Intra-operative contrast-enhanced ultrasound improves image enhancement in the evaluation of liver tumors.

BACKGROUND: Intra-operative hepatic tumor ultrasound assessment can be difficult in patients with abnormal hepatic parenchyma because of the inability to enhance echogenic differences. METHODS: Prospective pilot study of intra-operative ultrasound contrast enhancement in the evaluation of liver tumors to establish safety, dosing, and increased image enhancement with ultrasound contrast evaluation. A single bolus of perfluten lipid microspheres was then injected and ultrasound images were then re-recorded and saved. RESULTS: Twenty consecutive patients underwent contrast-enhanced ultrasound evaluation during the operative procedure. All patients received at least one bolus dose of microspheres (median 2 dose, range 1-3), without change in heart rate, blood pressure, end tidal CO(2), oxygen saturation, and sedation monitoring at the time of dosing and until 4 hr post-bolus doses. Two blinded independent readers found the contrasted images to have a statistically greater degree of enhancement (median improvement of 4, P = 0.01) and greater degree of size/border characteristics in the contrasted images (median improvement of 5, P = 0.01) for all histologies. In five patients, the extent of hepatic resection was altered from partial to complete lobectomy in order to obtain acceptable oncologic margin. CONCLUSIONS: Contrast-enhanced ultrasound is safe and effective in pre-resection and pre-ablation treatment planning.

Factors associated with recurrence and survival following hepatectomy for large hepatocellular carcinoma: a multicenter analysis.

BACKGROUND: Optimal management of large (>5 cm) hepatocellular carcinoma (HCC) remains controversial. We sought to determine the factors associated with recurrence and survival for patients with large HCC following hepatectomy. METHODS: An analysis of a combined prospective database from two tertiary care centers was performed on consecutive patients who underwent hepatectomy for HCC > 5 cm. Univariate and multivariate analyses were performed to determine factors associated with recurrence, disease-free (DFS) and overall survival (OS). RESULTS: Seventy-eight patients were identified: 32 (41%) had hepatic fibrosis. Forty-six patients (59%) underwent a major hepatectomy with a morbidity rate of 41% and a mortality rate of 13%. Fibrosis was associated with male gender (P = 0.045), hepatitis C (P = 0.003), higher Child-Pugh (P < 0.0001) and Okuda score (P = 0.002), smaller tumors (6.25 cm vs. 10.5 cm; P < 0.001), positive-margin resection (P = 0.01), and death (P = 0.047). Factors associated with recurrence include tumor multifocality (P = 0.03) and vascular invasion (P = 0.02). Predictors of OS include multifocal tumors (P = 0.05), margin status (P = 0.02), vascular invasion (P = 0.01), and treatment complications (P = 0.004). The median overall DFS and OS were 12 and 20 months, respectively. Fibrosis had no impact on DFS (P = 0.24) or OS (P = 0.20). CONCLUSIONS: For patients with HCC larger than 5 cm, tumor-related factors predict outcomes and survival.

Do melanoma patients from Southern climates have a worse outcome than those from Northern climates?

Sun exposure is known to cause melanoma; what is not known is whether patients from the Southern United States have a different profile of clinicopathologic factors and outcomes than those from the Northern United States. Data from a prospective, randomized trial on surgery for cutaneous melanoma were analyzed. All patients underwent wide excision and sentinel lymph node biopsy. Patients were categorized into two groups: Northern or Southern according to their state of residence. Clinicopathologic factors and outcomes were compared between groups. A total of 2025 patients were included in the analysis; 1214 (60%) were from Southern states. The median follow-up was 52 months. Despite significant differences in clinicopathologic features between groups on both univariate and multivariate analysis, two important factors, namely primary tumor thickness and ulceration were not different, nor was the rate of lymph node metastasis. Additionally, there were no differences in disease-free survival or overall survival between the two groups. Significant differences exist between primary melanomas based on geographic regions; however there are no differences in survival. Cumulative versus episodic sun exposure may play some role in these differences.

Should hepatic metastatic colorectal cancer patients with extrahepatic disease undergo liver resection/ablation?

