Early Prediction of Post-hepatectomy Liver Failure in Patients Undergoing Major Hepatectomy Using a PHLF Prognostic Nomogram.

BACKGROUND: Liver resection (LR) is the main modality of treatment for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). Post-hepatectomy liver failure (PHLF) remains the most dreaded complication. We aim to create a prognostic score for early risk stratification of patients undergoing LR. METHODOLOGY: Clinical and operative data of 472 patients between 2000 and 2016 with HCC or CRLM undergoing major hepatectomy were extracted and analysed from a prospectively maintained database. PHLF was defined using the 50-50 criteria. RESULTS: Liver cirrhosis and fatty liver were histologically confirmed in 35.6% and 53% of patients. 4.7% (n = 22) of patients had PHLF. A 90-day mortality was 5.1% (n = 24). Pre-operative albumin-bilirubin score (p = 0.0385), prothrombin time (p < 0.0001) and the natural logarithm of the ratio of post-operative day 1 to pre-operative serum bilirubin (SB) (ln(POD1Bil/pre-opBil); p < 0.0001) were significantly independent predictors of PHLF. The PHLF prognostic nomogram was developed using these factors with receiver operating curve showing area under curve of 0.88. Excellent sensitivity (94.7%) and specificity (95.7%) for the prediction of PHLF (50-50 criteria) were achieved at cut-offs of 9 and 11 points on this model. This score was also predictive of PHLF according to PeakBil > 7 and International Study Group for Liver Surgery criteria, intensive care unit admissions, length of stay, all complications, major complications, re-admissions and mortality (p < 0.05). CONCLUSIONS: The PHLF nomogram ( https://tinyurl.com/SGH-PHLF-Risk-Calculator ) can serve as a useful tool for early identification of patients at high risk of PHLF before the 'point of no return'. This allows enforcement of closer monitoring, timely intervention and mitigation of adverse outcomes.

Predictors of post-hepatectomy liver failure in patients undergoing extensive liver resections for hepatocellular carcinoma.

BACKGROUNDS/AIMS: To determine the prevalence of post-hepatectomy liver failure/insufficiency (PHLF/I) in patients undergoing extensive hepatic resections for hepatocellular carcinoma (HCC) and to assess the predictive value of preoperative factors for post-hepatectomy liver failure or insufficiency (PHLF/I). METHODS: A retrospective review of patients who underwent liver resections for HCC between 2001 and 2013 was conducted. Preoperative parameters were assessed and analyzed for their predictive value of PHLF/I. Definitions used included the 50-50, International Study Group of Liver Surgery (ISGLS) and Memorial Sloan Kettering Cancer Centre (MSKCC) criteria. RESULTS: Among the 848 patients who underwent liver resections for HCC between 2001 and 2013, 157 underwent right hepatectomy (RH) and extended right hepatectomy (ERH). The prevalence of PHLF/I was 7%, 41% and 28% based on the 50-50, ISGLS and MSKCC criteria, respectively. There were no significant differences in PHLF/I between RH and ERH. Model for End-Stage Liver Disease (MELD) score and bilirubin were the strongest independent predictors of PHLF/I based on the 50-50 and ISGLS/MSKCC criteria, respectively. Predictive models were developed for each of the criteria with multiple logistic regression. CONCLUSIONS: MELD score, bilirubin, alpha-fetoprotein and platelet count showed significant predictive value for PHLF/I (all p<0.05). A composite score based on these factors serves as guideline for physicians to better select patients undergoing extensive resections to minimize PHLF.

Follicular dendritic cell sarcoma of the liver with metachronous small bowel and splenic metastases: a case report and literature review.

Follicular dendritic cell sarcoma (FDCS) of the liver is an extremely rare disease, accounting for a mere 0.4% of all soft tissue sarcomas. FDCS most commonly involves lymph nodes but also affects extranodal sites such as the gastrointestinal system, oral cavity, liver, spleen and pancreas, albeit less commonly. It is widely considered a low-to-intermediate grade malignancy. We report a case of FDCS with metachronous involvement of the liver, small intestines and spleen, its imaging, histological findings and its management.

