Clinical Factors Predicting Better Survival Outcome for Pulmonary Metastasectomy of Hepatocellular Carcinoma.

BACKGROUND: In patients with lung metastasis of hepatocellular carcinoma (HCC), it remains uncertain how a better survival outcome can be predicted after metastasectomy. This study aims to identify clinical factors that may be used to guide patient selection for such a therapeutic modality. A total of 28 patients who received pulmonary metastasectomy for HCC between 1993 and 2012 were identified. All relevant clinical factors were extracted from medical records up to September 2015. Patients were classified into high- and low-risk groups according to survival outcome after metastasectomy. All pertinent clinical factors were analyzed for correlation with survival outcome. SUMMARY: The overall survival of 28 patients after pulmonary metastasectomy was studied first. The survival curve was biphasic and reached a plateau at 40 months after metastasectomy. The results indicate the presence of 2 groups of patients with a different survival outcome. Among all clinical parameters, remission status in the liver before pulmonary metastasectomy and distant metastasis-free interval between the last treatment of HCC and the occurrence of lung metastasis were found to be significantly associated with excellent survival outcome after pulmonary metastasectomy (p = 0.019 and 0.007 by Fisher exact test, and p = 0.002 and 0.0002 by Cox regression analysis).

Serum midkine as a prognostic biomarker for patients with hepatocellular carcinoma.

Gene expression profiles of paired hepatocellular carcinoma (HCC) and adjacent noncancerous liver tissue samples revealed preferential expression of midkine in HCC. This finding suggested the clinical usefulness of midkine measurement in serum for monitoring HCC treatment response, recurrence, and progression. A prospective study in 285 patients, 144 in complete remission and 141 at risk for developing de novo HCC, was conducted. The changes in serum midkine level were in parallel with disease activity in about 81% of patients with HCC. The study also revealed that rapidly rising serum midkine levels occurred in patients in the terminal stage of HCC. The rising rate of serum midkine levels was inversely correlated with remaining survival days. However, serum midkine measurement did not detect emergence of new HCC in most patients in complete remission and in high-risk people without a history of HCC. Serum midkine levels can be useful to monitor HCC progression, and a sharp rise signals the approach of end of life in patients with HCC.

A simple, innovative way to reduce rhinitis symptoms after sedation during endoscopy.

BACKGROUND: Supplmental oxygen is routinely given via nasal cannula (NC) to patients undergoing moderate sedation for endoscopy. Some patients complain of profuse rhinorrhea and/or sneezing after the procedure, which results in additional medical costs and patient dissatisfaction. OBJECTIVES: To determine the causal relationship between the route of oxygen delivery and troublesome nasal symptoms, and to seek possible solutions. METHODS: Patients (n=836) were randomly assigned to one of the three following groups: the NC group (n=294), the trimmed NC (TNC) group (n=268) and the nasal mask (NM) group (n=274). All received alfentanil 12.5 µg/kg and midazolam 0.06 mg/kg, and adjunct propofol for sedation. Supplemental oxygen at a flow rate of 4 L/min was used in the NC and TNC groups, and 6 L/min in the NM group. The incidence of nasal symptoms and hypoxia were assessed. RESULTS: The incidence of rhinitis symptoms was significantly higher in the NC group (7.1%) than in the TNC (0.4%) and NM (0%) groups (P<0.001). The incidence of hypoxia was lower in the NC group (3.1%) (P=0.040). All hypoxia events were transient (ie, less than 30 s in duration). On spirometry, the mean value of the lowest saturation of peripheral oxygen was found to be significantly lower in the NM group (96.8%) than in the NC group (97.7%) (P=0.004). CONCLUSIONS: Trimming the NC or using NMs reduced the incidence of rhinitis symptoms; however, the incidence of hypoxia was higher. Further investigation regarding the efficiency of oxygen supplementation is warranted in the design of novel oxygen delivery devices.

Is final TNM staging a predictor for survival in locally advanced rectal cancer after preoperative chemoradiation therapy?

