A. Alexander

In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two‐stage liver resection

Portal vein embolization (PVE) has become a standard procedure to increase the future liver remnant (FLR) and enable curative resection of initially unresectable liver tumours. This study investigated the safety and feasibility of a new two‐stage liver resection technique that uses in situ liver transection (ISLT) and portal vein ligation before completion hepatectomy.

Infusion of CD133+ bone marrow-derived stem cells after selective portal vein embolization enhances functional hepatic reserves after extended right hepatectomy: a retrospective single-center study.

Objective:This study was designed to evaluate the clinical outcome of patients undergoing portal vein embolization (PVE) and autologous CD133+ bone marrow–derived stem cell (CD133+ BMSC) application before extended right hepatectomy. Background:We have previously shown that portal venous infusion of CD133+ BMSCs substantially increases hepatic proliferation, when compared with PVE alone. Methods:Among 40 consecutive patients with a median follow-up of 28 months (7.4–57.2) scheduled for extended right hepatectomy, we compared a preconditioned group with PVE and CD133+ BMSC cotreatment (PVE+SC group, n = 11) and a group pretreated only with PVE (PVE group, n = 11). Functional and overall outcomes after extended right hepatectomy were evaluated. Patients without presurgical treatment served as controls (n = 18). Results:In preconditioned patients, mean hepatic growth of segments II/III 14 days after PVE in the PVE+SC group was significantly higher (138.66 mL ± 66.29) when compared with that of PVE group patients (62.95 mL ± 40.03; P = 0.004). There were no significant differences among all 3 groups regarding general and oncological characteristics and functional parameters on postoperative day (POD) 7. Lack of hepatic preconditioning, extrahepatic extension of resection, and postoperative complications were of negative prognostic value, using univariate analysis (P < 0.05). In multivariate analysis, freedom from postoperative major complications (P = 0.012), coagulation status on POD 7 (international normalized ratio < 1.4; P = 0.027), and presurgical expansion of the future liver remnant volume (P = 0.048) were positively associated with overall survival. Post hoc analysis revealed a better survival for the PVE+SC group (P = 0.028) compared with the PVE group (P = 0.094) and compared with controls. conclusion:Promising data from this survival analysis suggest that PVE, together with CD133+ BMSC pretreatment, could positively impact overall outcomes after extended right hepatectomy.

Leiomyosarcoma of the inferior vena cava: Radical surgery and vascular reconstruction

BackgroundVascular leiomyosarcoma are rare tumors typically originating from the inferior vena cava (IVC). Due to nonspecific clinical signs most tumors are diagnosed at advanced stages. Complete surgical resection remains the only potential curative therapeutic option. Surgical strategy is particularly influenced by the level of the IVC affected. Due to the topographic relation to the renal veins level-II involvement of the IVC raises special surgical challenges with respect to the maintenance of venous outflow.Case presentationWe herein report two cases of leiomyosarcoma of the IVC with successful en bloc resection and individualized caval reconstruction. One patient presented with a large intramural and intraluminal mass and received a complete circumferential resection. Reconstruction was performed by graft replacement of the caval segment affected. The other patient displayed a predominantly extraluminal tumor growth and underwent semicircumferential resection of the IVC including the confluence of the left renal vein. In this case vascular reconstruction was performed by cavoplasty and reinsertion of the left renal vein into the proximal portion of the IVC. Resection margins of both patients were tumor free and no clinical signs of venous insufficiency of the lower extremity occurred.ConclusionThis paper presents two cases of successfully managed leiomyosarcomas of the vena cava and exemplifies two different options for vascular reconstruction in level II sarcomas and includes a thorough review of the literature.

Vascular invasion in pancreatic cancer: tumor biology or tumor topography?

BACKGROUND Although vascular resection in pancreatic adenocarcinoma increases the resection rate, involvement of the vascular structures frequently is assumed to be associated with a more aggressive tumor biology and tumor cell dissemination. Our studys aim was to assess the correlation of vascular tumor involvement with adverse, clinicopathologic prognosticators and with the extent of tumor cell dissemination. METHODS We studied 108 patients who had undergone pancreatic resection, of whom 39 underwent vascular resection. Clinical parameters and the postoperative course were recorded. Formalin-embedded lymph node samples as well as bone marrow aspirates were screened immunohistochemically for disseminated tumor cells. Univariate and multivariate analyses were performed using the log-rank test and the Cox proportional-hazard models. RESULTS Overall, 2,388 lymph nodes and bone marrow aspirates from 49 matched patients were screened immunohistochemically. Fully 50% of the patients had disseminated tumor cells in lymph nodes and 27% in bone marrow. The mean observation period in cohort was 28 months. Vascular resection did not correlate with prognostically relevant parameters. Disseminated tumor cells in lymph nodes were associated with a decrease in relapse-free survival (P = .016) and were confirmed as independent indicators for a decrease in metastasis-free survival at multivariate analysis. There was no adverse prognostic influence of vascular resection, and there was no increased frequency of disseminated tumor cells in patients undergoing vascular resection. CONCLUSION These results support the hypothesis that the presence of vascular tumor involvement of peripancreatic vessels seems to be an indicator of unfavorable tumor topography, instead of being a sign of adverse tumor biology. Thus, vascular resection in pancreatic cancer appears to be warranted to achieve tumor-free margins.