On developing a pragmatic strategy for clinical trials: A case study of hepatocellular carcinoma.

Randomised controlled trials (RCTs) with sufficiently high statistical power are not always feasible for patients when the administration of the treatment is burdensome. Nevertheless, useful information concerning the relative effectiveness of the Test and Standard therapies, may be gleaned from under powered trials, non-randomised comparative studies and/or clinician's beliefs: the latter possibly additionally providing some suggestion of the strength of evidence required in order to adopt the Test therapy into clinical practice. In such circumstances, a Bayesian synthesis may be useful in quantifying the evidence of treatment effectiveness. In this article, we aim to present a Bayesian approach for synthesizing the cumulative evidence of the use of adjuvant hepatic intra-arterial iodine-131-lipiodol (I131L) following curative resection in hepatocellular carcinoma (HCC) patients. We constructed a posterior distribution using the information from two small RCTs, three non-randomised comparative studies, three single arm studies and the views of investigators on the use of I131L. This distribution enables calculation of the probability that the Test therapy is more effective than the Standard by a pre-stipulated amount. If this is very high, then for example, one may conclude the Test may replace the Standard therapy. If it is not, then the Standard would be retained for clinical use. Despite a strong early indication of the effectiveness of I131L, the evolving evidence over a 10-year period became more sceptical of its value. Although highly recommended, difficulties of implementing a Bayesian approach in this context are highlighted.

Rectal arterio-portal fistula: an unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt.

Gastrointestinal arterio-venous malformations are a known cause of gastrointestinal bleeding. We present a rare case of persistent rectal bleeding due to a rectal arterio-portal venous fistula in the setting of portal hypertension secondary to portal vein thrombosis. The portal hypertension was initially surgically treated with splenectomy and a proximal splenorenal shunt. However, rectal bleeding persisted even after surgery, presenting us with a diagnostic dilemma. The patient was re-evaluated with a computed tomography mesenteric angiogram which revealed a rectal arterio-portal fistula. Arterio-portal fistulas are a known but rare cause of portal hypertension, and possibly the underlying cause of continued rectal bleeding in this case. This was successfully treated using angiographic localization and super-selective embolization of the rectal arterio-portal venous fistula via the right internal iliac artery.The patient subsequently went on to have a full term pregnancy. Through this case report, we hope to highlight awareness of this unusual condition, discuss the diagnostic workup and our management approach.

Validation of five contemporary prognostication systems for primary pancreatic endocrine neoplasms: results from a single institution experience with 61 surgically treated cases.

BACKGROUND: Presently, several systems for the prognostication of pancreatic endocrine neoplasms (PENs) exist and the most appropriate classification system has not been clearly defined. This study aims to validate the performance of the 2004 World Health Organization (WHO), European Neuroendocrine Tumor Society (ENETS), Memorial Sloan-Kettering Cancer Center (MSKCC), American Joint Committee for Cancer (AJCC) TNM staging and Bilimoria criteria in a cohort of patients with PENs who underwent surgery at a single institution. METHODS: This study is a retrospective review of 61 consecutive patients who underwent surgical treatment for PEN. Actuarial disease-specific survival (DSS) of all 61 patients and recurrence-free survival (RFS) of 53 patients who had curative resection were analysed. RESULTS: On univariate analyses, tumour size ≥50 mm, non-curative resection, lymph node involvement, presence of distant metastases, presence of necrosis, mitotic count ≥2/10 hpf and poor differentiation were associated with decreased DSS. Tumour size ≥50 mm, lymph node involvement, lymphovascular invasion, presence of necrosis and mitotic count ≥2/10 hpf were associated with decreased actuarial RFS. All five staging systems were useful in stratifying the 61 patients according to actuarial DSS. However, the MSKCC grading and ENETS grading systems were not statistically significant in stratifying DSS in the 61 patients. In the 53 patients who underwent curative resection, the WHO, ENETS, MSKCC, AJCC staging and the MSKCC grading systems were successful in stratifying the patients according to actuarial RFS. However, the Bilimoria scoring and ENETS grading systems were not useful in prognosticating these 53 patients. CONCLUSION: All five classification systems were useful for the prognostication of surgically treated PENs in our patient cohort.

