrasonographic images and the pathological findings.

RESULTS

• ? Cancer was significantly more frequent at the sites of targeted biopsy where CEUS findings suggested cancer (36.3%) than at sites of systematic biopsy (17.7%, odds ratio = 2.7, P = 0.0026).
• ? In cases with prostate‐specific antigen (PSA) level <10 ng/mL, in particular, prostate cancer was detected at a significantly higher rate by targeted biopsy than by systematic biopsy (27.3 vs 9.5%, odds ratio = 3.4, P = 0.013).
• ? Pathological examination found 26 tumours in prostatectomy specimens. The diameters of the 10 CEUS‐identified tumours were significantly greater than those of the 16 lesions missed by US (mean 18.7 vs 5.9 mm).
• ? CEUS findings suggestive of cancer varied widely: strong contrast enhancement, rapid contrast enhancement, vessels with abnormal perfusion and low contrast enhancement.

CONCLUSIONS

• ? CEUS could be useful for targeted biopsy in patients with a PSA level <10 ng/mL.
• ? The CEUS findings suggestive of prostate cancer are more varied than previously reported.
• ? Detailed examination of CEUS images and application of the data to prostate biopsy could lead to more efficient diagnosis.

     

α-Fetoprotein-to-Total Tumor Volume Ratio Predicts Post-operative Tumor Recurrence in Hepatocellular Carcinoma

Background/Aims

Serum α-fetoprotein (AFP) and total tumor volume (TTV) are important factors linked with post-operative tumor recurrence in hepatocellular carcinoma (HCC) patients. We investigated the role of a new prognostic marker, AFP-to-TTV ratio, in predicting HCC recurrence.

Methods

A total of 655 HCC patients undergoing resection were analyzed.

Results

In the multivariate logistic model, serum AFP level [odds ratio (OR) 32.459, p?=?0.012] and TTV (OR 0.006, p?=?0.01) were independently associated with a higher AFT/TTV ratio. The 1-, 3-, and 5-year tumor recurrence rates were 29 %, 55 %, and 68 %, respectively. In the Cox proportional hazards model, alcoholism (hazard ratio [HR], 1.354, p?=?0.028), international normalized ratio of prothrombin time ≥1.01 (HR, 1.349, p?<?0.001), multiple nodules (HR, 1.381, p?=?0.004), main tumor diameter ≥4?cm (HR, 1.535, p?=?0.001), macrovascular invasion (HR, 1.362, p?=?0.016), and AFP/TTV ratio ≥1.5 (HR, 1.49, p?<?0.001) were independently associated with tumor recurrence. In subgroup analysis, a higher AFP/TTV ratio was significantly associated with tumor recurrence in patients characterized by macrovascular invasion, TTV?≥?40 cm³, or main tumor diameter ≥4cm (all p?=?0.001).

Conclusion

The AFP/TTV ratio, a newly proposed marker for predicting post-operative tumor recurrence in HCC, is a feasible surrogate and may be useful in selecting super-high-risk patients for tumor recurrence.     

Patients with Multiple Hepatocellular Carcinomas Within the UCSF Criteria Have Outcomes After Curative Resection Similar to Patients Within the BCLC Early-Stage Criteria

Background

Surgical strategies for the treatment of multiple hepatocellular carcinomas (HCC) remain controversial. This study compared the prognostic power of the University of California, San Francisco (UCSF) criteria with the Barcelona Clinic Liver Cancer (BCLC) early-stage criteria.

Methods

Clinical and survival data of 162 multiple-HCC patients in Child-Pugh class A who underwent curative resection were retrospectively reviewed. Prognostic risk factors were analyzed using univariate and multivariate analyses.

Results

UCSF criteria were shown to independently predict overall and disease-free survival. In patients within the UCSF criteria, 3-year overall and disease-free survivals were significantly better than in those exceeding the UCSF criteria (68 vs. 34?% and 54 vs. 26?%, respectively; both p?p?=?0.506 and 57 vs. 50?%, p?=?0.666, respectively). Tumors within the UCSF criteria were associated with a lower incidence of high-grade tumor (p?=?0.009), microvascular invasion (p?=?0.005), 3-month death (p?=?0.046), prolonged Pringle’s maneuver (p?=?0.005), and surgical margin <0.5?cm (p?Conclusions Multiple HCC patients within the UCSF criteria benefit from curative resection. Expansion of curative treatment is justified.     

Routine Anterior Approach During Right Hepatectomy: Results of a Prospective Randomised Controlled Trial

Trial Design

A prospective randomised controlled trial was designed to evaluate the advantages of routine application of the anterior approach during right hepatectomy.

Methods

The study was conducted between March 2005 and April 2009 in a tertiary hepatobiliary?Cpancreatic centre. Patients scheduled for right hepatectomy for primary or metastatic tumours, without infiltration of segment 1, inferior vena cava or main bile duct, were randomly assigned to right hepatectomy using either an anterior or a classic approach. The primary study endpoint was overall blood loss.

