Durgatosh Pandey

Long term outcome and prognostic factors for large hepatocellular carcinoma (10 cm or more) after surgical resection.

BackgroundSurgical resection is the standard treatment for hepatocellular carcinoma (HCC). However, the role of surgery in treatment of large tumors (10 cm or more) is controversial. We have analyzed, in a single centre, the long-term outcome associated with surgical resection in patients with such large tumors.MethodsWe retrospectively investigated 166 patients who had undergone surgical resection between July 1995 and December 2006 because of large (10 cm or more) HCC. Survival analysis was done using the Kaplan-Meier method. Prognostic factors were evaluated using univariate and multivariate analyses.ResultsOf the 166 patients evaluated, 80% were associated with viral hepatitis and 48.2% had cirrhosis. The majority of patients underwent a major hepatectomy (48.2% had four or more segments resected and 9% had additional organ resection). The postoperative mortality was 3%. The median survival in our study was 20 months, with an actuarial 5-year and 10-year overall survival of 28.6% and 25.6%, respectively. Of these patients, 60% had additional treatment in the form of transarterial chemoembolization, radiofrequency ablation or both. On multivariate analysis, vascular invasion (P < 0.001), cirrhosis (P = 0.028), and satellite lesions/multicentricity (P = 0.006) were significant prognostic factors influencing survival. The patients who had none of these three risk factors had 5-year and 10-year overall survivals of 57.7% each, compared with 22.5% and 19.3%, respectively, for those with at least one risk factor (P < 0.001).ConclusionsSurgical resection for those with large HCC can be safely performed with a reasonable long-term survival. For tumors with poor prognostic factors, there is a pressing need for effective adjuvant therapy.

Surgical management of gallbladder cancer

Gallbladder cancer is a very common malignancy in the northern part of India. Surgery is the only potentially curative modality of treatment for this disease. Radical cholecystectomy is the optimal surgical standard for resectable gallbladder cancer. This includes cholecystectomy, liver resection (wedge, segments 4b and 5, or extended right hepatectomy), and regional lymphadenectomy along the hepatoduodenal ligament, behind the duodenum and pancreatic head, common hepatic artery and celiac axis. Controversies regarding extent of liver resection, lymphadenectomy and role of multiorgan resection have been discussed. Incidental gallbladder cancer is often detected on histopathologic examination of the simple cholecystectomy specimen removed for a presumed gallstone disease. Revision surgery should be performed for incidental cancers that invade muscularis propria or beyond (T1b or more). Advanced gallbladder cancer should be treated non-operatively with a palliative intent. Obstructive jaundice in the setting of an advanced gallbladder cancer can be palliated with biliary stenting by endoscopic or transhepatic means. Occasionally, a surgical biliary bypass may be indicated to relieve intractable pruritus in a jaundiced patient with gallbladder cancer. There is no role of a planned R2 resection of advanced gallbladder cancer for the purpose of cytoreduction. Further improvement in the management of gallbladder cancer will need integration of systemic chemotherapy with radical surgery.

Adrenal metastasis from intrahepatic cholangiocarcinoma

Intrahepatic cholangiocarcinoma is an uncommon disease with surgical resection as the only potentially curative modality of treatment. The pattern of failure in such tumours is recurrence in the remnant liver or metastases to lymph nodes, peritoneum and bones (1, 2). We report a case of intrahepatic cholangiocarcinoma with adrenal metastasis that was treated with simultaneous hepatic and adrenal resection. Adrenal metastasis from intrahepatic cholangiocarcinoma has not yet been reported in the published literature. A 68-year-old Indonesian gentleman was diagnosed with synchronous adrenal nodule with a large tumour in the left lateral segment of the liver. Left lateral segmentectomy with left adrenalectomy was performed on 6 November 2004. The histopathology report of the resected specimen revealed a tumour (9.0 7.0 6.8 cm size) in the liver with features of moderately differentiated intrahepatic cholangiocarcinoma. The nodule in the left adrenal gland was 1 cm in size and had histological features of metastatic cholangiocarcinoma (Fig. 1). Following postoperative recovery, he was treated with four cycles of Gemcitabine and Cisplatin. In April 2006, he had recurrence of the disease in bone (right ilium), both lungs, and in the left adrenal bed. He received palliative radiotherapy for the painful lesion in the right ilium and was started on palliative chemotherapy with Gemcitabine and Xeloda. Two years following adrenalectomy, he is alive with recurrent disease. The options of treatment of a metastatic cholangiocarcinoma are limited. Such patients are generally treated with palliative chemotherapy or supportive care. Lessons from other solid malignancies like colorectal cancers and sarcomas have emphasized the value of surgical resection of metastatic disease when feasible (3, 4). As our patient had a solitary adrenal metastasis, he was treated with simultaneous liver and adrenal resection. This is the first report of adrenal metastasis from intrahepatic cholangiocarcinoma. The patient developed recurrence in spite of an aggressive treatment with surgical resection and postoperative chemotherapy. The therapeutic options need to be further explored in order to provide hope to patients with metastatic cholangiocarcinoma.

Jaundice after radical cholecystectomy and bile duct resection: a case of postoperative acute viral hepatitis a confounding the clinical picture.

Gallbladder cancer is a common cancer in the northern part of India [1]. Radical cholecystectomy is the only curative option for patients with resectable disease. Resection of the common bile duct may be required if the tumor/lymph node is seen to involve the CBD or if the cystic duct margin is positive [2]. Postoperative jaundice in the setting of radical cholecystectomy with CBD resection usually points to stricture of the hepaticojejunostomy or recurrence of the cancer. We report a patient who had postoperative jaundice caused by viral hepatitis after having undergone radical cholecystectomy with CBD resection.