Impact of the introduction of laparoscopic wedge resection as a surgical option for suspected small/medium-sized gastrointestinal stromal tumors of the stomach on perioperative and oncologic outcomes.

BACKGROUND: The present study is designed to determine the feasibility and impact of the introduction of laparoscopic wedge resection as a surgical option for the treatment of suspected small/medium-sized (<7 cm) gastric gastrointestinal stromal tumors (GISTs). METHODS: The study involved a retrospective review of 53 consecutive patients who underwent laparoscopic or open wedge resection of a suspected gastric GIST. It was divided into two consecutive time periods wherein laparoscopic resection was a surgical option only in the latter period. Comparisons were made between the outcomes of patients who underwent laparoscopic versus open wedge resection and the outcomes of patients treated during the two consecutive time periods (to determine the impact of the introduction of laparoscopic wedge resection), RESULTS: Fourteen patients (26%) underwent laparoscopic wedge resection with 1 conversion. The pathological exam showed that 41 patients (77%) had a GIST. Laparoscopic resection was significantly associated with a longer operative time, an earlier return of bowel function, earlier resumption of liquid and solid diet, decreased duration of parenteral or epidural analgesia use, and shorter postoperative hospitalization compared to open resection. There was no statistical difference in the rate of R1 resection and actuarial recurrence-free survival for the two approaches. Comparison between the two time periods demonstrated that the introduction of the laparoscopic approach in the latter period resulted in an earlier return of bowel function, earlier resumption of liquid and solid diet, and decreased duration of parenteral or epidural analgesia. CONCLUSIONS: Laparoscopic wedge resection for gastric GIST can be safely adopted. It is associated with a more favorable perioperative outcome than the open approach. Its introduction as a surgical option has resulted in an improvement in perioperative outcomes without compromising oncologic safety at our institution.

Outcome after curative resection of large (>or=10 cm) gastric gastrointestinal stromal tumors: how frequent is adjacent organ involvement and is concomitant distal pancreatectomy necessary?

INTRODUCTION: Complete tumor resection with clear margins including adjacent organs is the treatment of choice for gastrointestinal stromal tumors (GISTs). However, true tumor invasion of adjacent organs has been reported to be rare. Concomitant distal pancreatectomy (DP) for suspected tumor infiltration is not infrequently performed during resection of large gastric GISTs. This study aims to determine the true frequency of adjacent organ involvement by large gastric GISTs with particular attention to the pancreas and compares the outcome after curative resection with and without a concomitant DP in order to determine if DP is truly necessary. METHODS: A retrospective review of 37 patients who underwent curative resection of large (>or=10 cm) gastric GISTs was conducted. RESULTS: Wedge resections were performed in 22, partial gastectomies in nine, and total gastrectomies in six patients. The median operative time was 180 min (range, 60-330 min), and the patients had a median postoperative stay of 8 days (range, 4-29 days). Overall, there were eight (22%) morbidities including two (5%) mortalities. Nineteen (51%) had concomitant adjacent organ resection, and these included 15 (41%) DPs with splenectomies. Direct organ invasion was demonstrated in 5/19 patients (26%) and 7/30 organs (23%) resected. Only 1/15 (6.7%) DP specimens demonstrated tumor infiltration. Comparison between the patients with and without a concomitant DP demonstrated that performance of a DP was associated with a longer operation time [225 min (range, 105-305 min) vs 158 min (60-330 min), P=.002)], increased postoperative stay [9 days (range, 7-29 days) vs 7.5 days (4-19 days), P=.042], and increased postoperative morbidity [6 (40%) vs 2 (9%), P=.025]. The DP cohort also had a statistically significant poorer 5-year recurrence free survival (22% vs 60%, P=.017). CONCLUSION: Although adjacent organ involvement is not uncommon with large gastric GISTs, concomitant DP is usually unnecessary as direct pancreatic invasion is rare. Furthermore, concomitant DP with splenectomy is associated with an increase in postoperative morbidity.

Ampullary carcinoma: effect of preoperative biliary drainage on surgical outcome.