BACKGROUND: Surgical therapy has been proven to be the mainstay of treatment for hepatic metastases from colorectal cancer (CRM) in the appropriate patient. Previous contraindications were patients with extrahepatic disease (EHD) do not benefit from liver resection or ablation. We hypothesized that the survival of patients with EHD who receive aggressive multimodality care would be the same as those without EHD. METHODS: A review of our 1305 patient prospective hepato-pancreatico-biliary database from August 1995 to April 2008 identified 383 patients with surgical management of metastatic CRM to the liver. RESULTS: A total of 39 patients with limited EHD underwent liver resection/ablation vs 344 patients without EHD. There were no significant differences in hepatic disease burden (mean clinical risk score of 2.3 and 2.1 in patients with and without EHD, P=.19, and median number of hepatic metastases of 2 in each group, P=.88) or size of the largest lesion (mean 4.6 vs 4.5 cm with and without EHD, P=.84). EHD consisted of lung metastases in 33%, nodal metastases in 21%, peritoneal in 15%, unknown in 15%, and other in 15%. There was no difference in patients with and without EHD undergoing surgical with resection only in 41% vs 48%, ablation only in 31% vs 30%, and combined resection and ablation in 28% vs 22% (P=.61). Overall survival in patients with EHD was not significantly different (median survival 24 vs 33 months, P=.06). CONCLUSIONS: A thorough understanding of the biology of disease and appropriate multimodality care can lead to improved survival in patients with EHD, when compared with chemotherapy alone.

An evaluation of 2537 gastrointestinal stromal tumors for a proposed clinical staging system.

HYPOTHESIS: A gastrointestinal stromal tumor (GIST) staging system can be created with the Surveillance, Epidemiology and End Results (SEER) database. DESIGN: A review of records in the SEER database from 2537 patients with GISTs from June 1, 1977, through August 1, 2004. PATIENTS AND METHODS: Patients were compared using all available clinicopathologic factors, and a TGM (tumor, grade, metastasis) staging system was created according to these parameters. Survival data were analyzed using Kaplan-Meier methods, log-rank analyses, and Cox regression models. RESULTS: Median follow-up time was 21 months, 47.6% of patients were men, and the median age was 64 years; 5.0% had lymph node involvement, and 22.6% had distant metastasis. Tumor size (T1, < or =70 mm; T2, >70 mm; P <.001), grade (G1, grades I and II; G2, grades III and IV; P <.001), and the presence of metastases (M0, no; M1, yes; P <.001) did affect overall survival. When combined in a TGM staging system, grade and metastasis were the factors most predictive of survival. CONCLUSIONS: A staging system for GISTs that provides valuable prognostic information was developed. Further work to refine this system and validate it with other data sets should be undertaken. Mitotic index and standardized reporting may provide additional prognostic information and should be recorded for all tumors so that the most accurate staging system can be created.

The impact of obesity on outcomes following pancreatectomy for malignancy.

BACKGROUND: Obesity has previously been shown to correlate with higher stage and decreased survival in pancreatic cancer. The aim of this study was to determine the impact of obesity on operative outcomes, recurrence, and overall survival. METHODS: A review of our 1345 patient prospective hepatopancreaticobiliary database was performed to identify patients undergoing pancreatic resection from January 1991 to August 2008 for adenocarcinoma. Obesity was defined as a body mass index (BMI) > 30 kg/m(2). Data was analyzed using Wilcoxon, t test, and chi-square methods. Survival was analyzed using log-rank analysis. Postoperative complications were assessed using a 5-point scale. P < .05 was considered significant. RESULTS: Of 306 patients undergoing pancreatic resection for pancreatic adenocarcinoma examined, 68 were defined as obese. There was no significant difference seen in length of stay, operative time, tumor size, or node status. Obese patients had a higher operative blood loss (median 650 vs. 400 mL, P = .0008). Obese patients were more likely to suffer postoperative complications (67.6% vs. 50.4%, P = .01). There was no significant difference seen in disease-free survival or overall survival (22.1 months for obese vs. 25.6 months for nonobese, P = .5; 19.8 months for obese vs. 23.5 months for nonobese, P = .46). CONCLUSION: Obese patients had a higher rate and greater severity of postoperative complications, with increased operative blood loss. However, obese patients did not demonstrate any significant difference in specific oncologic factors or survival. These data suggest an equivalent biologic effect of obesity on pancreatic cancer survival.

Chemoprevention of metaplasia initiation and carcinogenic progression to esophageal adenocarcinoma by resveratrol supplementation.

