Paolo Mercantini

Hemoperitoneum from a Spontaneous Rupture of a Giant Hemangioma of the Liver: Report of a Case

Hemangioma is the most common benign tumor of the liver and it is often asymptomatic. Spontaneous or traumatic rupture, intratumoral bleeding, consumption coagulopathy, and rapid growth are mandatory surgical indications. We report a case of giant hemangioma of hepatic segments II and III, which presented as hemoperitoneum, and were treated successfully with preoperative transcatheter arterial embolization (TAE) and hepatic bisegmentectomy. A PubMed Medline search has identified up to now 32 cases of spontaneous rupture of hepatic hemangioma in adults (age >14 years) without a history of trauma, including the present case. Twenty-seven out of these were reviewed. Sixteen (84.2%) of 19 tumors of known size were giant hemangiomas (mean diameter 14.8 cm; range 6–25). Twenty-two (95.7%) patients underwent surgery. Thirteen patients (59.1%) had a resection, 5 (22.8%) were sutured, and 4 (18.1%) underwent tamponade. Three (23%) out of the 13 resected patients died. Four patients (30.8%) underwent TAE prior to elective hepatic resection without any operative mortality. Among the 5 sutured patients, 2 (40%) died as well as 3 (75%) out of 4 patients who underwent tamponade. The mortality rate of all surgery patients was 36.4% (8/22).

Is laparoscopic adrenalectomy safe and effective for adrenal masses larger than 7 cm

BackgroundLaparoscopic adrenalectomy (LA) has become the gold standard treatment for small (less than 6 cm) adrenal masses. However, the role of LA for large-volume (more than 6 cm) masses has not been well defined. Our aim was to evaluate, retrospectively, the outcome of LA for adrenal lesions larger than 7 cm.Patients and methods18 consecutive laparoscopic adrenalectomies were performed from 1996 to 2005 on patients with adrenal lesions larger than 7 cm.ResultsThe mean tumor size was 8.3 cm (range 7–13 cm), the mean operative time was 137 min, the mean blood loss was 182 mL (range 100–550 mL), the rate of intraoperative complications was 16%, and in three cases we switched from laparoscopic procedure to open surgery.ConclusionsLA for adrenal masses larger than 7 cm is a safe and feasible technique, offering successful outcome in terms of intraoperative and postoperative morbidity, hospital stay and cosmesis for patients; it seems to replicate open surgical oncological principles demonstrating similar outcomes as survival rate and recurrence rate, when adrenal cortical carcinoma were treated. The main contraindication for this approach is the evidence, radiologically and intraoperatively, of local infiltration of periadrenal tissue.

Role of the Lymph node ratio in pancreatic ductal adenocarcinoma. Impact on patient stratification and prognosis

Survival after resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumor grading have been identified. Aim of the study was to evaluate the prognostic significance of the lymph node ratio (LNR) for resected pancreatic ductal adenocarcinoma.

The laparoscopic approach with antireflux surgery is superior to the thoracoscopic approach for the treatment of esophageal achalasia. Experience of a single surgical unit.

BACKGROUND: Since its first description in the early 1990s, minimally invasive Heller myotomy has become the treatment of choice for esophageal achalasia. We report the experience of a single unit with thoracoscopic Heller myotomy (THM) and laparoscopic Heller myotomy (LHM) and we analyze the short- and long-term surgical outcomes in patients treated by each of the two approaches. METHODS: We evaluated retrospectively 33 patients who underwent surgical treatment for achalasia. Sixteen patients underwent THM without an antireflux procedure, and 17 patients underwent LHM and partial anterior fundoplication (n = 10) or closure of the angle of His (n = 7). RESULTS: Mean operative time was significantly shorter for LHM than for THM (150 vs 222 min, respectively) (p = 0.0001). Mean hospital stay was significantly shorter after LHM than after THM (2.0 ± 1.0 vs 5.1 ± 2.2 days, respectively) (p = 0.0001). Six of 16 patients (37.5%) in the THM group experienced persistent or recurrent dysphagia compared to one of 17 patients (5.8%) in the LHM group (p = 0.04). Heartburn developed in five patients (31.2%) after THM and in one patient (5.8%) after LHM (p = 0.07). Regurgitation developed in four patients (25%) after THM and in one patient (5.8%) after LHM (p = 0.149). Lower esophageal sphincter (LES) basal pressure decreased significantly from 30.1 ± 5.07 to 15.3 ± 2.1 after THM and from 32.1 ± 5.9 to 10.5 ± 1.7 after LHM (p = 0.0001). Mean esophageal diameter was significantly reduced after LHM compared to THM (from 54.5 ± 5.7 mm to 27.1 ± 3.3 mm vs 50.8 ± 7.6 mm to 37.2 ± 6.9 mm, respectively) (p = 0.0001). CONCLUSION: In our experience, LHM is associated with a shorter operative time and a shorter hospital stay, and it is superior to THM in relieving dysphagia. LHM with partial anterior fundoplication should be considered the treatment of choice for achalasia.