AIM: To evaluate the influence of preoperative biliary drainage on morbidity and mortality after surgical resection for ampullary carcinoma. METHODS: We analyzed retrospectively data for 82 patients who underwent potentially curative surgery for ampullary carcinoma between September 1993 and July 2007 at the Singapore General Hospital, a tertiary referral hospital. Diagnosis of ampullary carcinoma was confirmed histologically. Thirty-five patients underwent preoperative biliary drainage (PBD group), and 47 were not drained (non-PBD group). The mode of biliary drainage was endoscopic retrograde cholangiopancreatography (n = 33) or percutaneous biliary drainage (n = 2). The following parameters were analyzed: wound infection, intra-abdominal abscess, intra-abdominal or gastrointestinal bleeding, septicemia, biliary or pancreatic leakage, pancreatitis, gastroparesis, and re-operation rate. Mortality was assessed at 30 d (hospital mortality) and also long-term. The statistical endpoint of this study was patient survival after surgery. RESULTS: The groups were well matched for demographic criteria, clinical presentation and operative characteristics, except for lower hemoglobin in the non-PBD group (10.9 +/- 1.6 vs 11.8 +/- 1.6 in the PBD group). Of the parameters assessing postoperative morbidity, incidence of wound infection was significantly less in the PBD than the non-PBD group [1 (2.9%) vs 12 (25.5%)]. However, the rest of the parameters did not differ significantly between the groups, i.e. sepsis [10 (28.6%) vs 14 (29.8%)], intra-abdominal bleeding [1 (2.9%) vs 5 (10.6%)], intra-abdominal abscess [1 (2.9%) vs 8 (17%)], gastrointestinal bleeding [3 (8.6%) vs 5 (10.6%)], pancreatic leakage [2 (5.7%) vs 3 (6.4%)], biliary leakage [2 (5.7%) vs 3 (6.4%)], pancreatitis [2 (5.7%) vs 2 (4.3%)], gastroparesis [6 (17.1%) vs 10 (21.3%)], need for blood transfusion [10 (28.6%) vs 17 (36.2%)] and re-operation rate [1 (2.9%) vs 5 (10.6%)]. There was no early mortality in either group. Median survival was 44 mo (95% CI: 34.2-53.8) in the PBD group and 41 mo (95% CI: 27.7-54.3; P = 0.86) in the non-PBD group. CONCLUSION: Biliary drainage before surgery for ampullary cancer significantly reduced postoperative wound infection. Overall mortality was not influenced by preoperative drainage.

Accurate preoperative localization of insulinomas avoids the need for blind resection and reoperation: analysis of a single institution experience with 17 surgically treated tumors over 19 years.

INTRODUCTION: Presently, the need for and choice of preoperative localization tests for insulinomas remain controversial. We report the results from a single institution experience whereby the management policy adopted was that of accurate preoperative localization before surgical exploration. MATERIALS AND METHODS: From 1990 to 2008, 17 patients with a clinical and biochemical diagnosis of an insulinoma who underwent surgery were retrospectively reviewed. The diagnosis of all insulinomas were confirmed pathologically. RESULTS: All tumors were localized preoperatively and an average of 2.2 preoperative localization studies including 1.4 noninvasive studies and 0.8 invasive studies were utilized per patient. Invasive localization modalities were more sensitive (92%) than noninvasive modalities in localizing insulinomas (71%). Intra-arterial calcium stimulation with hepatic venous sampling was the most sensitive invasive modality (100%), whereas magnetic resonance imaging was the most sensitive noninvasive modality (63%). Fifteen of 17 tumors (88%) were localized intraoperatively via inspection/palpation and/or intraoperative ultrasonography. Both insulinomas which were not localized intraoperatively were localized correctly to the distal pancreas via preoperative transhepatic portal venous sampling. None of the patients required a blind resection or surgical reexploration for failed localization. All 17 patients underwent complete surgical resection which included eight enucleations and nine distal pancreatectomies with a cure rate of 94% (16/17) at a median follow-up of 35 (range, 1-217) months. The postoperative morbidity and long-term outcome of enucleation was similar to distal pancreatectomy despite a higher rate of microscopic margin involvement. CONCLUSION: Accurate preoperative localization of insulinomas is useful as it eliminates the need for blind distal pancreatectomy and avoids reoperation. Complete surgical resection is the treatment of choice, and whenever possible, a pancreas-sparing approach such as enucleation should be adopted.

