Surgical and combined treatment of patients with Klatzkin's tumor.

Surgery as being a preferential method of treatment of patients with cholangiocarcinoma is associated with high complications and mortality levels while demonstrating poor long-term outcomes. Optimization of preoperative management and improvement of the results of surgical treatment for patients with proximal extrahepatic bile duct carcinoma. From January 1998 to December 2013 surgical treatment was performed in 36 patients (19 males, 17 females) with Klatzkin's tumor, from whom 10 patients obtained postoperative chemotherapy. Bismuth-Corlette type III-IV tumor stage was determined in 30 (83.3%) patients. Portal vein resection was performed in 13 (36.1%) patients. 27 (75.5%) patients underwent R0 resection. Postoperative mortality rate consisted 16.7%, complications were revealed in 87.1% of cases. 6 (16.7%) patients required additional surgery and interventional procedures were performed in other 20 (55.5%) patients to fix postoperative complications. Overall 5-year survival rate in R0-resection group was 40.1%, median - 29 months. In postoperative chemotherapy group overall 3-year survival rate was 66.7% which was twice higher than in surgery group but the difference was not statistically significant (p=0.35). The improvement of short-term outcomes of surgical treatment for patients with Klatzkin's tumor requires optimization of preoperative management and detailed adherence of surgical techniques. Combination of surgery with postoperative chemotherapy showed the trend to improvement of overall survival.

[Results of the repeated hepatic surgery on the reason of malignant tumors].

The work is based on an analysis of 95 clinical observations of patients with primary and metastatic liver disease who were in the surgical department of tumors of the liver and pancreas of the State Research Institute named by N.N. Blokhin of RAMS from 1990 to 2011. All patients underwent two or more liver resections. Of all 95 patients included in this study, 64 underwent repeated interventions over a liver colorectal metastases. 10 patients had the operations, which were performed for primary hepatocellular carcinoma of the liver. In 21 patients re-resection were performed for metastatic lesions of other tumor nosology. Postoperative mortality in tumor lesions of the liver in patients who underwent repeat resection was 1.05%, postoperative complications occurred in 38.9% of patients. All patients with colorectal liver metastases who underwent repeat resection of various sizes, five-year survival rate was 53.3±8.8%. Median 35.9 months. The low level of mortality and acceptable level of postoperative complications in patients re-operated liver tumor, as well as high rates of long survival confirm the thesis about the need for such interventions as part of combined treatment of this difficult group of patients.

[Surgical treatment of hepatocellular carcinoma].

Experience of surgical treatment of 171 patients, suffering hepatocellular carcinoma (HCC), was summarized. Extensive hepatic operations were performed in 99 (71.2%) patients, of them in 22.2%--on the concurrent hepatic cirrhosis background. Late results of treatment, depending on the main prognostic factors present, were analyzed. Cumulative survival in the terms of 5, 10 and 20 years have constituted 53.5, 37.3 and 28.8% accordingly. Accomplishment of a radical hepatic resection for HCC permits to achieve a durable remission of a tumoral process. While revealing a concurrent hepatic cirrhosis stage B (according to Child--Pugh classification) it is appropriate to use a hepatic transplantation and other methods of treatment, including chemoembolization, radiofrequency ablation, chemotherapy.

[Hepatopancreatoduodenal resection - are there any perspectives?].

1380 operations on liver, mostly for metastatic lesions were carried out during 1990-2010 years. Gastro-pancreaticoduodenal resection for lesions with periampullary localization was carried out to 580 patients. Combined surgical intervention on liver and pancreas was carried out in 20 cases. These observations formed our study. Direct and long-term results of treatment were analyzed in operated patients. It is shown gastropancreaticoduodenal resection though having high level of postoperative complications is well tolerated and can be recommended for wide application in clinical practice.

[The prognostic value of tumor cells blood circulation after liver surgery for cancer lesions].

The study aimed to prove the prognostic meaning of micrometastases blood circulation during liver resections for cancer lesions. 33 patients took part in the study. Circulating micrometastases were detected in blood using immunocytological method with pancytoceratine antibodies KL-1 and CAM 5.2. The majority of patients had colon cancer liver metastases (72,7%). Blood was sampled once in 8 patients, the rest 25 patients had double sampling: before and after liver mobilization. Patients with multiple liver metastases demonstrated tumor cells circulation more often. Of 58 tests, 25 were positive for tumor cells. 3-year survival in those patients was 45,7 ± 13,1%, 5-year survival was 24,4 ± 13,3%. Survival rates for patients with no circulating tumor cells detected were significantly higher.