Resveratrol (3,5,4'-trihydroxy-trans-stilbene), a polyphenol found in the skin of the grape and red wine, has been found to have chemopreventitive effects in some carcinogenic models. The effects of resveratrol on the initiation of Barrett's metaplasia and the carcinogenic progression to esophageal adenocarcinoma have not been evaluated. The aim of this study was to evaluate the effects of resveratrol on the transition from reflux esophagitis to Barrett's metaplasia to dysplasia to esophageal adenocarcinoma in an established rat model. Male Sprague-Dawley rats underwent esophagoduodenal anastomosis as per institutional approved protocol. They were then treated twice weekly with intraperitoneal injection of 7 mg/kg of resveratrol or saline. Additional nonoperated rats served as controls. The rats in each group were assigned to 1, 3, or 5-month subgroups. The distal esophagus was preserved for blinded histopathological examination at the time of harvest. Thirty-one animals in the 5-month resveratrol group showed a decreased severity of esophagitis (P<0.0001), incidence of intestinal metaplasia (P = 0.3567), and incidence of carcinoma (P = 0.4590) as compared with both the saline and nonoperated control groups. In conclusion, morphological characteristics consistent with decreased esophagitis and incidences of metaplasia and esophageal adenocarcinoma were seen on histopathology in the resveratrol group. Resveratrol resulted in a small diminution of the carcinogenic effects and progression to metaplasia, and further human studies are designed to explore the potential anticarcinogenic mechanism.

Is selective internal radioembolization safe and effective for patients with inoperable hepatocellular carcinoma and venous thrombosis?

BACKGROUND: The goal of this study was to examine the safety and efficacy of selective internal radioembolization (SIR) for hepatocellular carcinoma (HCC) with portal vein or caval thrombosis (VT), or both. Recent reports have demonstrated that SIR is safe for patients with HCC, but the impact on efficacy of venous thrombosis is unknown. STUDY DESIGN: Prospective single-arm study of the use of Therasphere in patients with unresectable HCC enrolled from January 2004 to June 2007. Patients were categorized into three groups based on VT status and therapy. RESULTS: Fifty-two patients were enrolled: 20 patients without VT who received SIR, 15 patients with VT who were treated, and 17 patients (10 with VT) who were not treated because of preprocedure screening failure. Fifty-eight treatments were administered, with a median of two treatments per patient (range of one to three treatments). Child's score was different between groups. Of the VT patients treated, 67% had portal VT, 7% had cava VT, and 26% had both. There were no treatment-related deaths. There was no difference in complications among groups (p = 0.34). Treated patients without thrombosis had a median overall survival of 13.9 months versus 2.7 months for those treated with thrombosis and 5.2 months for the untreated group given best supportive care only (p = 0.01). CONCLUSIONS: SIR is safe in patients with HCC. Although SIR can be delivered with minimal morbidity, there might be no benefit for patients with VT. Continued emphasis on multimodality therapy in this population is needed to improve survival.

Radiofrequency ablation vs. resection for hepatic colorectal metastasis: therapeutically equivalent?

INTRODUCTION: The role of ablation for hepatic colorectal metastases (HCM) continues to evolve as ablation technology changes and systemic chemotherapy improves. Our aim was to evaluate the therapeutic efficacy of radiofrequency ablation (RFA) of HCM compared to surgical resection. METHODS: A retrospective review of our 1,105 patient prospective hepatic database from August 1995 to July 2007 identified 192 patients with only hepatic resection or only ablation for HCM. RESULTS: Patients who underwent RFA were similar to resection patients based on a similar Fong score (1.8 vs. 2.1 p = 0.28), presence of extrahepatic disease (15% vs. 9% p = 0.19), mean number of hepatic lesions (2.8 vs. 2.1 p = 0.14), and prior chemotherapy (67% vs. 60% p = 0.33). Median time to recurrence was shorter with ablation than resection (12.2 vs. 31.1 months; p < 0.001). Recurrence at the ablation-resection site was more common with ablation than resection occurring 17% vs. 2% (p < or = 0.001) of the time, respectively. Distant recurrence in the liver was also more common with ablation occurring in 33% of patients vs. 14% for resection (p = 0.002). CONCLUSIONS: Surgical resection is associated with a lower chance of recurrence and a longer disease-free interval than RFA and should remain the treatment of choice in resectable HCM.

Preoperative chemotherapy does not increase morbidity or mortality of hepatic resection for colorectal cancer metastases.