Advanced Pancreatic Adenocarcinoma: Complete Histological Response After Palliative Therapy with Gemcitabine and Cisplatin

Pancreatic adenocarcinoma is one of the most lethal cancers, as indicated by a mortality incidence ratio of 98 % [1]. Over half of the patients have metastases on presentation, whereas only 15 % of patients will have resectable disease [2]. Although complete surgical resection is the only curative treatment option for this cancer entity, even with surgery prognosis remains poor due to the high propensity of the tumor for locoregional or metastatic recurrence [3, 4]. Adjuvant and neoadjuvant regimens might be potential therapeutic options for improving the outcome of these patients. Unfortunately, pancreatic carcinoma is considered to be among the most chemoresistant of human malignancies. However, gemcitabine in monotherapy has been the standard of treatment during the last decade, showing superior clinical benefit to single-agent 5-fluorouracil [5]. Numerous agents have been tested against and in combination with this standard, and many clinical trials have failed to demonstrate an improvement in overall survival with the addition of different drugs to gemcitabine [6, 7]. However, recently published data indicate that the combination of gemcitabine with platinum analogs significantly improves prognosis in patients with progressive pancreatic carcinoma [8]. We present a case of a patient with locally advanced, initially unresectable pancreatic cancer with complete remission after chemotherapy with gemcitabine and cisplatin, enabling surgical treatment with curative intent.

Erratum to: Reexcision of Soft Tissue Sarcoma: Sufficient Local Control but Increased Rate of Metastasis

The references to ‘‘our institution’’ in both the Abstract and Methods sections of the original paper may be misleading to the reader as the authors’ intent was to refer to both Heinrich-Heine-University Dusseldorf and the University of Hamburg. All surgeons that collected patients and data, analyzed data, performed follow up, or wrote the original paper moved from the University of Hamburg to Heinrich-HeineUniversity Dusseldorf in 2003.

Hepatocyte Growth Factor (HGF)-Konzentrationen im Patientenserum sind nach partieller Hepatektomie mit dem Ausmaß an Parenchymverlust und mit postoperativ peripher mobilisierten CD34+ und CD133+ Stammzellen positiv korreliert

In this study we investigated paracrine factors like HGF, insulin like growth factor 1 (IGF-1) stroma derived factor 1 (SDF-1) and stem cell factor (SCF) for correlation with peripheral progenitor mobilisation in the early course of hepatic resection using FACS-analyses in 30 patients and the extend of partial hepatectomy. CT-scan volumetry pre-operatively and 24 h following resection was utilized to determine the exact extend of liver volume loss. Serum growth fators and chemokine levels were compared among 20 patients with resection volume of less than 20 % (group A) of the pre-operative total liver volume – tumor volume (TLV) and 10 patients with a resection extend of 30 to 65 % (group B). In addition, peripheral CD133+ and CD34+ progenitor cells in peripheral blood were contrasted between the two groups up to post OP day (POD) 21. Early subsequent to the end of resection HGF (0, 6 and 24 h), SDF-1 (0, 3 and 6 h) and IGF-1 (3 h) were significantly increased in comparison to group A. We revealed a significant elevation from day 2 following liver surgery for CD133+ cells which was only seen for group B individuals and which was significantly superior to group A patients (p = 0.005). CD34+ cells demonstrated similar kinetics and differences among groups, however to a lesser extend. Only HGF directly correlated with mobilised mobilised CD34+ and CD133+ peripheral cells early after resection, independent of the extend of hepatectomy. These data suggest HGF to play a role in mobilisation of CD133+ and CD34+ cells respectively in regeneration processes subsequent to larger extend of loss of hepatic tissue.

Immunohistochemical Detection of Hepatic CEA+ Cells: Hepatic Tumor Cell Dissemination in Colorectal Cancer Patients—Limits of Surgery?

AIMS Hepatic recurrence following resection of liver metastases occurs in about half of the patients. This is attributed to insufficient margins by some authors, while others accuse the presence of occult tumor cell dissemination. METHODS Representative samples of the hepatic margin of 32 patients were examined. Clinicopathologic parameters of the primary tumors of metastatic lesions as well as the width of hepatic resection margin and postoperative adjuvant therapies were recorded. RESULTS Occult tumor cells were identified in 18 patients (56%). Postoperative adjuvant therapy was associated with longer relapse-free survival. CONCLUSIONS Immunohistochemical detection of occult tumor cells is feasible and a frequent finding in the remaining tissue after hepatic metastasectomy.

Partial Hepatectomy is paralleled by peripheral, resection-volume depending mobilisation of CD133+ stem cells

In this study we investigated peripheral progenitor mobilisation in the early course of hepatic resection using FACS-analyses in 30 patients. CT-scan volumetry pre-operatively and 24h following resection was utilized to determine the exact extent of liver volume loss. 20 patients with resection volume of less than 20% (group A) of the pre-operative total liver volume — tumor volume (TLV) were contrasted to 10 patients with a resection extent of 30 to 65% (group B) concerning peripheral CD 133+ and CD34+ progenitor cells in peripheral blood. We revealed a significant elevation from day 2 following liver surgery for CD133+ cells which was only seen for group B individuals and which was significantly superior to group A patients (p=0.005). CD34+ cells demonstrated a similar kinetic (p=0.04; day 2) for group B if contrasted to group A, however differences were less pronounced. Such differences among groups were demonstrated for the whole observation period of 90 days. These data suggest both, CD133+ cells to demonstrate an increase in larger resections and being predominantly mobilised if contrasted to CD34+ cells. We demonstrate for the first time a correlation of loss of liver parenchyma and the level of peripheral stem cell mobilisation. CD133+ cells seem to play a dominant role in that respect if contrasted to CD34+ cells supporting CD133 as a selection marker for therapeutic BMSC application.