BACKGROUND: Neoadjuvant chemoradiation therapy has improved the local control rate and overall survival in locally advanced rectal cancers. The purpose of this retrospective study is to evaluate the correlation between the final pathologic stage and survival in these patients. METHODS: Patients with biopsy-proven rectal carcinoma, pretreatment staging by magnetic resonance imaging such as T3 or T4 tumors, or node-positive disease were treated with preoperative concomitant 5-fluorouracil-based chemotherapy and radiation, followed by radical surgical resection. Clinical outcome with survival, disease-free survival, recurrence rate, and local recurrence rate were compared with each T and N findings using the American Joint Committee on Cancer Tumor-Node-Metastasis (TNM) staging system. RESULTS: A total of 248 patients were enrolled in this study. Overall survival and disease-free survival at 1, 3, and 5 years were 97.1, 92, and 89.9% and 87.5, 71.1, and 69.5%, respectively. Thirty-six patients (14.5%) had a pathologic complete response after neoadjuvant therapy. The recurrence rate was significantly different between the pathologic complete response group and residual group (5.6 vs 31.1%; P = .002). Five-year disease-free survival was significantly better in the complete response group than the residual tumor group (93 vs 66%; P = .0045). There was no statistical difference in survival or locoregional recurrence rate between these two groups. CONCLUSIONS: Posttreatment pathologic TNM stage is correlated to disease-free survival and tumor recurrence rate in locally advanced rectal cancer after preoperative chemoradiation. Also, pathologic complete response to neoadjuvant treatment has its oncologic benefit in both overall recurrence and disease-free survival.

Extrapelvic endometriosis complicated with colonic obstruction.

Endometriosis is often seen in gynecology practice and is treated medically. However, intestinal involvement of endometriosis causing obstruction is relatively uncommon and is hard to differentiate from malignancy before surgery. Herein, we present a case of acute colonic obstruction caused by rectal endometriosis. Repeat colonoscopic biopsy and imaging studies could not differentiate the lesion from malignancy. Segmental resection with anastomosis was performed to relieve the symptom and confirm the diagnosis. We present this unusual disease in general surgical practice and also review the literature. The incidence, symptoms, diagnosis, treatment, and risk of malignancy of intestinal endometriosis are discussed.

Xanthogranulomatous appendicitis.

Xanthogranulomatous inflammation is an uncommon, though well-recognized entity that has been described in various organs but mostly commonly in the kidney and gallbladder. There have been few reports of its occurrence in the appendix. We report a 39-year-old man who presented with fever, right lower quadrant abdominal pain and mass. Abdominal computed tomography (CT) revealed diffuse wall thickening over the terminal ileum and cecum with involvement of the mesentery. CT-guided biopsy showed colitis with infiltration of lymphocytes, neutrophils and eosinophils. The patient's illness responded to intravenous antibiotics, but relapsed after switching to oral antibiotics. After the second course of intravenous antibiotics was given without resolution of symptoms, exploratory laparotomy was performed. Although operative findings favored colitis of the cecum, cancer of the cecum could not be completely ruled out. Right hemicolectomy was done and pathology confirmed the diagnosis of xanthogranulomatous appendicitis. This case illustrates that xanthogranulomatous appendicitis may mimic a locally advanced cancer, has a benign course, and can be cured by surgical resection.

Early gastric MALT lymphoma.

The endoscopic findings of mucosa-associated lymphoid tissue (MALT) lymphoma were classified into exophytic and infiltrative types by Palmer and Seifert. Normal-appearing gastric MALT lymphoma is quite uncommon, and only one case had been reported in the literature. Here we report the case of a 49-year-old woman who underwent esophagogastroduodenoscopy for health screening. Endoscopy revealed indistinct follicular gastritis mucosal change and a duodenal ulcer scar, and random biopsy was taken from her stomach to check for the presence of Helicobacter pylori (H. pylori). Biopsy revealed chronic gastritis with H. pylori, and atypical lymphoid infiltration highly suggestive of MALT lymphoma. Polymerase chain reaction study using primers specific for immunoglobulin heavy chain gene showed a clonal B cell lymphoproliferation consistent with MALT lymphoma. Treatment with amoxicillin, clarithromycin, and omeprazole for H. pylori rendered complete resolution of the disease. In conclusion, follicular gastritis may be a high-risk condition that gives rise to MALT lymphoma, and further investigation is indicated.

Radiation-induced liver disease after three-dimensional conformal radiotherapy for patients with hepatocellular carcinoma: dosimetric analysis and implication.