[Gastropancreatoduodenal resection for malignant tumors, complicated with obstructive jaundice].

The experience of 329 gastropancreatoduodenal resections for malignant tumors of the periampullary zone has been reviewed. The obstructive jaundice complicated the disease in 237 (70%) patients. The fact required various modalities of the preoperative artificial bile drainage. To evaluate the jaundice influence on the perioperative period, patients were divided in 4 groups, considering the bile drainage modality and bilirubin blood levels. The early postoperative period was respectively analyzed, which led to the conclusion that bilirubin blood level has no influence on either intraoperative characteristics or postoperative morbidity and mortality. For the reason of that, radical treatment of the periampullary cancer, complicated by the obstructive jaundice, does not require preoperative bile drainage.

[The possibilities of surgical treatment of hepatocellular cancer in patients with liver cirrhosis].

154 radical liver resections were performed on the reason of the hepatocellular cancer, of them 33% in patients with liver cirrhosis. Liver function was assessed using the Child--Pugh score. Liver cirrhosis and extensive liver resections proved to be the independent complication and lethality risk factors. The extensive liver resections were performed in 70%. The postoperative morbidity rate was 44.8%, the lethality was 5.8%. The concomitant liver cirrhosis reliably worsens postoperative complications (p = 0.001) and lethality (p = 0.0001) rates. The long-term treatment results were analyzed. Thus, liver resection proved to be an appropriate treatment for patients with hepatocellular cancer and liver cirrhosis Child--Pugh stage A, but a thorough patient selection is recommended. Liver resection is contraindicated by liver cirrhosis Child--Pugh stage B. The orthotopic liver transplantation is recommended in such cases, considering that Milan criteria are observed. The rest cases should consider the possibilities of radiofrequency ablation, transarterial chemoembolization, chemotherapy.

[Surgical and combined treatment of patients with metastatic liver and lymph nodes invasion by colorectal cancer].

527 patients were operated on for liver colorectal cancer metastases. Of all cases of lymphadenectomy during liver resections, lymph nodes invasion was morphologically proved in 43 patients. 3- and 5-year survival rate in this group was 12,8+/-6.6% and 6.4+/-5.6%, respectively. No patients survived a ten-year interval. Maximal follow-up period was 62 months, median - 17 months. 3-year disease-free survival rate was 5.1+/-4.8%. No 5-year disease-free survival was registered. Inclusion of oxaliplatin in adjuvant chemotherapy regimen allowed the dramatical improvement of survival rates.

[Advanced hepatic resection for malignancy].

125 patients with hepatic neoplasms were observed during 1998-2008 years. Trisectionectomy was carried out to 84 patients with colorectal metastatic affection of liver, which amounted 67.2% of all cases. Hepatocellular carcinoma was the second most frequent malignancy to be observed--23 patients (18.4%). 6 patients (4.8%) with cholangiocellular carcinoma went further. 12 patients (9.6%) with non-colorectal metastatic tumors of liver were united into one group. In postoperative period adjuvant chemotherapy was carried out to 60 patients with colorectal metastatic affection of liver. In all patients with hepatic tumors undergoing trisectionectomy postoperative lethality amounted 6.4% (n=8), in patients with colorectal metastatic affection of liver--5.95% (n=5), in patients with primary hepatic tumors--3.45% (n=1), in patients with non-colorectal metastatic affection of liver--16.66% (n=2). Lethality was caused by acute hepatic failure in all observations. Postoperative complications were observed in 44.05% of patients with colorectal cancer and in 44.83% of patients with primary hepatic tumors. Hepatic failure was the most frequent complication. In case of colorectal metastatic affection three-year probability of survival amounted 30.94+/-6.6% in patients undergoing trisectionectomy, five-year--10.4+/-8%. Median 16 months. On conditions that adjuvant chemotherapy was carried out, three-year survival probability increased to 40.53+/-8.1%, five-year--to 10.4+/-8%. Median 17 months. One-year survival probability in patients with primary hepatic tumors undergoing trisectionectomy amounted 92.46+/-5.1%, three-year - 59.44+/-12.3%, five-year--44.58+/-15.8%. Median 42 months. Low level of postoperative lethality, allowable level of postoperative complications and good indices of survival probability in long-term period allow considering that trisectionectomy as a surgical technique is absolutely appropriate.

