The Role of Surgical Expertise and Surgical Access in Retroperitoneal Sarcoma Resection - A Retrospective Study.

Background: Retroperitoneal sarcoma (RPS) is a rare disease often requiring multi-visceral and wide margin resections for which a resection in a sarcoma center is advised. Midline incision seems to be the access of choice. However, up to now there is no evidence for the best surgical access. This study aimed to analyze the oncological outcome according to the surgical expertise and also the incision used for the resection. Methods: All patients treated for RPS between 2007 and 2018 at the Department of Visceral Surgery and Medicine of the University Hospital Bern and receiving a RPS resection in curative intent were included. Patient- and treatment specific factors as well as local recurrence-free, disease-free and overall survival were analyzed in correlation to the hospital type where the resection occurred. Results: Thirty-five patients were treated for RPS at our center. The majority received their primary RPS resection at a sarcoma center (SC = 23) the rest of the resection were performed in a non-sarcoma center (non-SC = 12). Median tumor size was 24 cm. Resections were performed via a midline laparotomy (ML = 31) or flank incision (FI = 4). All patients with a primary FI (n = 4) were operated in a non-SC (p = 0.003). No patient operated at a non-SC received a multivisceral resection (p = 0.004). Incomplete resection (R2) was observed more often when resection was done in a non-SC (p = 0.013). Resection at a non-SC was significantly associated with worse recurrence-free survival and disease-free survival after R0/1 resection (2 vs 17 months; Log Rank p-value = 0.02 respectively 2 vs 15 months; Log Rank p-value < 0.001). Conclusions: Resection at a non-SC is associated with more incomplete resection and worse outcome in RPS surgery. Inadequate access, such as FI, may prevent complete resection and multivisceral resection if indicated and demonstrates the importance of surgical expertise in the outcome of RPS resection.

Value of MRI/CT Image Fusion for Targeting "invisible" Lesions in Stereotactic Microwave Ablation (SMWA) of Malignant Liver Lesions: A Retrospective Analysis.

PURPOSE: To assess the technical feasibility of MRI/CT image fusion and completeness of ablation treatment for primary or metastatic liver lesions invisible on contrast-enhanced CT planning scans and outcome in patients treated with stereotactic microwave ablation (SMWA). MATERIALS AND METHODS: The study was approved by the local ethics committee. Patients who underwent SMWA between January 2015 and December 2018 were retrospectively analyzed. All liver lesions for which MRI/CT fusion was performed due to invisibility on pre-interventional CT planning scans were included and reassessed. The outcome measurement was successful ablation of the lesion at first follow-up imaging. RESULTS: During the study period, 236 patients underwent 312 SMWAs with ablation of 496 lesions. Twenty-four lesions in 15 patients (mean age, 62 years; range, 43-80 years) were included. Following MRI/CT image fusion, all 24 lesions could be sufficiently localized to perform SMWA. The first follow-up imaging showed complete ablation of 22 lesions. Two initially incompletely ablated lesions were hepatocellular carcinomas and were successfully re-ablated afterwards. CONCLUSION: SMWA with MRI/CT image fusion is an accurate and safe treatment option for patients with liver lesions not detectable on contrast-enhanced CT planning scans. MRI/CT image fusion may allow more patients with malignant liver lesions to benefit from local ablation treatment even if their lesions are not visible on CT planning examinations.

Surgical treatment strategies for hepatic alveolar echinococcosis.

Alveolar echinococcosis is a severe and rare helminthic disease with increasing incidence in endemic regions. Herein, available evidence on curative surgical and potential palliative approaches was reviewed. Such strategies have to be applied in the context of available resources in different health-care systems. Complete resection followed by adjuvant therapy remains the only curative treatment available. Curative surgery is performed by open or laparoscopic approach depending on the extent of the disease and the experience of the surgical team. Palliative resections are typically not indicated, because the availability of endoscopic treatments of biliary complications and long-term benzimidazoles represent efficient alternatives to surgery. Liver transplantation as an alternative to palliative surgery has not been shown to be superior to long-term conservative therapy. Immunosuppressive therapy might additionally contribute to fatal disease recurrence after transplantation.

Elevated incidence of alveolar echinococcosis in immunocompromised patients.

INTRODUCTION: Recent experimental data has revealed that the course of alveolar echinococcosis (AE) depends on adaptive immunity. For this study, we aimed to analyze the incidence and outcome of AE in immunocompromised humans. MATERIAL AND METHODS: Retrospective analysis of 131 patients with a median age of 54 years treated for AE between 1971 and 2017 at a Swiss tertiary referral Centre. Fifty-two percent were females and 65 patients (50%) were diagnosed incidentally. Fourteen patients (16%) were operated on laparoscopically. Overall, median follow-up was 48 months. RESULTS: New diagnoses have increased fourfold in immunocompetent and tenfold in immunocompromised patients in the past decade (p ≤ 0.005). Forty-one patients (31.3%) had co-existing or previous immunosuppressive conditions including 16 malignancies (36%), 11 auto-immune diseases or immunosuppressive therapies (31%), 5 infectious diseases (11%), 4 chronic asthma conditions (9%), 2 previous transplantations (4%) and 4 other immunocompromising conditions (9%). Serum levels of anti-Em18, -Em2 and -EgHF antibodies were neither associated with immunocompetence at diagnosis nor during follow-up, but significantly decreased after treatment with benzimidazole (n = 43) or surgery (n = 88) in all patients. Adjuvant therapy for ≥1 year (p = 0.007) with benzimidazole and resection status (R0) (p = 0.002) were both correlated with recurrence-free survival. Survival at 5 and 10 years after surgery was 97% and 94%, respectively, and after conservative treatment 91% and 73%, respectively. Curative surgery (p = 0.014) and immunocompetence (p = 0.048) correlated significantly with overall survival. CONCLUSION: The incidence of human AE has increased over the last 2 decades with surgical interventions resulting in excellent outcomes. We have observed an association of immunosuppressive conditions with both incidence and survival of AE eventually justifying the implementation of a screening program for patients at risk in endemic regions.

Nestin as a marker in the classification of adrenocortical tumors.

Expression of the intermediate filament, nestin, was long believed to be restricted to neuroectodermal stem cells. However, nestin expression has recently been detected in several tumors. Since adrenocortical carcinoma, a tumor entity still very difficult to classify, may gain the ability to aberrantly express neuroectodermal proteins including chromogranin A and synaptophysin, we asked the question whether nestin might also be detected in adrenocortical carcinomas, and if so, whether it might serve as a tool for clinical pathology. Therefore, we studied the expression of nestin in normal adrenal glands, adrenocortical adenomas, and adrenocortical cancers using specific immunohistochemistry and semi-quantitative reverse transcriptase-polymerase chain reaction. Immunostaining was nestin-positive in 1 out of 9 normal adrenal glands (11%), 2 out of 20 adrenocortical adenomas (10%), and 13 out of 16 adrenocortical carcinomas (81%). Expression of nestin mRNA could be detected in all microdissected tissues, independently of their grade of dedifferentiation. We conclude that our findings provide further evidence that nestin, as a marker, is not restricted to neuronal stem cells and nestin expression is worth to be studied in adrenocortical tumors.