A single-institution experience with eight CD117-positive primary extragastrointestinal stromal tumors: critical appraisal and a comparison with their gastrointestinal counterparts.

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) arising from outside the gut wall also termed extragastrointestinal stromal tumors (EGISTs) are reported to be rare. Presently, their pathogenesis remains controversial, and recently, it has been proposed that EGISTs may be the result of extensive extramural growth of GISTs which lose contact with the gut wall. This study presents a single-institution experience with eight EGISTs and compares their clinicopathological features with mural GISTs in order to determine further insight to their possible origin. METHODS: Between 1997 and 2008, 156 patients with pathologically proven CD117-positive primary GISTs were retrospectively reviewed. Eight tumors were identified as EGISTs, 104 were gastric GISTs, and 44 were small-bowel GISTs. Mural GISTs were classified as extramural or intra/transmural according to their gross pattern of growth. RESULTS: There were five male and three female patients with a median age of 58 years (range, 42-81 years). All patients were symptomatic, and the tumors were located in the greater omentum (n = 2), lesser sac (n = 2), lesser omentum, retroperitoneum, small-bowel mesentery, and pancreas. The median tumor size was 140 mm (range, 55 to 220 mm). Seven of eight EGISTs were found to be in close association to the adjacent gut wall. Pathological examination demonstrated that two tumors demonstrated focal involvement of the muscularis propria of the adjacent gut wall. Four tumors demonstrated tumor abutting or adherent to the serosa but no muscle involvement and one tumor was separated from the serosa. Comparison between the clinicopathological features of EGISTs with extramural GISTs and intra/transmural GISTs demonstrated that EGISTs were significantly larger [140 range (55-220) mm vs 80 (5-260) mm vs 50 (15-190) mm, P = 0.049, P < 0.001 respectively]. CONCLUSION: The occurrence of true EGISTs is rare. Most cases demonstrate some form of communication or contact with the gut wall, and EGISTs are significantly larger than extramural or intra/transmural GIST. These observations suggest that most, if not all, cases of EGISTs are likely to represent mural GISTs with extensive extramural growth with eventual loss of contact with the muscle layer of the gut.

Critical appraisal of 232 consecutive distal pancreatectomies with emphasis on risk factors, outcome, and management of the postoperative pancreatic fistula: a 21-year experience at a single institution.

OBJECTIVE: To critically analyze a large single-institution experience with distal pancreatectomy (DP), with particular attention to the risk factors, outcome, and management of the postoperative pancreatic fistula (PF). DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: A total of 232 consecutive patients with pancreatic or extrapancreatic disease necessitating DP over 21 years. INTERVENTIONS: Twenty-one patients underwent spleen-preserving DP, 117 underwent DP with splenectomy, and 94 underwent DP with multiorgan resection. MAIN OUTCOME MEASURES: The perioperative and postoperative data of patients who underwent DP were analyzed. This included factors associated with postoperative morbidity with particular attention to the PF (defined by the International Study Group of Pancreatic Fistula) and changing trends in operative and perioperative data during the study period. RESULTS: The overall operative morbidity and mortality were 47% (107 patients) and 3% (7 patients), respectively. During the study period, the rates of resection increased from 3 cases to 23 per year, and increasingly these were performed for smaller and incidental lesions. The morbidity rate remained unchanged, but there was a decline in postoperative stay and the need for care in the intensive care unit. Pancreatic fistulas occurred in 72 patients (31%); 41 (18%) were grade A, 13 (6%) grade B, and 18 (8%) grade C. Increased weight, higher American Society of Anesthesiologists score, blood loss greater than 1 L, increased operation time, decreased albumin level, and sutured closure of the stump without main duct ligation were associated with a postoperative PF on univariate analysis. A DP with splenectomy was associated with a higher incidence of grade B or C PF and non-PF-related complications. Ninety-two percent of PFs were successfully managed nonoperatively. Clinical outcomes correlated well with PF grading, as evidenced by the progressive increase in outcome measures such as postoperative stay, readmissions, reoperations, radiologic interventions, and non-PF-related complications from grade A to C PFs. CONCLUSIONS: Pancreatic fistula is the most common complication after DP and its incidence varies depending on the definition applied. Several risk factors for developing a PF were identified. Splenic preservation after DP is safe. The grade of a PF correlates well with clinical outcomes, and most PFs may be managed nonoperatively.

