Raphael L. C. Araujo

End-to-end renal vein anastomosis to preserve renal venous drainage following inferior vena cava radical resection due to leiomyosarcoma.

BACKGROUND When retrohepatic inferior vena cava (IVC) resection is required, for example, for IVC leiomyosarcoma, reconstruction is recommended. This is particularly true when the renal vein confluence is resected to preserve venous outflow, including that of the right kidney. METHODS Two patients with retrohepatic IVC leiomyosarcoma involving renal vein confluences underwent hepatectomy with en bloc IVC resection below the renal vein confluence. IVC reconstruction was not performed, but end-to-end renal vein anastomoses were, including a prosthetic graft in 1 case. RESULTS The postoperative course was uneventful with respect to kidney function, anastomosis patency assessed using Doppler ultrasonography and computerized tomography, and transient lower limb edema. DISCUSSION End-to-end renal vein anastomosis after a retrohepatic IVC resection including the renal vein confluence should be considered as an alternative option for preserving right kidney drainage through the left renal vein when IVC reconstruction is not possible or should be avoided.

INFLUENCE OF HEPATOCELLULAR CARCINOMA ETIOLOGY IN THE SURVIVAL AFTER RESECTION.

ABSTRACT Background: Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer and its incidence is increasing around the world in the last decades, making it the third cause of death by cancer in the world. Hepatic resection is one of the most effective treatments for HCC with five-year survival rates from 50-70%, especially for patients with a single nodule and preserved liver function. Some studies have shown a worse prognosis for HCC patients whose etiology is viral. That brings us to the question about the existence of a difference between the various causes of HCC and its prognosis. Aim: To compare the prognosis (overall and disease-free survival at five years) of patients undergoing hepatectomy for the treatment of HCC with respect to various causes of liver disease. Method: Was performed a review of medical records of patients undergoing hepatectomy between 2000 and 2014 for the treatment of HCC. They were divided into groups according to the cause of liver disease, followed by overall and disease-free survival analysis for comparison. Results: There was no statistically significant difference in the outcomes of the groups of patients divided according to the etiology of HCC. Overall and disease-free survival at five years of the patients in this sample were 49.9% and 40.7%, respectively. Conclusion: From the data of this sample, was verified that there was no prognostic differences among the groups of HCC patients of the various etiologies.

Patient selection for the surgical treatment of resectable colorectal liver metastases

Advances in surgery and chemotherapy regimens have increased the long‐term survival of patients with colorectal liver metastases (CRLM). Although liver resection remains an essential part of any curative strategy for resectable CRLM, chemotherapy regimens have also improved the long‐term outcomes. However, the optimal timing for chemotherapy regimens remains unclear. Thus, this review addressed key points to aid the decision‐making process regarding the timing of chemotherapy and surgery for patients with resectable CRLM. J. Surg. Oncol. 2017;115:213–220.

CENTRAL HEPATECTOMY FOR BILIARY CYSTADENOMA: PARENCHYMA-SPARING APPROACH FOR BENIGN LESIONS

Sweden. Report of 49 patients. Dis Colon Rectum. 1990 Oct;33(10):874-7. 7. Jorge E, Harvey HA, Simmonds MA, Lipton A, Joehl RJ. Symptomatic malignant melanoma of the gastrointestinal tract. Operative treatment and survival. Ann Surg. 1984 Mar;199(3):328-31. 8. Kantarovsky A, Kaufman Z, Zager M, Lew S, Dinbar A. Anorectal region malignant melanoma. J Surg Oncol. 1988 Jun;38(2):77-9. 9. Knysh VI, Timofeev IuM, Serebriakova ES. [Treatment of melanomas of the anorectal region]. Vopr Onkol. 1987;33(3):74-8. 10. Pyper PC, Parks TG. Melanoma of the anal canal. Br J Surg. 1984 Sep;71(9):671-2. 11. Singh W, Madaan TR. Malignant melanoma of the anal canal. Am J Proctol. 1976 Feb;27(1):49-55. 12. Slingluff CL Jr, Vollmer RT, Seigler HF. Anorectal melanoma: clinical characteristics and results of surgical management in twenty-four patients. Surgery. 1990 Jan;107(1):1-9. 13. Wong JH, Cagle LA, Storm FK, Morton DL. Natural history of surgically treated mucosal melanoma. Am J Surg. 1987 Jul;154(1):54-7.