[Surgical treatment of patients with colorectal cancer and severe concurrent cardio-vascular diseases].

The study population comprised 14 patients, operated on account of colon cancer (n=2), sigmoid cancer (n=1), rectal cancer (n=6), synchronous rectal and prostatic cancer (n=1) and lung (n=1) and liver (n=2) colon cancer metastases. The diagnosed concurrent cardiovascular pathology was: coronary heart disease (n=8), valve disease (n=2), aortic aneurism (n=2), coronary heart disease combined with aortic aneurism (n=2). Simultaneous operations were performed in 3 patients, 11 patients were operated on consecutively. No deaths were registered after simultaneous operations. In the group of consecutive operations 2 patients had died of myocardial infarction and cardiac decompensation. 3 (21,4%) patients died of tumor relapse during the follow-up period. The rest 9 patients are under observation for 3 months to 10 years, 2 patients achieved a 5-year cancer-free survival time.

[The combined treatment of colorectal cancer with liver metastases].

The direct and follow-up results of surgical and combined treatment of colorectal cancer with liver metastases are presented. Complication rate after liver resections was 28.4% and lethality was 3.5%. Follow-up results evidence the decrease of survival in patients with adjuvant chemotherapy after surgery. The safety of oxalyplatin in patients after liver resections, including its intraarterial infusion through the hepatic artery is shown. Oxalyplatin-based chemotherapy regimen tended to be more effective in comparison with 5-fluorouracil scheme, especially in patients with synchronous or multiple liver metastases. Considering that the difference is not statistically significant, further studies of oxalyplatin influence on survival of patients with colorectal liver metastases are necessary.

[Multivisceral resections at disseminated abdominal tumors].

Overall 131 multivisceral resections at disseminated abdominal malignant tumors have been performed. The main arguments to extended operations were local dissemination of tumor (35.1%), synchronous hepatic metastases (49.6%), combination of local dissemination with synchronous metastases (6.1%), isolated synchronous tumors (6.1%), and multiple metastases with polyorganic localization (3%). The rate of postoperative complications and lethality at the patients undergone multivisceral operations were 34.3 and 6.8% respectively. There were no significant differences in postoperative complications rate and lethality between adjusted multivisceral and standard operations groups.

[Synchronous operations in metastatic cancer of the liver].

The resection of the liver has been performed in 661 patients including 154 (23.3%) cases of synchronous metastatic cancer of the liver. Among the latter patients primary tumor was removed in one stage with liver resection in 56% cases. Elderly age of the patients, multiple bilobular foci in the liver, size of the foci more than 10 cm, traumatic operations on the primary focus were not contraindications to synchronous operations. Surgical treatment for colorectal cancer should be supplemented with adjuvant chemotherapy. The long-term results demonstrate better survival after synchronous operations for colorectal cancer.

[Surgical and combined treatment of multiple and bilobar metastatic affection of the liver].

Short- and long-term results of surgical treatment in combination with local exposures (cryo- and thermo-destruction) and adjuvant chemotherapy in patients treated for multiple and bilobar metastatic affection of the liver were studied. Postoperative lethality was 2,5% (n=2) due to liver insufficiency. Specific for liver resection complications (bile outflow, moderate hepatic failure) do not exceed 20,5%. Five-year survival of patients with solitary bilobar metastatic affection of the liver (not more than two foci) was 39,1+/-14,3%. This demonstrates that solitary bilobar hepatic metastases is not a negative prognostic factor for surgical treatment. Long-term results of treatment of patients with multiple metastases of colorectal cancer to the liver are worse, but 1-, 2-, and 3-year survival demonstrates validity of surgical policy in treatment of these patients. Postoperative chemotherapy significantly improves long-term survival of patients with multiple or/and bilobar metastases of colorectal cancer to the liver.

[Characterization of lymphokine-activated killer cells obtained from the natural killers--T cells of patients with hepatic tumor lesion]. / Kharakteristika limfokinaktivirovannykh killerov, poluchennykh iz natural'nykh killerov, -- T-kletok bol'nykh s opukholevym porazheniem pecheni.

To analyze the functions of lymphokine-activated killer cells (LAKC) and to study their phenotype are of paramount importance in the assessment of their role in antitumor immunity. The natural killers--hepatic T cells--have been shown to be used to prepare LAKS that have a higher cytotoxic activity than LAKS that are generalized from peripheral mononuclear cells.