Which is the optimal risk stratification system for surgically treated localized primary GIST? Comparison of three contemporary prognostic criteria in 171 tumors and a proposal for a modified Armed Forces Institute of Pathology risk criteria.

BACKGROUND: This study aims to validate and compare the performance of the National Institute of Health (NIH) criteria, Huang modified NIH criteria, and Armed Forces Institute of Pathology (AFIP) risk criteria for gastrointestinal stromal tumors (GISTs) in a large series of localized primary GISTs surgically treated at a single institution to determine the ideal risk stratification system for GIST. METHODS: The clinicopathological features of 171 consecutive patients who underwent surgical resection for GISTs were retrospectively reviewed. Statistical analyses were performed to compare the prognostic value of the three risk criteria by analyzing the discriminatory ability linear trend, homogeneity, monotonicity of gradients, and Akaike information criteria. RESULTS: The median actuarial recurrence-free survival (RFS) for all 171 patients was 70%. On multivariate analyses, size >10 cm, mitotic count >5/50 high-power field, tumor necrosis, and serosal involvement were independent prognostic factors of RFS. All three risk criteria demonstrated a statistically significant difference in the recurrence rate, median actuarial RFS, actuarial 5-year RFS, and tumor-specific death across the different stages. Comparison of the various risk-stratification systems demonstrated that our proposed modified AFIP criteria had the best independent predictive value of RFS when compared with the other systems. CONCLUSION: The NIH, modified NIH, and AFIP criteria are useful in the prognostication of GIST, and the AFIP risk criteria provided the best prognostication among the three systems for primary localized GIST. However, remarkable prognostic heterogeneity exists in the AFIP high-risk category, and with our proposed modification, this system provides the most accurate prognostic information.

Outcome of distal pancreatectomy for pancreatic adenocarcinoma.

OBJECTIVES: To determine the outcome of patients undergoing distal pancreatectomy for pancreatic adenocarcinoma. METHODS: A retrospective review of 39 patients undergoing distal pancreatectomy for adenocarcinoma. RESULTS: Thirty patients underwent surgery for ductal adenocarcinoma, 5 for malignant intraductal papillary mucinous neoplasm and 4 for mucinous cystadenocarcinoma. Malignant cystic neoplasms were significantly less likely to demonstrate perineural invasion, more likely to be well-differentiated, of lower T stage and of lower AJCC staging compared to ductal adenocarcinoma. These had a longer median disease-specific survival (42 (3-144) vs. 15 (14-16) months, p = 0.002). Eight patients underwent extended resections. These were associated with longer operating times compared to standard resections but there was no difference in surgical morbidity or mortality, blood transfusions, length of hospitalization or long-term survival. Univariate analysis demonstrated that R2 resection, size >30 mm, lymph node involvement, need for perioperative blood transfusion, serum albumin <40 g/l and platelet count <200/microl were predictors of survival for ductal adenocarcinoma. CONCLUSIONS: Malignant cystic neoplasms have less aggressive behavior and more favorable outcome compared to ductal adenocarcinoma. R2 resection, larger tumor size, lymph node involvement, perioperative transfusion, decreased serum albumin and low platelet count are factors associated with decreased survival in patients with ductal adenocarcinoma undergoing distal pancreatectomy.

How useful are clinical, biochemical, and cross-sectional imaging features in predicting potentially malignant or malignant cystic lesions of the pancreas? Results from a single institution experience with 220 surgically treated patients.