Hepatic metastasis from colorectal cancer (mCRC) is best treated with a multidisciplinary approach. Conflicting data exist regarding the impact of preoperative chemotherapy on morbidity and mortality after hepatectomy. We hypothesized that preoperative chemotherapy does not adversely impact complications or mortality associated with hepatectomy. A retrospective analysis was performed and included patients with mCRC who underwent hepatectomy from 1996 to 2006. Patients were separated into two groups: those who received preoperative chemotherapy and those who did not. Univariate and multivariate analyses were performed to determine the factors associated with morbidity and mortality. Kaplan-Meier analyses were performed to determine disease-free survival (DFS) and overall survival (OS). One hundred eighty-six patients were analyzed: 112 (60%) received preoperative chemotherapy for a median of 4.2 months. Eighty patients (43%) underwent major hepatectomy. When comparing the two groups, there were no differences in hepatic tumor size (median 3 cm; p = 0.35), type of resection (p = 0.62), stage (p = 0.44) or location (p = 0.10) of the primary tumor, preoperative carcinoembryonic antigen (CEA) level (p = 0.80), or number of nodes in lymphadenectomy (p = 0.62). Only number of positive nodes after colectomy (p = 0.02), age (p < or = 0.0001), and combined resection/radiofrequency ablation (RFA) (p = 0.004) were statistically different between the two groups. There was no difference in rates of morbidity (p = 0.81), mortality (p = 0.29), DFS (p = 0.25) or OS (p = 0.30). We conclude that the use of preoperative chemotherapy did not increase the risk of complications or death for patients undergoing hepatectomy for metastatic colorectal cancer. Pre-hepatectomy chemotherapy appears to be safe and is an important part of the multidisciplinary approach for this disease.

Preoperative performance status predicts outcome following heated intraperitoneal chemotherapy.

BACKGROUND: Peritoneal carcinomatosis has a typical natural history of bowel obstruction and death. Significant evidence suggests that cytoreduction with heated intraperitoneal chemotherapy (HIPEC) improves long-term survival for these tumors. METHODS: A retrospective case series of patients who underwent initial HIPEC treatment was performed at 2 moderate-volume centers. Clinicopathologic data were reviewed and univariate analyses performed to determine predictors of periprocedural complications. RESULTS: Twenty-eight patients underwent HIPEC procedures. The most common pathologies were colonic adenocarcinoma and pseudomyxoma peritonei. The median preoperative peritoneal cancer index was 9.5. Thirteen patients had 34 complications, with no postoperative deaths. Pleural effusion and wound infection were the most common complications. Preoperative performance status and the extent of disease were predictive of complications. CONCLUSIONS: Cytoreduction and HIPEC can be done at moderate-volume centers with morbidity and mortality rates comparable with published results from large-volume centers. Preoperative performance status and the extent of disease predict postoperative complications.

Analysis of 900 appendiceal carcinoid tumors for a proposed predictive staging system.

BACKGROUND: Appendiceal carcinoid tumors (ACTs) are rare, and little is known about the long-term prognosis for these tumors because no staging system exists. Therefore, we sought to investigate prognostic factors associated with ACTs and to create a predictive staging system to accurately estimate prognosis. HYPOTHESIS: In patients with ACTs, TNM staging will accurately predict prognosis. DESIGN: Retrospective review of 15 983 patients with carcinoid tumors in the Surveillance Epidemiology and End Results (SEER) database from January 1, 1977, to December 31, 2004. SETTING: SEER database study. PARTICIPANTS: Nine hundred patients with ACTs (552 females and 348 males; mean age, 47.1 years [age range, 9-89 years]; mean size of the primary tumor, 2.4 cm [range, 0.1-11.5 cm]). Main Outcome Measure Clinicopathologic features in patients with ACTs that affect prognosis using a newly created TNM staging system incorporating these parameters. RESULTS: Lymph node metastasis was found in 137 patients (24%), and distant metastatic disease in 89 patients (10%). Stage-specific survival was statistically significant between stages (P < .001) but not within stages. At multivariate analysis, patient age, primary tumor size, histologic features, lymph node involvement, and distant metastasis were significant factors predicting survival. CONCLUSIONS: Our newly developed TNM staging system accurately predicts prognosis in patients with ACTs. A TNM staging system for ACTs will be helpful not only for physician education about factors that affect the outcome with this disease but also to observe trends in prognosis.

The use of self-expanding silicone stents in esophagectomy strictures: less cost and more efficiency.