CDX1 expression is reduced in colorectal carcinoma and is associated with promoter hypermethylation

The CDX1 homeobox gene encodes a transcription factor specifically expressed in normal intestinal and colonic epithelia, and CDX1 gene expression is affected during colorectal tumour progression. In this study, real‐time quantitative RT‐PCR was used to investigate CDX1 expression in 26 colorectal carcinomas. Reduced expression of CDX1 was observed in 19 of 26 colon carcinomas compared to matched normal colonic mucosa: the decrease in CDX1 expression ranged between 0.10 and 0.79 (21–90% decrease; mean 64.75% ±22; p = 0.001). Mutation and loss of heterozygosity (LOH) analyses were then used to determine if reduced CDX1 expression was due to genetic alteration. No CDX1 gene mutations, but two known polymorphisms in exon 1, were observed. LOH was observed in 33% of the tumours investigated but this was not related to CDX1 expression. Since aberrant promoter methylation is a well‐known mechanism that participates in gene silencing, the methylation status of the CDX1 5′ CpG island promoter was also investigated. PCR amplification of bisulphite‐treated DNA followed by cloning was performed in 7 carcinomas that showed low expression of CDX1 and in 1 colonic carcinoma without reduced expression. Promoter hypermethylation occurred in carcinomas in which CDX1 reduced expression was present. These results suggest that CDX1 promoter hypermethylation is one of the molecular mechanisms that accounts for reduced CDX1 gene expression in colorectal carcinoma. Copyright

Prognostic Evaluation of the New American Joint Committee on Cancer/International Union Against Cancer Staging System for Hepatocellular Carcinoma: Analysis of 112 Cirrhotic Patients Resected for Hepatocellular Carcinoma

BackgroundIn 2002, the American Joint Committee on Cancer and the International Union Against Cancer redefined the T-classification for hepatocellular carcinoma, shifting the cutoff value for tumor size from 2 to 5 cm and giving more emphasis to vascular invasion.MethodsA retrospective cohort study was conducted on 223 consecutive patients with hepatocellular carcinoma observed between 1990 and 2002. One hundred twelve were resected and considered for retrospective analysis. Univariate and multivariate analyses were performed on several clinicopathologic variables. After classification according to each staging system, the long-term survival of different stages was compared. The prognostic value of each staging system was further evaluated by entering each stage, in turn, into the Cox regression model with other clinicopathologic variables. The median follow-up was 19 months.ResultsOn multivariate analysis, the viral etiology of cirrhosis and the presence of multiple nodules were independent prognostic factors. When the new staging system was entered into the multivariate analysis, it was the only independent factor (P = .02). When stratified according to the old tumor-node-metastasis system, there were no significant differences in the survival between stage I and II (P = .14) or between stage IIIA and IVA (P = .33); only the survival of stage II and IIIA was different (P < .01). When stratified according to the new tumor-node-metastasis system, there were significant differences between stage I and II (71.7% vs. 54.7%; P = .02).ConclusionsThe new staging system is a more reliable and objective method for T classification. It is easy to use in clinical practice and is better at stratifying curatively resected patients with respect to prognosis.

Advanced digestive neuroendocrine tumors: Metastatic pattern is an independent factor affecting clinical outcome

Objectives The objective of this study was to determine the impact of different metastatic spread patterns on outcome in advanced digestive neuroendocrine tumors (NETs). Methods This was a retrospective analysis of patients with stage IV NETs, classified as group 1 (unilobar liver metastases), group 2 (bilobar liver metastases), group 3 (extra-abdominal metastases). End points were overall survival (OS) and progression-free survival (PFS). Risk factor analysis was performed using Cox proportional hazard model. Results Of the 229 patients, 135 (58.9%) had pancreatic, and 94 (41.1%) small bowel NETs: 32 (13.9%) were included in group 1, 179 (78.2%) in group 2, and 18 (7.9%) in group 3. Median Ki67 was 4.5%. Overall, 5-year OS was 55%. Different OS was observed among the 3 groups: median survival not reached, 81 and 8 months, respectively (P < 0.001). Median PFS was 18 months. Both OS and PFS were significantly affected by Ki67 and metastatic spread pattern. Conclusions The stratification of stage IV NET patients based on metastatic patterns, alongside Ki67, predicts the clinical outcome. The extent of metastatic disease is a previously unrecognized variable, which should be considered when evaluating the results of treatments in NET patients with advanced disease.

Early changes of muscle insulin-like growth factor-1 and myostatin gene expression in gastric cancer patients

Cachexia increases morbidity and mortality of cancer patients. The progressive loss of muscle mass negatively affects physical function and quality of life. We previously showed reduced muscle insulin‐like growth factor‐1 (IGF‐1) expression and enhanced myostatin signaling in tumor‐bearing animals. This study was aimed at investigating whether similar perturbations occur in gastric cancer patients.

Is EUS-FNA of solid-pseudopapillary neoplasms of the pancreas as a preoperative procedure really necessary and free of acceptable risks?

BACKGROUND Solid-pseudopapillary neoplasms (SPNs) of the pancreas are infrequent tumors since, as of 2014, only 2744 patients have been described. Its rarity, unclear histogenesis, pleomorphic aspect on radiology (cystic, solid or mixed) and unpredictable biological behavior with an insidious high-grade malignant potential make SPN difficult to recognize preoperatively even in its target patient population which is predominantly composed of young women (about 87% of cases). METHODS Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed to improve the preoperative diagnostic yield for this tumor and obviate the risks formerly given by percutaneous biopsy. RESULTS In light of our experience, such a procedure could not be so innocuous as generally acknowledged. CONCLUSION We report the first case of rupture of pancreatic SPN following EUS-FNA and entertain both the actual and potential complications ensuing from this type of mishap.

Solitary left axillary metastasis after curative surgery for right colon cancer

mouth. GFPO is postulated to arise at the pharyngo-oesophageal junction in the muscle deficient Laimer-Haeckermann triangle when a flap of mobile, redundant submucosa prolapses distally, slowly enlarging over time. Endoscopic differentiation of bulky GFPO lesions from oesophageal sarcoma or leiomyoma may be difficult. Misguided attempts at radical longitudinal resection of the oesophagus should be avoided. Endoscopic resection is appropriate in selected, generally smaller lesions though care must be taken with potentially large feeding vessels. An open left cervical approach provides access to larger lesions with minimal morbidity.