Results

Sixty-six patients were randomly allocated to undergo right hepatectomy with an anterior (AA group n?=?33) or a classic approach (CA group n?=?33). Sixty-five patients were included in the analysis (33 in AA group and 32 in CA group). There was no significant difference in patient age, diagnosis, preoperative hepatic biochemistry and tumour size between the two groups. Overall blood loss (437?ml?±?664 in AA group vs.500?ml?±?532.3 in CA group; p?=?0.960) and bleeding during transection (p?=?0.973) were similar between two groups. Perioperative blood transfusion rates were 18?% in the AA group and 9.3?% in the CA group (p?=?0.253). Time of parenchymal transsection was significantly longer in AA group (75.1?±?26.6?min vs. 56.7?±?17.5?min, p?=?0.01). There was no difference between both groups for postoperative prothrombin time, serum transaminase and total bilirubin levels. One patient died in each group (p?=?0.746). The two groups had similar morbidity rates.

Conclusion

Routine application of the anterior approach during right hepatectomy does not decrease intraoperative blood loss and morbidity rate.     

Influence of tumour differentiation on survival after resection for rectal cancer in a series of 1296 patients

The influence of differentiation grade on tumour staging, local recurrence and long term survival prospects has been evaluated in a series of patients managed by resection for rectal cancer. Differentiation was known in 1095 of 1296 patients. Well-differentiated tumours were over-represented among Dukes' stage A cases and poorly differentiated among those with disseminated disease (P less than 0.001). Local recurrence was twice as common (31%) after curative resection of poorly differentiated tumours than of well (14%) or moderately (17%) differentiated. Five year cancer specific survival rates after resection (curative and palliative combined) of tumours of good, average or poor differentiation were 68%, 59% and 33%, respectively. After potentially curative resection, survival was also significantly worse in patients with poorly differentiated tumours (P less than 0.001); 5 year survival rates of patients with tumours of good, average or poor differentiation were 75%, 71% and 51%, respectively. Survival prospects beyond 5 years in patients with Dukes' stage A tumours were significantly reduced when the tumour was poorly differentiated; 5 and 10 year survival rates were 76% and 40%, respectively. However, patients with Dukes' stage C tumours of poor differentiation had an identical 5 and 10 year cancer specific survival, 26%. Patients with mucoid type tumours had worse survival prospects than those with non-mucoid type (P less than 0.02).     

Outcomes of 101 Consecutive Surgical Resections of Gastroenteropancreatic Neuroendocrine Tumours (GEPNETs) at Tata Memorial Hospital: a Referral Bias for Nonfunctional Duodenopancreatic Tumours and the Need for Greater Awareness of GEPNETs as a Distinct Entity

Data from India regarding the disease spectrum and surgical results of neuroendocrine tumours (GEPNETs) are sparse. Tempered surgical radicality in a high-volume oncology centre, conforming to existing guidelines, may further our understanding of tumour characteristics and behavioural patterns of nonfunctional GEPNETs. Surgical outcomes of patients with histopathologically confirmed GEPNETs from January 2003 to December 2013 were analyzed from a prospectively maintained database. Tumour grade, organ of primary tumour, perioperative factors, quality/radicality of resection and presence of metastatic disease were correlated with perioperative outcomes, overall survival and disease-free survival. Ninety of the 101 operated patients had nonfunctional tumours. These comprised radical resections (n?=?69), organ-preserving procedures (n?=?16) and inoperable tumours (n?=?5). The primary tumour sites were pancreatic in 48 patients and gastroenteric in 42 patients. The overall perioperative morbidity and mortality rates were 30 and 3 %, respectively. Fifteen patients harboured metastatic disease at presentation. At a median follow-up of 22 months, 18 patients had residual disease, 7 developed recurrences and 10 patients died. The estimated actuarial 5-year overall survival was 81.6 %, and disease-free survival was 67.2 %. Tumour grade and organ of origin (pancreatic vs. gastroenteric) did not influence long-term survival (p?=?0.315 and p?=?0.624, respectively), but presence of metastatic disease at presentation significantly affected long-term survival (p?=?0.009). Nonfunctional pancreatic/duodenal neuroendocrine tumours (NETs) accounted for 76 % of surgical resections at our centre with the minority being other resections. In selected patients with nonfunctional NETs, organ-preserving surgery may provide equivalent long-term survival with decreased operative morbidity. Although tumour grade is considered to be an important prognostic factor, the presence of metastatic disease at presentation also determines long-term survival. The referral bias suggests the need for greater awareness given the favourable long-term outcomes of these tumours. There is a need to correct this referral bias by increasing the awareness of GEPNETs in India.     

Neuroendocrine tumours of the ampulla of Vater: clinico-pathological features, surgical approach and assessment of prognosis

Background/aims

Neuroendocrine tumours occur very rarely in the ampulla of Vater and their clinical behaviour is unknown. The aim of this study is to assess the clinico-pathological features, surgical approach and prognosis of these patients.