BACKGROUND: Benign and postoperative anastomotic esophageal strictures remain a common problem in the management of esophageal diseases and cancer. Repeated dilation remains the most common treatment algorithm. Esophageal stenting with a removable plastic stent is another option. This study evaluated the dysphagia effects and cost of removable silicone stents in the management of benign and postoperative anastomotic strictures compared with standard repeat dilation. METHODS: A matched case-control study was done of benign esophageal stricture treatments from July 2004 to August 2006 in all patients treated for benign esophageal strictures identified in a prospectively maintained esophageal database. Eighteen patients had a retrievable silicone-covered stent placed, and 24 were treated with standard repeated dilations without stents. Early esophageal stenting vs repeated dilation in esophagectomy strictures and other benign strictures was compared. RESULTS: The median number of dilatations was two (range, 1 to 3) for the 18 stent patients, with all stents placed for 3 months' duration, and four dilations (range, 2 to 12) in 24 patients treated solely with dilatation. An evaluation of median, high, and low total charges, net revenue, and direct margin demonstrated that the use of a removable stent after one failed dilation was more cost-efficient than repeated dilations. CONCLUSIONS: In patients who do not respond to initial dilation, placement of removable esophageal stent at the second dilation leads to improved quality of life and dysphagia relief. Early use of a removable esophageal stent is significantly more cost-efficient when two or more esophageal dilations are avoided.

Adequate lymphadenectomy results in accurate nodal staging without an increase in morbidity in patients with gastric adenocarcinoma.

BACKGROUND: Proper resection in gastric cancer should include more than 15 lymph nodes for accurate staging. We sought to determine if adequate nodal dissection would result in more accurate N staging without an increase in mortality. METHODS: Data from a prospectively maintained (January 1996 to August 2006) foregut malignancy database were reviewed, and trends in treatment from 3 time periods (1996-1998, 1999-2001, and 2002-2006) were compared. RESULTS: Three hundred fifty-three patients treated had an average number of nodes examined of 13.1, with a significant increase in the number of nodes from years 1996 to 1998 (9.2), 1999 to 2001(10.2), and 2002 to 2005 (15.9) (P = .001). There was a significant decrease in 30-day (11.9% to 11.8% to 3.5%, P = .001) and 60-day mortality (15.2% to 18.6% to 10.6%, P = .001) during those same time periods. CONCLUSIONS: Through an increase in multidisciplinary collaboration, the surgical standards in gastric cancers has improved, with greater lymph node evaluation, greater lymph node staging accuracy, and decreased overall mortality.

Mixed ductal-endocrine carcinoma of the pancreas with synchronous papillary carcinoma-in-situ of the common bile duct: a case report and literature review--synchronous pancreatic and bile duct tumors.

This report is a case of a 58-year-old woman with a mixed ductal-endocrine carcinoma of the pancreas and a synchronous carcinoma-in-situ of the common bile duct. She presented with intractable itching from obstructive jaundice. Magnetic resonance imaging scan showed dilated intrahepatic biliary and common bile ducts. Endoscopic retrograde cholangiopancreatography revealed an ulcerated lesion of the ampulla. Biopsies from this lesion showed adenocarcinoma. Subsequently, pancreatoduodenectomy was performed for the diagnosis of peri-ampullary carcinoma. Gross examination revealed a 2-cm irregular, ulcerated lesion obstructing the distal 0.5 cm of the common bile duct within the head of the pancreas. On histopathological examination, it was discovered that this lesion contained two separate neoplasms: papillary carcinoma-in-situ of the intraparenchymal portion of the common bile duct and a mixed ductal-endocrine carcinoma of the pancreas. Mixed ductal-endocrine carcinoma of the pancreas is very rare. Finding it in conjunction with a synchronous, overlying papillary carcinoma carcinoma-in-situ of the common bile duct has not been previously described.

The use of dynamic positron emission tomography imaging for evaluating the carcinogenic progression of intestinal metaplasia to esophageal adenocarcinoma.

BACKGROUND: In this study, we investigate the use of PET scanning in the carcinogenic progression of reflux esophagitis to Barrett's esophagus to high grade dysplasia to esophageal adenocarcinoma, and correlate the uptake levels of 18F-FDG related to histological changes, and the rates of proliferation and apoptosis. METHODS: An established esophagoduodenal anastomsis rat model in conjunction with micro-PET scanning at 1 week, 1 month, 3 month, and 6 month after procedure was performed. RESULTS: Increased uptake levels of 18F-FDG were observed in the esophagi after EDA procedure. The higher level of 18F-FDG uptake within esophageal epithelium was identified in intestinal metaplastic transformation and esophagoduodenal adenocarcinoma by histological examination. CONCLUSIONS: Dynamic PET scanning represents a powerful tool in analyzing morphological carcinogenic transformation non-invasively in the esophagus. 18F- FDG accumulation was a sensitive marker in reflux esophageal injury carcinogenic progression from intestinal metaplasia to EAC.

