Tumor regression grades, K-RAS mutational profile and c-MET in colorectal liver metastases.

INTRODUCTION: Recently TRG, necrosis grade and the rate of viable cancer cells of colorectal liver metastases were correlated with the response to chemotherapy treatments, whereas K-RAS mutations and c-MET over-expression were correlated with the prognosis. METHODS: 58 resection specimens were assessed for regression grades. Patients undergone neo-adjuvant treatments were compared to patients who underwent therapy exclusively adjuvantly. We investigated the K-RAS mutational profile, the c-MET over-expression along with patients' survivals curves. RESULTS: Patients undergone neo-adjuvant treatment presented significant higher fibrosis rates and lower rates of viable cells. 36.7% of the patients had a K-RAS mutation and the 26.7% presented c-MET over-expression, but these features did not correlate with patients' clinical/pathological data. Survival analysis documented that K-RAS WT patients presenting c-MET over-expression had worse outcomes. CONCLUSION: Fibrosis and the rate of viable cells significantly correlate with the response to chemotherapy treatments. c-MET is a promising marker in K-RAS WT patients.

Ischemic Postconditioning of the Liver Graft in Adult Liver Transplantation.

BACKGROUND: Ischemia-reperfusion (I/R) injury is the main cause of graft failure in liver transplantation (LT). Ischemic postconditioning (IPo) has shown to be beneficial against I/R injury. Our objective was to compare the results of LT with or without IPo. METHODS: One hundred patients undergoing LT alternatively received IPo or not. At the time of arterial reperfusion, IPo consisted of three 1-minute arterial occlusions, interspersed with 1-minute reperfusion pauses. The primary endpoint was postoperative aspartate aminotransferase (AST) peak value; early graft dysfunction and histological I/R injury were secondary endpoints. RESULTS: Median postoperative AST peak values was similar in both groups (426 vs 463 IU/L, P = 0.21); no difference was found in other postoperative liver function tests. In the IPo group, fewer grafts presented severe histological I/R injury (12% vs 28%; P = 0.029). Ischemic postconditioning did not induce changes in cellular apoptosis but triggered autophagy in periportal areas. Independent predictors of severe I/R injury were IPo (odds ratio, 0.20; P = 0.008) and arterial warm ischemia duration (odds ratio, 1.05; P = 0.008). Early graft dysfunction rate was similar in both groups (20% versus 26%, P = 0.47) and was associated with severe histological I/R injury and longer cold ischemia. Morbidity, mortality, and 1-year graft and patient survival were similar in both groups. CONCLUSIONS: Ischemic postconditioning did not influence postoperative AST peak values or other liver function tests. However, our results showed a better tolerance to I/R injury on histological findings of grafts receiving IPo. Future studies are necessary to optimize the IPo protocol in LT, to clarify its clinical impact, and to deepen the molecular understanding.

Impact of reversible cardiac arrest in the brain-dead organ donor on the outcome of adult liver transplantation.

Several donor and graft characteristics are associated with higher failure rates for deceased donor liver transplantation (LT). The influence of reversible cardiac arrest in the donor on these failure rates is unclear because of scarce and inconsistent data. The aim of this study was to determine whether reversible cardiac arrest in the donor could affect the early postoperative outcome of LT. From January 2008 to February 2010, 165 patients underwent LT, and they were retrospectively divided into 2 groups: a cardiac arrest group (34 patients who received grafts from donors who had experienced reversible cardiac arrest before organ procurement) and a control group (131 patients who received grafts from donors without a history of reversible cardiac arrest). The postoperative complications and the graft and recipient outcomes were prospectively recorded for all the patients. Graft failure was defined as death or the need for retransplantation within 90 days of LT. Donors in the cardiac arrest group displayed higher serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels than donors in the control group [AST: 104 (19-756) versus 42 IU/L (10-225 IU/L), P < 0.001; ALT: 73 (13-869) versus 29 IU/L (6-549 IU/L), P < 0.001]. However, no difference in the graft failure rates was found between the 2 groups (11.8% versus 8.4%, P = 0.51). The biological parameters 5 and 7 days after LT and the peak AST/ALT levels were similar for the 2 groups. Furthermore, the 2 groups had similar graft and patient survival rates at the 6-month mark (87% and 88%, respectively). In conclusion, our study shows that brief and reversible cardiac arrest in organ donors does not affect post-LT allograft survival and function, even though liver function test values are higher for these donors. However, the risk of using these grafts needs to be balanced against the potential benefits for the recipients.