[Ways to improve tolerance to gastro-pancreatic-duodenal resection]. / Puti uluchsheniia perenosimosti gastropankreatoduodenal'noi rezektsii.

Immediate results of 125 gastropancreatoduodenal resection (GPDR) performed for cancer of the pancreatoduodenal zone are presented. Despite extended surgery volume (15 GPDR were extended, in 14 patients resection of the major vessels was performed) postoperative lethality decreased to 1.6% due to lowered rate of severe postoperative complications (first of all insufficiency of pancreato- and biliodigestive anastomosis). Ways of prophylaxis of these complications consist in conduction of percutaneous puncture transhepatic cholangiostomy as the method of choice for billiary decompression before surgery in patients with tumor obstructive jaundice, precise surgical technique, creation of pancreatogastroanastomosis on reconstructive stage of GPDR.

[Liver resection in locally-spread and metastatic kidney cancer]. / Rezektsii pecheni pri mestno-rasprostranennom i metastaticheskom rake pochki.

The postoperative outcome and survival were studied in patients operated for renal cancer with involvement of the liver. 9 patients have undergone radical nephrectomy and 12 patients--hepatic resections for direct hepatic involvement (2), synchronous (2) and metachronous (8) metastases of renal cell carcinoma. Right hemihepatectomy was performed in 2 and wedge resection in 10 cases. A complete resection was performed in 8 of 9 patients while one patient with direct hepatic invasion was found to have positive surgical margins. Postoperative lethality was absent but complications occurred in 6 patients: pancreatitis (1), pneumonia (3), hepatic abscess (1), hepatic and renal failure followed by GI bleeding (1). At follow-up, two patients died of progressive disease 4 and 68 months after the surgery and one was lost for follow-up. One patient with positive surgical margins is alive with pulmonary and liver metastases 16 months after surgery. Five patients are alive with no evidence of relapse 6, 10, 12, 19 and 56 months after the operation. Thus, the aggressive surgical approach is justified and should be considered in patients with renal cancer and hepatic involvement.

[Surgical treatment of endocrine-cell tumors of hepato-pancreatic-duodenal zone (comment of the editor)]. / Khirurgicheskoe lechenie éndokrinno-kletochnykh opukholei gepatopankreatoduodenal'noi zony (kommentarii redkollegii).

Endocrine-cell tumors of hepatopancreatoduodenal zone are rare diseases. Their rate doesn't exceed 1-4% of all tumors of this location. 79 patients with endocrine-cell tumors of hepatopancreatoduodenal zone were treated, 67 of them underwent surgical treatment (operability was 67.1%) Radical operations were performed in 45 patients (gastropancreatoduodenal resection--17, distal resection of the pancreas--16, tumor enucleation--5, hemihepatectomy--3, liver resection--4). Prognosis of endocrine-cell tumors of hepatopancreatoduodenal zone is relatively favorable. In radically operated patients the presence of metastases to lymph nodes doesn't influence long-term results which are better than ones of chemo- or radiotherapy. Correlation between long-term results of surgery and age of patients, tumor sizes and its histologic structure was not revealed. Radicality of surgery is the only factor influencing prognosis. It is necessary to expand indications for extended operations, and to perform multi-stage operations in some cases of recurrences.

[Ultrastructural phenotypes of tumor cells of endocrine-cellular neoplasms of hepatopancreatoduodenal organs and their role in determining the degree of malignancy and prognosis of these diseases]. / Ul'trastrukturnye fenotipy opukholevykh kletok éndokrinno-kletochnykh novoobrazovanii organov gepatopankreatoduodenal'noi zony i ikh znachenie v opredelenii stepeni zlokachestvennosti i prognoza étikh zabolevanii.

78 tumors of the hepatopancreoduodenal system were studied clinically, cytologically and ultrastructurally. Hormonal disturbances were observed in 36% of the patients. The 5-year survival after radical surgery did not depend on the tumor size, tumor cell atypia or metastases to the regional lymph nodes. The prognosis was worse when the tumor was located in the liver. Ultrastructural features of the tumor cells were reliable criteria of the malignancy degree and tumor prognosis. The prognosis, recurrence-free interval and survival improve with an increase in the number of ultrastructurally differentiated cells and organoids in cytoplasm, and with a reduction in nuclear polymorphism and number of dark cells. The degree of histologic and ultrastructural differentiation of tumor cells may not coincide.