PURPOSE: To analyze the correlation of radiation-induced liver disease (RILD) with patient-related and treatment-related dose-volume factors and to describe the probability of RILD by a normal tissue complication probability (NTCP) model for patients with hepatocellular carcinoma (HCC) treated with three-dimensional conformal radiotherapy (3D-CRT). METHODS AND MATERIALS: Between November 1993 and December 1999, 93 patients with intrahepatic malignancies were treated with 3D-CRT at our institution. Sixty-eight patients who were diagnosed with HCC and had complete 3D dose-volume data were included in this study. Of the 68 patients, 50 had chronic viral hepatitis before treatment, either type B or type C. According to the Child-Pugh classification for liver cirrhosis, 53 patients were in class A and 15 in class B. Fifty-two patients underwent transcatheter arterial chemoembolization with an interval of at least 1 month between transcatheter arterial chemoembolization and 3D-CRT to allow adequate recovery of hepatic function. The mean dose of radiation to the isocenter was 50.2 +/- 5.9 Gy, in daily fractions of 1.8-2Gy. No patient received whole liver irradiation. RILD was defined as Grade 3 or 4 hepatic toxicity according to the Common Toxicity Criteria of the National Cancer Institute. All patients were evaluated for RILD within 4 months of RT completion. Three-dimensional treatment planning with dose-volume histogram analysis of the normal liver was used to compare the dosimetric difference between patients with and without RILD. Maximal likelihood analysis was conducted to obtain the best estimates of parameters of the Lyman NTCP model. Confidence intervals of the fitted parameters were estimated by the profile likelihood method. RESULTS: Twelve of the 68 patients developed RILD after 3D-CRT. None of the patient-related variables were significantly associated with RILD. No difference was found in tumor volume (780 cm(3) vs. 737 cm(3), p = 0.86), normal liver volume (1210 cm(3) vs. 1153 cm(3), p = 0.64), percentage of normal liver volume with radiation dose >30 Gy (V(30 Gy); 42% vs. 33%, p = 0.05), and percentage of normal liver volume with >50% of the isocenter dose (V(50%); 45% vs. 36%, p = 0.06) between patients with and without RILD. The mean hepatic dose was significantly higher in patients with RILD (2504 cGy vs. 1965 cGy, p = 0.02). The probability of RILD in patients could be expressed as follows: probability = 1/[1 + exp(-(0.12 x mean dose - 4.29))], with coefficients significantly different from 0. The best estimates of the parameters in the Lyman NTCP model were the volume effect parameter of 0.40, curve steepness parameter of 0.26, and 50% tolerance dose for uniform irradiation of whole liver [TD(50)(1)] of 43 Gy. Patients with RILD had a significantly higher NTCP than did those with no RILD (26.2% vs. 15.8%; p = 0.006), using the best-estimated parameters. CONCLUSION: Dose-volume histogram analysis can be effectively used to quantify the tolerance of the liver to RT. Patients with RILD had received a significantly higher mean dose to the liver and a significantly higher NTCP. The fitted volume effect parameter of the Lyman NTCP model was close to that from the literature, but much lower in our patients with HCC and prevalent chronic viral hepatitis than that reported in other series with patients with normal liver function. Additional efforts should be made to test other models to describe the radiation tolerance of the liver for Asian patients with HCC and preexisting compromised hepatic reserve.

Colorectal cancer screening in asymptomaic adults: comparison of colonoscopy, sigmoidoscopy and fecal occult blood tests.

BACKGROUND AND PURPOSE: Fecal occult blood tests (FOBT) and flexible sigmoidoscopy have previously been recommended for colon cancer screening. More recently, studies have recommended colonoscopy due to the high rates of advanced neoplasm not detected by FOBT and sigmoidoscopy. Previous studies of the effectiveness of colonoscopic screening in Taiwan were limited to families of patients with colorectal cancer. This study compared colonoscopy, sigmoidoscopy and FOBT for colorectal cancer screening in asymptomatic adults. METHODS: Screening colonoscopies and FOBT were performed in asymptomatic adults enrolled in our health-screening program between January 1997 and December 2000. Advanced neoplasm was defined as the presence of a polyp larger than 1 cm, polyps with villous or severe dysplastic features, or cancer. The junction of the splenic flexure and descending colon was defined as the boundary of the proximal and distal colon, and it was presumed that the distal colon would be examined using sigmoidoscopy in all patients. Data on the prevalence of polyps, advanced neoplasm, and cancer among different age groups were obtained. The results of chemical and immunologic FOBT were compared. The anatomic distributions of advanced neoplasm and cancer were analyzed. RESULTS: A total of 7,411 colonoscopic examinations were included in the analysis. Advanced neoplasms were present in 93 examinations (1.3%), including 16 cancers (0.2%). Chemical FOBT detected 20.2% of advanced neoplasms and 37.5% of cancers. Immunologic FOBT detected 48.3% of advanced neoplasms and 87.5% of cancers. If sigmoidoscopy had been performed in place of colonoscopy, 26.9% of advanced neoplasms and 12.5% of cancers would not have been detected. CONCLUSIONS: Colonoscopy can detect neoplastic lesions undetectable by FOBT and sigmoidoscopy in asymptomatic subjects. These results suggest that colonoscopy should be the method of choice in colon cancer screening.