Vagner Jeismann

Pathological factors and prognosis of resected liver metastases of colorectal carcinoma: implications and proposal for a pathological reporting protocol

Colorectal cancer is a leading cause of death worldwide. The liver is the most common site of distant metastases, and surgery is the only potentially curative treatment, although the recurrence rate following surgery is high. In order to define prognosis after surgery, many histopathological features have been identified in the primary tumour. In turn, pathologists routinely report specific findings to guide oncologists on the decision to recommend adjuvant therapy. In general, the pathological report of resected colorectal liver metastases is limited to confirmation of the malignancy and details regarding the margin status. Most pathological reports of a liver resection for colorectal liver metastasis lack information on other important features that have been reported to be independent prognostic factors. We herein review the evidence to support a more detailed pathological report of the resected liver specimen, with attention to: the number and size of liver metastases; margin size; the presence of lymphatic, vascular, perineural and biliary invasion; mucinous pattern; tumour growth pattern; the presence of a tumour pseudocapsule; and the pathological response to neoadjuvant chemotherapy. In addition, we propose a new protocol for the evaluation of colorectal liver metastasis resection specimens.

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.

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

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Rare cause of abdominal incidentaloma: Hepatoduodenal ligament teratoma.

The occurrence of a hepatoduodenal ligament teratoma is extremely rare, with only a few cases reported in the literature. This case report describes the discovery of a hepatoduodenal ligament lesion revealed during abdominal ultrasonography for cholelithiasis-related abdominal pain in a 27-year-old female. Cross-sectional imaging identified a 5 cm × 4 cm heterogeneous mass of fat tissue with irregular calcification located in the posterior-superior aspect of the head of the pancreas. An encapsulated lesion showing no invasion to the common bile duct or adjacent organs and vessels was exposed during laparotomy and resected. Intraoperative cholangiography during the cholecystectomy showed no abnormalities. The postoperative course was uneventful. Pathological analysis of the resected mass indicated hepatoduodenal ligament teratoma. This case report demonstrates that cross-sectional imaging, such as computed tomography, can reveal suspected incidences of this rare type of teratoma, which can then be confirmed after pathologic analysis of the specimen. The prognosis after complete surgical resection of lesions presenting with benign pathological features is excellent.

Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases

Histomorphological features have been described as prognostic factors after resection of colorectal liver metastases (CLM). The objectives of this study were to assess the prognostic significance of tumor budding (TB) and poorly differentiated clusters (PDC) among CLM, and their association with other prognostic factors.

Evolution in the surgical management of colorectal liver metastases: Propensity score matching analysis (PSM) on the impact of specialized multidisciplinary care across two institutional eras

Liver metastases are indicators of advanced disease in patients with colorectal cancer. Liver resection offers the best possibility of long‐term survival. Surgical strategies have evolved in complexity in order to offer resection to a greater number of patients, requiring specialized multidisciplinary care. The current paper focused on analyzing outcomes of patients treated after the development of a dedicated cancer center in our institution.

Reply to “Poorly differentiated clusters in colorectal liver metastases: Prognostic significance in synchronous and metachronous metastases”

Dear Dr. Barresi and colleagues, We thank you for your interest in our recently published paper entitled “Prognostic significance of poorly differentiated clusters and tumor budding in colorectal liver metastases.” The papers published by Ueno et al and your group 3 about poorly differentiated clusters (PDC) in colorectal cancer inspired us to study PDC in colorectal liver metastasis (CLM). The different results in the studies may be explained by several differences in the methodological approach. For example, we evaluated the largest tumor among patients with more than one metastatic nodule, which was consistent with several previous reports. In contrast, the study by your group analyzed all metastatic nodules and reported the nodulewith the highest number of PDC (80% of patients with PDC versus 49.3% in our study). Another difference was that we identified 11 patients (4.8%) with PDC G3 (ten or more PDC under a microscopic field of ×20) versus only three patients (2%) with PDC G3 identified in your study. In turn, the low number of patients with PDC G3 might explain the lack of a statistical difference in overall survival (OS) and disease-free survival (DFS) in your study. Of note, similarly to your results, patients in our cohort who had PDC in CLMhad aworseOS andDFS (P = 0.019 and P = 0.002) comparedwith patients without PDC. However, we chose to use PDC G3 among patients with CLM because this variable was an independent prognostic factor in the logistic regression. In addition, according the original definition described by Ueno et al, PDC can appear within the tumor and/or at the advancing edge. In our study, we considered the sum of PDC rather than a specific location as in your series. Further studies are needed to validate the PDC location as a prognostic factor. There are different definitions of synchronous/metachronous CLM. We considered metachronous disease when CLM appeared after 12 months from diagnosis of primary tumor as proposed by Fong et al. In an era of multidisciplinary care for CLM that combines surgery and systemic therapy, patients with CLM diagnosed at or before surgery for the primary tumor are usually submitted to neoadjuvant chemotherapy as recommended by the European consensus. In our cohort, 83 patients (36.2%) had CLM diagnosed at or before colorectal resection and 59 of them (71.1%) received chemotherapy before liver resection (unpublished data). The effects of chemotherapy on histopathology are complex 9 and its consequences in CLM associated PDC are unknown. In contrast to the primary colorectal tumor where a pre-treatment biopsy is usually available, pre-chemotherapy pathological evaluation of the CLM was generally not available. In addition, patients with less aggressive disease (eg, small single nodule, metachronous disease, low CEA levels) tend to be operated without preoperative chemotherapy, while patients with more aggressive CLM are usually submitted to neoadjuvant systemic treatment, which may lead to a possible bias. Our understanding of CLM continues to grow and many new pathological prognostic factors have been described in the last years. CLM has increasingly been recognized not only as a secondary metastatic tumor, but also as an independent tumor with its own specific characteristics, behavior, and prognosis. Recently, our group published a proposal regarding standardized pathological reporting of CLM specimens based on described prognostic factors. Such standardize reporting can provide more information beyond margin status and secondary tumor confirmation. In an era where costefficiency is an important concern, the reporting of PDC does not add charges related to immunohistochemical staining, since PDC can be evaluated in routine hematoxilin and eosin staining. We completely agree that further studies are needed to elucidate the role of PDC in CLM. Despite questions about the prognostic impact of PDC grade, presence, or location, both studies indicate that PDC in CLMmay be a promising prognostic factor.

Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis

BACKGROUND Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation. METHODS A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed. RESULTS 21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95%CI: 22-47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = -43 ml; 95%CI: -74-(-13); P = 0.005, N = 1738]; shorter hospital stay [MD = -1.9 days; 95%CI: -3.2-(-0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = -0.05; 95%CI: -0.10-(-0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality. DISCUSSION Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.

LIVER RESECTION IN BRAZIL: A NATIONAL SURVEY

ABSTRACT Background: Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario. Aim: To provide an overview on the current spread of liver surgery in Brazil, focusing on groups´ profile, operative techniques and availability of resources. Method: From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country. Results: Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers. Conclusion: This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results

Background: Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery. Materials and Methods: Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated. Results: In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear. Conclusions: This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.