Gabriel Liberale

Fluorescence Imaging After Indocyanine Green Injection for Detection of Peritoneal Metastases in Patients Undergoing Cytoreductive Surgery for Peritoneal Carcinomatosis From Colorectal Cancer: A Pilot Study.

Objective: The aim of this study was to evaluate the role of fluorescence imaging (FI) using an intraoperative injection of free indocyanine green (ICG) in the detection of peritoneal metastases (PM) due to colorectal cancer (CRC). Background: A large proportion of patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy will have local recurrence. This is, in part, related to the presence of small undetected nodules in the peritoneal cavity. Near-infrared FI-guided surgery has provided new opportunities for detection of nonvisible lesions during cancer surgery. Methods: Patients with PM from CRC admitted for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were selected for participation in this study (NCT02032485). Free ICG, at 0.25 mg/kg of patient weight, was intravenous (IV)-injected intraoperatively. Tumor-to-background ratio was calculated for all suspect resected PM. Results: Sixty-three of 78 peritoneal resected nodules in 14 patients were evaluated for fluorescence, among them, 53 were malignant (84%) and 10 benign (16%). Twenty-six were hypofluorescent, 16 moderately hyperfluorescent, and 21 hyperfluorescent. Amongst the 42 nodules of the 9 patients with nonmucinous adenocarcinoma, the mean tumor-to-background ratio was 1.92 (SD 0.67) in malignant and 1.02 (SD 0.06) in benign nodules (P = 0.0099). In 4 of 14 patients (29%), the surgery was modified by intraoperative ICG-FI, which detected additional PM not found using visualization and palpation. Conclusions: This pilot study demonstrates that non-mucinous PM of CRC can be visualized intraoperatively using ICG-FI. Furthermore, ICG-FI findings resulted in modification of the planned surgery in 29% of patients.

Inducing resectability of chemotherapy refractory colorectal liver metastasis by radioembolization with yttrium-90 microspheres.

Liver metastases represent the principal cause of death for patients with advanced colorectal cancer. Resection remains the only potentially curative treatment. Selective internal radiation therapy by means of the administration of yttrium-90 labeled resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) into the arterial supply of the liver is a local treatment option for patients with unresectable malignant liver tumors. We report the case of a patient with an unresectable liver colorectal metastasis refractory to chemotherapy downstaged to allow resectability after selective internal radiation therapy.

Fluorescence imaging after intraoperative intravenous injection of indocyanine green for detection of lymph node metastases in colorectal cancer.

PURPOSE This short communication aims at reporting the potential role of ICG fluorescence imaging after an intraoperative IV injection in the detection of lymph nodes (LNs) of a colorectal cancer origin. PATIENTS AND METHODS Two patients who were included in a protocol study evaluating the role of ICG in the detection of peritoneal metastases of colorectal origin (Protocol NCT-01995591) also had fluorescent LNs at exploration with a dedicated near-infrared camera system (Photodynamic Eye, PDE; Hamamatsu Photonics, Hamamatsu, Japan). An IV injection of ICG was delivered intraoperatively at 0.25 mg/kg. All LNs were also explored for their fluorescence, and tumor to background ratio (TBR) was calculated with IC-Calc 2.0 program. RESULTS One patient had two retroperitoneal lymph node metastases and one mesocolic on a pre-operative work-up. The three tumoural lymph nodes at histopathology were hyperfluorescent in comparison to other uninvolved LNs. One patient had no pre-operatively known LN metastases and had one epigastric hyperfluorescent LN discovered at intraoperative exploration. This LN of 6 mm in size was malignant at histopathology. CONCLUSION This is the first report about tumoural LN of colorectal cancer origin detected by fluorescence imaging with intraoperative IV free-ICG injection. ICG fluorescence imaging by intraoperative IV injection represents an easy method for detecting metastatic LNs in colorectal cancer. This proof of concept should lead to further research in this field.

How should we treat mucinous appendiceal neoplasm? By laparoscopy or laparotomy? A case report.

Abstract Appendicular mucocele (AM) usually denotes a dilatation of the appendiceal lumen as a result of mucus accumulation that may be related to various neoplastic and non-neoplastic processes. Most of them are discovered incidentally. Treatment consists in complete resection avoiding rupture of the cyst in the peritoneal cavity. Indeed, rupture of such a cystic lesion in the peritoneal cavity can induce a catastrophic complication such as ‘pseudomyxoma peritonei’(PMP). Therefore, some authors recommend an open surgical treatment. Currently, the debate concerning the best surgical technique to adopt for AM remains controversial. We report a case of AM found incidentally and treated by laparoscopy. The macroscopic aspect of the appendix suggested the diagnosis intra-operatively and every effort was made to avoid cystic rupture during appendicular resection. The histopathological diagnosis was mucinous cystadeno-ma. The patient is doing well at 2-year follow-up. The reported case and literature review show us that AM is not a contra-indication for laparoscopic surgery, but major concern resides in the early recognition of such a lesion at laparoscopy and in taking appropriate precautionary measures to avoid rupture in the peritoneal cavity.