Guidelines for the management of neuroendocrine tumours by the Brazilian gastrointestinal tumour group

Neuroendocrine tumours are a heterogeneous group of diseases with a significant variety of diagnostic tests and treatment modalities. Guidelines were developed by North American and European groups to recommend their best management. However, local particularities and relativisms found worldwide led us to create Brazilian guidelines. Our consensus considered the best feasible strategies in an environment involving more limited resources. We believe that our recommendations may be extended to other countries with similar economic standards.

Local and Systemic Treatment of Potentially Resectable Colorectal Liver Metastases

Advances in surgical fields and chemotherapy regimens have been increasing long-term outcomes for patients with Colorectal Liver Metastases (CRLM). The liver resection remains the main treatment for resectable CRLM, but the progress of the chemotherapy regimens has been changing the oncologic approach for those patients who present unrespectable liver disease treated with chemotherapy who reach tumor shrinkage allowing hepatic resection. Looking for potentially resectable CRLM, it seems that chemotherapy should always be offered as additional treatment to curative-intention liver resections, increasing Recurrence Free Survival (RFS), but not affecting Overall Survival (OS). The optimal timing for each chemotherapy regimen has not been answered by Randomized Clinical Trials (RCT) yet. Retrospective series are biased on different patient selection for different chemo modalities. The best candidate for each regimen of chemotherapy could not yet be defined, but clearly patients with more aggressive disease were preferred to preoperative chemo regimens testing chemo responsiveness and selecting “good responders” before surgery. These patient selection criteria have not been standardized yet but the rational of additional chemotherapy, regardless the timing of administration, has been assumed as stand of care for patients who underwent curative-intent resection. The main objective of this review was to collect information to be taken in consideration for different approaches in the management of CRLM

Chronic Pancreatitis Associated with Chylous Ascites Simulating Liver Cirrhosis

Purpose. Ascites, esophageal varicose veins, and acute digestive bleeding are unusual in the clinical presentation of chronic pancreatitis; however, these symptoms are frequently observed in patients with liver cirrhosis. Moreover, it is unlikely to observe chylous ascites in both presentations. Method. We report a patient who presented with chronic pancreatitis with splenic vein thrombosis, necrosis of the pancreatic neck and tail, esophageal varicose veins with previous bleeding, and chylous ascites. After partial pancreatectomy, his treatment was based on low-fat oral diet with medium-chain triglycerides with remarkable resolution of the chylous ascites. After 3 years, he presented with decompensated chronic pancreatitis and underwent plexus alcoholization and biliary-enteric deviation with an unremarkable postoperative course. Conclusion. Ascites is rarely associated with chronic pancreatitis, and chylous ascites is even rarer. The treatment of atraumatic chylous ascites is based on resolution of the obstructive causes and should include drainage and a low-fat diet with medium-chain triglycerides.

Interpretation of Results from Tables, Graphs, and Regressions in Cancer Research

Tables and graphs are often used in clinical research articles. This chapter especially considers these items and addresses the way to create Tables and the ways to interpret graphs and curves in oncologic clinical research. Tables must present complete and clear access to data, and Figures should work as an enabler resource to better reveal interesting points in the article. The main tools used to identify associations between exposure and outcomes in clinical research are univariate regression and multivariate regression; here we describe the use of these methods. However, despite being widely used in cancer research, these tools are not easily interpreted, are sometimes overused, and may be associated with hidden biases.

Sample Size Calculation in Oncology Studies

Sample size calculation is at the core of study design. It is defined as the calculation of the minimum number of subjects to be included in a study in order to detect a true effect or value and must always to be performed a priori. Several aspects have to be considered when computing a sample size, including assumptions of expected outcomes in the control and experimental groups, type I and II error rates, power, and the dropout rate. Without proper sample size calculation, the results of a clinical study can be misleading, not generalizable to other settings, more likely to be false negative or false positive, and might even be associated with ethical implications. Additionally, careful planning and accurate reporting of this calculation ensures transparency and reliability and allows the reproducibility of results.

The Many Different Designs of Phase II Trials in Oncology

Phase II trials are an important component of drug development in oncology. Their objective is to screen for preliminary signals of efficacy of new anticancer agents and to provide further information on drug toxicity. Many different phase II trial designs have been envisioned and utilized according to cancer behavior, type of drug effects on tumors, study endpoints, and treatment settings. The trials are generally classified as either single- or multiple-arm non-randomized trials or randomized phase II trials. Within each group, there are numerous different designs, with the most common ones being single-arm phase II trials, biomarker-driven trials, randomized “pick the winner” trials, randomized controlled phase II studies, randomized discontinuation trials, and crossover studies. The aim of this chapter is to provide an overview of the different designs of phase II cancer trials and to discuss the advantages and disadvantages of each design.