Biological Behavior of Perihepatic Lymph Node Metastasis and Its Impact on Prognosis Following Liver Resection for Colorectal Metastases

Bennett et al. have done a commendable job in analyzing the impact of perihepatic lymph node metastases following partial hepatectomy for colorectal metastases. The conclusion that involvement of perihepatic lymph nodes would adversely affect outcome is not surprising. What is remarkable is that, despite their involvement, the 3-year overall survival was 76% for the immunohistochemistry (IHC)-positive group and 25% for the hematoxylin and eosin (H&E)-positive group. This is a fairly good result and it opens the discussion about the biological behavior of the perihepatic lymph node metastasis in the presence of liver metastasis. Metastases from colorectal cancers are amenable to curative resection; this has been shown quite convincingly for liver metastases and also for selected patients with lung metastases. Involvement of other extrahepatic sites is generally considered incurable. The involvement of perihepatic lymph nodes in the presence of liver metastasis is a unique circumstance. Whether the perihepatic lymph nodal involvement represents metastasis from the liver metastasis or is a manifestation of metastasis from the colorectal primary itself is a matter of debate. This distinction is important because these two mechanisms represent two different biological behaviors of this disease. If the perihepatic nodes are metastatic from colorectal primary itself, there are at least two detectable sites of distant metastases and the probability of having micrometastasis at other sites would be quite high; thus the disease is more likely to be disseminated. On the other hand, if these lymph nodes are metastatic from the liver metastasis, it would be somewhat similar to a regional disease of liver if the colorectal primary has been controlled. This gives an opportunity to treat both the metastases (liver and perihepatic lymph nodes) with curative intent. Hence, the prognosis in such a situation would be better than if these nodes were metastatic from the colorectal primary itself. This view is in variance to that of Bennett et al., who state that ‘‘tumor deposits in these lymph nodes likely represent spread from metastases within the liver itself rather than from the primary tumor, and this might explain the dismal survival in these patients.’’

In Favor of Axillary Lymph Node Dissection: The Need for a Pragmatic View

I read with great interest the article by Samphao et al. in which the authors have comprehensively reviewed the management of axilla in women with breast cancer. Certain issues, however, need further discussion. The recent trend of minimizing axillary surgery in clinically node-negative patients is based on two considerations: its lack of benefit in improving survival and the concerns about the morbidity following axillary lymph node dissection (ALND). The NSABP B-04 trial, which dealt with the first issue, showed no significant improvement in survival with ALND in clinically node-negative patients. One must remember, however, the limitations of this study. This study had a power of only 25% to show a real 5% difference in survival between each of the arms of the nodenegative group. This means that there was at least a 75% probability that a statistically significant difference would not have been shown even if a real 5% difference in survival existed. This trial, with its limitations, still showed a significant improvement in locoregional control following ALND. In a 25-year follow-up report, 18.6% of women with clinically node-negative breast cancer in the totalmastectomy-alone arm subsequently had pathologically proven ipsilateral axillary node metastasis as a first event. By the design of this trial, they would have undergone ALND, which thus contributed to disease control even in the group randomized not to receive any axillary treatment. In a Bayesian meta-analysis of six randomized trials examining prophylactic ALND, a survival advantage of 5.6% was shown in patients who underwent prophylactic ALND. The issue of morbidity following ALND too has been overemphasized. The safety and low morbidity of ALND has been shown by large-volume centers. ALND is a systematic surgery and one can minimize the complications by following certain basic principles:

Diabetes Cured by Pancreaticoduodenectomy: A Case Report of Glucagonoma Masquerading as Carcinoma of the Head of Pancreas.

The association between carcinoma of the pancreas and diabetes mellitus is well recognized [1–3]. This diabetes may also be a manifestation of a functional endocrine tumor of the pancreas. We report a diabetic patient who presented with obstructive jaundice and was diagnosed to have carcinoma of the pancreatic head. She underwent pancreaticoduodenectomy following which her diabetes got cured. The histopathology report revealed a malignant endocrine tumor in the pancreatic head with lymph nodal metastases.

Multimodal Treatment of Huge Hepatocellular Carcinoma

We thank Drs. Kobayashi and Pulitano for their comments and their interest in our article. Their views on the multimodal treatment of huge hepatocellular carcinoma (HCC) are quite similar to ours. HCC usually arises on the background of cirrhosis or chronic hepatitis, both of which may lead to a predisposition to tumor formation in other parts of the liver as well. Thus, multicentricity should not be considered equivalent to metastatic disease because it is a reflection of a field change in the liver. We believe in aggressive treatment of multicentric lesions. Unfortunately, surgical resection of all nodules in multicentric HCC is often not possible. Transarterial chemoembolization and radiofrequency ablation have proven to be most effective for small nodules. Therefore, the combination of surgical resection for the dominant large tumors and transarterial chemoembolization or radiofrequency ablation for other smaller nodules is logically appealing, and indeed has a curative potential for seemingly hopeless cases. We and others have shown the safety and efficacy of liver resection for huge HCC. Although we differ from the authors’ suggestion on the acceptance of R2 resection for the dominant lesion, we do accept close margins of resection. Thus, the multimodal approach to the treatment of large HCC and small contralateral lesions provides fresh hope to patients who would otherwise be managed with noncurative options. Durgatosh Pandey, Institute of Medical Sciences Banaras Hindu University Varanasi India e-mail: durgatosh@yahoo.co.in