Sentinel lymph nodes of colorectal carcinoma: reappraisal of 123 cases.

AIMS Results concerning the usefulness of the sentinel lymph node (SLN) in colorectal carcinoma have been discordant. The SLN technique may be used to guide surgical resection (lymph mapping), restrict the lymph node analysis solely to the SLN (accuracy) and upgrade tumor staging when micrometastases are specifically detected in the SLN. METHODS The blue dye injection technique was used. Serial sections of the SLNs were analyzed after hematoxylin-eosin (HES) staining. RESULTS The SLN technique was tested in 123 patients, successfully in 112/118 (feasibility 95%) (five intraoperative exclusions). On average, twenty lymph nodes (range: 5-74) and two SLNs (range: 1-5) were identified. Lymph mapping was used in 11% of patients to guide surgical resection; the SLN was negative in 14 of 36 N+ patients (39% false-negatives); HES staining enabled detection of micrometastases in 8 of 84 initially N0 patients (10% secondary upgrading to N+). CONCLUSION Limiting node analysis to the SLN cannot replace a complete pathology examination of all resected lymph nodes. Careful examination of serial sections of the SLN can however affect therapeutic decision making since staging may be upgraded in up to 10% of initially N0 patients.

Pituitary apoplexy after aortic abdominal aneurysm surgery: a case report.

Abstract Pituitary apoplexy (PA) occurring after surgery is a rare but life-threatening acute clinical situation following extensive haemorrhage or necrosis within a pituitary adenoma. Pituitary apoplexy has been reported to occur spontaneously in the majority of cases or in association with various inducing factors. One of the pathophysiological mechanism that has been postulated is the fall of arterial blood pressure inducing ischaemia followed by infarction of the pituitary gland. We report a case of pituitary apoplexy following aortic abdominal surgery. To our knowledge, this has not been previously reported. A 73-year old man complained of headache and diplopia. At clinical examination, he presented a right oculomotor nerve palsy. Magnetic resonance imaging (MRI) showed a haemorrhagic sellar mass. In our case, intraoperative hypotension could have been the precipitating factor. Diagnostic and therapeutic measures are discussed.

Biliary Pleural Fistula as a Complication of Radiofrequency Ablation for Liver Metastasis

Abstract Radiofrequency ablation (RFA) recently emerged as an efficient and safe local ablative method to treat unresecable liver tumours. Currently however, the full spectrum of potential complications of RFA remains undetermined. We report a case of severe biliary complication, associating main bile duct stricture and biliary pleural fistula, arising after extensive RFA for unresectable liver metastasis of central location. Treatment consisted of external drainage of the pleural effusion and internal endoscopic drainage via a biliary stenting. This description of a life-threatening complication emphazises the need to better knowledge of the contraindications of RFA, particularly for the treatment of large tumours at proximity of main bile ducts.

Ex vivo detection of tumoral lymph nodes of colorectal origin with fluorescence imaging after intraoperative intravenous injection of indocyanine green.

The aim of this study was to investigate the potential role of indocyanine green (ICG) fluorescence imaging after intraoperative intravenous (IV) injection for the “ex vivo” detection of metastatic lymph nodes (mLNs) of colorectal cancer origin.

Should Ruptured Liver Haemangioma Be Treated by Surgery or by Conservative Means ? A Case Report

Abstract Spontaneous rupture of a liver haemangioma is a rare but life-threatening acute clinical situation following haemorrhage within the liver, the subcapsular space and the peritoneal cavity in cases of capsular rupture. Rupture of a liver haemangioma has been reported to occur spontaneously in the majority of cases. In the past, prompt surgical treatment was recommended but was associated with high morbidity and mortality. Currently, conservative management and, in cases of recurrent haemorrhage, delayed surgery may be proposed. We report a case of spontaneous rupture of hepatic haemangioma treated by arterial embolisation and conservative means. The literature is also reviewed.

Diffuse intra-abdominal low grade fibromyxoid sarcoma with hepatic metastases: Case report and review of the literature

Introduction Low grade fibromyxoid sarcoma (LGFMS)1 is a rare soft tissue tumor involving deep soft tissues of the extremities and trunk. Abdominal location is extremely uncommon in which the few cases published in the literature are characterized by slow tumoral progression and long recurrence-free intervals. Methods We report the first case of an intra-abdominal LGFMS which was discovered incidentally in a 42-year-old woman presenting diffuse peritoneal nodules and hepatic metastasis on CT and MRI scans. Results The patient was successfully treated through conservative measures and remained asymptomatic at the 48 month follow-up. Conclusions This is the first reported case of LGFMS with peritoneal and hepatic metastases. Despite the discovery of an advance disease at exploration, the patient who refused a major surgical operation presents an uneventful follow-up and long term survival.