Methods

Six patients with neuroendocrine tumours of the ampulla of Vater treated with curative intent surgery at a single centre were retrospectively analysed. A univariate analysis of potential prognostic factors was also performed (data provided from the present study and literature review).

Results

Pancreaticoduodenectomy was curative in all the patients. Overall and disease-free survival rates were significantly better for G1/G2 tumours (p?=?0.006 and p?=?0.004, respectively). Although frequent, lymph node metastases did not influenced both overall (p?=?0.760) and disease-free survival rates (p?=?0.745). No significant differences of survival were observed in patients with ENETS stage I/II disease, as compared to ENETS stage III disease (p?=?0.169 and p?=?0.137, respectively). No differences were observed according to UICC staging system (p?=?0.073 and p?=?0.177, respectively). Tumours that are less than 2?cm or limited to the ampulla appear to have a better prognosis.

Conclusion

The WHO 2010 classification appear to accurately predict patient prognosis, while the ENETS or UICC staging systems have a limited value (especially in regard to lymph node metastases). Radical surgery (i.e. pancreaticoduodenectomy with lymphadenectomy) should be the standard approach in most patients with NET of the ampulla of Vater because this procedure removes all the potential tumour-bearing tissue.     

Prognostic value of ventricular wall fluorescence during 5-aminolevulinic-guided surgery for glioblastoma

Background

The meaning of the ventricular wall fluorescence during 5-aminolevulinic (5-ALA)-guided surgery in patients with glioblastoma (GBM) is still unknown. The authors studied the association between ventricle fluorescence, clinical outcome and survival, and described the histopathological findings of selective biopsies from the ventricular wall.

Methods

One hundred and forty patients diagnosed of GBM underwent fluorescence-guided surgery (FGS); 65 of them were naive GBM and ventricle fluorescence during surgery was annotated prospectively. Selective biopsies were collected from the ventricular wall when possible. Clinical and radiological data were registered, including age, Karnofsky Performance Scale (KPS) score, presence of hydrocephalus, overall survival (OS), tumour volume and location (periventricular vs non-periventricular) and leptomeningeal dissemination.

Results

During FGS the ventricle wall was opened just when the tumour was periventricular in the preoperative MRI (45 out of 65). In 28 of them (60?%) the fluorescence extended far away from the site of opening, while in 17 it ended just in the few millimetres around the tumour. All four patients who developed hydrocephalus had periventricular tumours and the ventricle wall had been opened during surgery. Statistically significant differences were seen in OS according to periventricular location (15?m vs 33?m, P?=?0.008 log rank). However, there was not significant relationship between ventricle fluorescence and hydrocephalus (P?=?0.75), nor survival (14?m vs 15.5?m, P?=?0.64).

Conclusions

Preoperative MRI predicts if the ventricle will be opened using the 5-ALA fluorescence, according to tumour location. It does not predict, however if the ventricle wall is going to be fluorescent or not. The fluorescence of the ventricle wall is not a predictor for complications or survival. Periventricular tumour location is an independent bad prognostic factor in GBM.     

Is Resection Equivalent to Transplantation for Early Cirrhotic Patients with Hepatocellular Carcinoma? A Meta-Analysis

Background

Whether liver resection or liver transplantation is optimal therapy for patients with hepatocellular carcinoma (HCC) remains undefined. A meta-analysis was conducted to answer this question.

Study Design

This study performed a systematic review of the published literature between January 2000 and April 2012.

Results

Nine retrospective studies, totaling 2,279 patients (989 resected and 1,290 transplanted), met the selection criteria. Older patients with larger tumors and less severe cirrhosis were identified in the resection group. At 1?year, resection demonstrated significantly higher overall [odds ratio (OR)?=?1.54; 95?% confidence interval (CI), 1.19?C1.98; p?=?0.001], but equivalent disease-free survival (OR?=?0.93; 95?% CI, 0.53?C1.63; p?=?0.80). At 5?years, there was no difference in overall survival (OR?=?0.86; 95?% CI, 0.61?C1.21; p?=?0.38), but a higher disease-free survival in transplanted patients was observed (OR?=?0.39; 95?% CI, 0.24?C0.63; p?<?0.001). When limiting our analysis to studies conducted in an intent-to-treat fashion, there was no difference in 5?year overall survival (OR?=?1.18; 95?% CI, 0.92?C1.51; p?=?0.19), but a significantly higher disease-free survival (OR?=?0.76; 95?% CI, 0.57?C1.00; p?=?0.05) in transplanted patients. At 10?years, transplantation had higher overall and disease-free survival rates.

Conclusion

Liver transplantation in patients with HCC results in increased late disease-free and overall survival when compared with liver resection. Nonetheless, the benefit of liver transplantation is offset by higher short-term mortality, donor organ availability, and long transplant wait times associated with more patient deaths. Understanding these differences in survival is helpful in guiding treatment. However, a properly controlled prospective trial is needed to define how best to treat HCC patients who are candidates for either therapy.