Hepatic malignant epithelioid hemangioendothelioma: a case report and review of the literature.

Malignant epithelioid hemangioendothelioma is a rare hepatic tumor of vascular origin. It is most commonly found in young to middle aged women, and the tumors vary in reported malignant potential. Compounds such as oral contraceptive pills, poly vinyl chloride, and Thorotrast have been identified as risk factors for subsequent disease development. Radiologic ("lollipop" sign, capsular flattening) and pathologic (Factor-VIII antigen staining positive) evaluation aids in the diagnosis. As with most mesenchymal tumors, surgical resection is the most effective means of controlling local disease and preventing distant metastasis, though adjuvant therapies have been offered for those that are unresectable or not transplant candidates. We present our case of a hepatic malignant epithelioid hemangioendothelioma and a review of the English-language literature.

Esophageal carcinoma histology affects perioperative morbidity following open esophagogastrectomy.

Background. Esophagectomy for esophageal cancer is being practiced routinely with favorable results at many centers. We sought to determine if tumor histology is a powerful surrogate marker for perioperative morbidity. Methods. Seventy three consecutive patients managed operatively were reviewed from our prospectively maintained database. Results. Adenocarcinoma (AC) was present in 52 (71%) and squamous cell (SCC) in 21 (29%). The use of neoadjuvant therapy was similar for the AC (34.62%) and SCC (42.86%) groups. The SCC group had a higher incidence of prior pulmonary disease than the AC group (23.8% versus 5.8%, resp.; P = .03). SCC patients were more likely to have a prolonged ICU stay than AC patients (P = .004) despite similar complication rates, EBL, and prognostic nutritional index. The SCC group did, however, experience higher grades of complications (P = .0053). Conclusions. Presence of SCC was the single best predictor of prolonged ICU stay and more severe complications as defined by this study. Only a past history of pulmonary disease was different between the two histologic subgroups.

Hepatic imaging characteristics predict overall survival in hepatocellular carcinoma.

BACKGROUND: Pathologic tumor-related factors, including vascular invasion, remain the only reliable predictor of recurrence and overall survival in hepatocellular cancer (HCC). Other preoperative factors, such as hepatitis status, degree of liver disease (cirrhosis), number of tumors, and size of tumors have been inconsistent in predicting outcome. The aim of this study is to demonstrate that standard radiological imaging characteristics will predict overall survival in HCC. METHODS: We identified 103 HCC treated in our department from January 1999 to June 2005. All images were reviewed by two blinded physicians and classified into one of three radiological characteristics: pusher/mass forming (well encapsulated without parenchymal violation), invader (non-encapsulated with violation of parenchyma), and hanger/pedunculated (encapsulated with a majority of the lesion suspended from segments II, III, IV b, V, and / or VI). RESULTS: The study included 61 males and 31 females with a median age of 61 years (range 23 to 90 years), a median of one lesion (range 1-10), a majority with <25% liver involvement, with a median lesion size of 6 cm (range 1 to 22 cm). Surgical therapy included hepatic resection 34 (33%), RFA 23 (22%), and liver transplantation 21 (20%). The distribution of radiological characteristics at initial evaluation was 54% pushers, 41% invaders, and 4% hangers. Median survival for invaders (8.2 months) and hangers (10.0 months) was significantly lower than for pushers (median 29 months) (p = 0.0007). CONCLUSION: Standard, reproducible radiological characteristics are predictive of outcome in patients with HCC. Greater emphasis on identifying preoperative factors remains imperative to better identify patients' biology and determine which should undergo resection or transplantation.

Retroperitoneal and visceral sarcomas: issues for the general surgeon.

Sarcomas represent a rare, heterogeneous group of malignant tumors that arise from the mesenchymal tissues of the body. Although infrequently encountered, these tumors generate vigorous academic interest and an ever-expanding volume of medical literature. Chemotherapy is widely regarded as ineffective because of the often-large tumor burden and lack of good therapeutic drugs. Radiation therapy is often difficult to administer because of locoregional toxicity. Fortunately, targeted immunologic therapies have shown promise in some specific gastrointestinal mesenchymal tumors. To date, sarcoma remains a malignancy best treated operatively. Given the wide heterogeneity and biology of these tumors and the amount of new data available, a review of the current literature is warranted. The first installment of this review series dealt with extremity and trunk soft tissue sarcomas; this one will focus on retroperitoneal and visceral sarcomas and the management challenges they pose.