Oncologic results of laparoscopic versus open hepatectomy for colorectal liver metastases in two specialized centers.

OBJECTIVE: Compare oncologic results of laparoscopic versus open hepatectomy for resection of colorectal metastases to the liver. SUMMARY AND BACKGROUND DATA: Open hepatectomy (OH) is the current standard of care for the management of colorectal liver metastases. Although the feasibility of laparoscopic hepatectomy (LH) has been established, only select centers have used this technique as their primary modality. At present there is no study comparing the oncologic outcomes for colorectal liver metastases patients undergoing LH versus OH. METHODS: Two groups composed of 60 patients each were obtained from 2 specialized liver units performing either OH or LH as their primary modality. Cohorts of 215 LH cases and 1783 OH were used to establish the study population. Patients were compared on an intention to treat basis using 9 preoperative prognostic criteria obtained from LiverMetSurvey. These included sex, age, primary tumor localization, number of tumors, diameter of tumor, distribution of metastases, presence of extrahepatic disease, initial respectability, and the use of prehepatectomy chemotherapy. Overall survival and disease-free survival were compared between OH and LH for a follow-up of 36 months. RESULTS: The median follow-up for the LH group is 30 months and 33 months for the OH group (P = 0.75). One-, 3-, and 5-year patient survival for LH was 97%, 82%, and 64% and 97%, 70%, and 56% in the OH group, respectively (P = 0.32). One-, 3-, and 5-year disease-free survival was 70%, 47%, and 35% and 70%, 40%, and 27% (P = 0.32), respectively for the 2 groups. CONCLUSION: In a highly specialized center, first line application of laparoscopic liver resection in selected patients can provide comparable oncologic results to treatment with open liver resection for patients with colorectal liver metastases.

Surgical approaches to solitary parathyroid adenoma: state of the art. Our early experience with intraoperative parathyroid hormone measurement.

We report our early experience with focused radioguided parathyroidectomy with intraoperative parathyroid hormone measurement in patients affected by primary hyperparathyroidism. Over a period of 2 months we performed 4 consecutive focused parathyroidectomies with intraoperative parathyroid hormone measurement, 3 of which radioguided. All patients had a preoperative localization of single gland disease by sestamibi scanning and/or ultrasound. Blood samples for parathyroid hormone measurement were taken at baseline (induction of anaesthesia), 10 minutes after adenoma excision and the day after surgery. Three of the 4 patients were discharged within 24 hours. In all cases a solitary adenoma was successfully identified and removed. As predicted by the appropriate fall in intraoperative parathyroid hormone levels, all patients were considered cured on the basis of normal levels of calcium and parathyroid hormone at 1-month follow-up. Targeted parathyroidectomy can be successfully performed in patients with preoperatively localized solitary adenoma. The appropriate decrease in intraoperative parathyroid hormone levels assures a curative operation. The use of radioguidance should be recommended when difficulties with gland identification are foreseen.

[Stromal tumors of the rectum: a case report and review of the literature]. / Tumori stromali gastrointestinali (GIST) a localizzazione rettale. Un nuovo caso e revisione della letteratura.

This paper describes a case of epithelioid leiomyosarcoma of the rectum in a patient admitted for constipation and rectal bleeding. After an initial biopsy diagnosis of leiomyoma, a local excision was performed, showing the malignant nature of the tumour. Consequently, the patient underwent an abdomino-perineal amputation, adjuvant radiation (50 Gy) and a 24-month follow-up, which revealed no signs of local or distant recurrence. Sarcomas of the rectum are rare and therefore poorly documented neoplasms. They belong to the wider group of gastrointestinal stromal tumours, which are classified in 4 histological types: (i) smooth muscle, (ii) neural, (iii) mixed and (iv) undifferentiated. Since they grow within the intestinal wall, the symptoms are usually few or late, leading to delays in diagnosis. The diagnostic and staging protocol of stromal tumours of the rectum includes CT and MRI. The treatment is primarily surgical, where possible, and should guarantee complete clearance of the tumour, which often requires an aggressive approach. Non-curative resection, high tumour grade and size > 10 cm, are considered unfavourable prognostic factors. Further trials are needed to establish the exact role of adjuvant therapy. Though it prolongs the disease-free interval, there is no clear evidence that it influences the overall survival.