BACKGROUND: This study aims to determine the use of preoperative clinical, biochemical, and cross-sectional imaging features for predicting malignancy in cystic lesions of the pancreas (CLP). STUDY DESIGN: Two hundred twenty patients who underwent operations for CLP or suspected CLP were reviewed. Patients were divided into two groups, patients undergoing operations for pseudocysts and patients undergoing operations for suspected cystic neoplasms. The predictive effect of various preoperative factors on the malignant potential of CLP was evaluated. RESULTS: Forty-four patients with a preoperative diagnosis of pseudocysts underwent operations for complications of pseudocyst. Forty-two were confirmed pathologically to have pseudocysts, but two were found, unexpectedly, to harbor malignant lesions. One hundred seventy-six patients underwent operations for suspected pancreatic cystic neoplasms. There were 70 benign, 51 potentially malignant, and 55 malignant CLP. On multivariate analysis, three factors, ie, elevated serum carcinoembryonic antigen (CEA) or carbohydrate antigen 19-9; cyst size > 3 cm; and presence of one or more of three morphologic features, such as solid component; peripheral calcification; and main duct dilation on cross-sectional imaging were independent predictors of malignancy. Presence of two or three of these factors had a positive predictive value of 88% in predicting a premalignant or malignant CLP. CONCLUSIONS: Most pancreatic pseudocysts can be accurately diagnosed preoperatively. In patients with suspected pancreatic cystic neoplasms, elevated serum CEA or carbohydrate antigen 19-9, cyst size > 3 cm, and presence of suspicious morphologic features on imaging are predictors of potentially malignant or malignant CLP. Patients with a high likelihood of a potentially malignant or malignant lesion based on these three factors should undergo operation without additional investigations.

A new chemoimmunotherapy regimen (OXAFI) for advanced hepatocellular carcinoma.

BACKGROUND: Chemotherapeutic treatment options for advanced unresectable and/or metastatic hepatocellular carcinoma (HCC) are limited. Currently available treatments are associated with low response rates and little evidence of improved survival, so we evaluated a new chemoimmunotherapy regimen. METHODS: Seven patients with unresectable and/or metastatic HCC were treated with intravenous oxaliplatin (30mg/m2) and doxorubicin (20mg/m2) given on days 1, 8 and 15 in a 28-day cycle, a daily continuous infusion of fluorouracil (200mg/m2) and subcutaneous interferon alfa-2b 5 MU administered thrice weekly (OXAFI). Treatment was administered to a maximum of six cycles. Data on the response to treatment, toxicity, surgical procedures and survival outcome was reviewed. RESULTS: The best response was three partial responses, three stable disease responses and one progressive disease response. Two patients underwent interval hepatic resection, and histological analysis in one patient showed a complete pathological response. Another patient underwent a liver transplant after four cycles of treatment. These three patients were alive with no evidence of disease at 23, 21 and 18 months follow-up, respectively. At a median follow-up of 14 months (range 2-23 months), one patient died 2 months after diagnosis due to progressive disease, while all six other patients were alive. Neutropenia was the predominant toxicity, but there were no episodes of febrile neutropenia, hospital admissions or deaths. There were no cases of hepatitis B virus re-activation. CONCLUSIONS: OXAFI shows activity in HCC and has manageable toxicity. Complete pathological remission is possible with this regimen.

Positron emission tomography with 2-deoxy-2-[18f] fluoro-D-glucose in the detection of malignancy in intraductal papillary mucinous neoplasms of the pancreas.

A 79-year-old Indian male was admitted with upper abdominal discomfort of 1-year duration which was associated with loss of weight and appetite. Serum tumor markers, including carcinoembryonic antigen and carbohydrate antigen 19-9, were within normal limits. A computed tomographic scan demonstrated a cystically dilated and tortuous pancreatic duct measuring 1.9 cm, suggestive of an intraductal papillary mucinous neoplasm. Fusion positron emission tomography/computed tomography with 2-deoxy-2-[18F] fluoro-D-glucose positron emission tomography (FDG-PET/CT) which was subsequently performed confirmed a metabolically active focus within the pancreatic head mass with a standard uptake value (SUVmax) of 3.5 compatible with carcinoma. A total pancreatectomy was performed and the final histology demonstrated a main-duct type intraductal papillary mucinous neoplasm with a focus of high-grade dysplasia compatible with carcinoma-in-situ. These images illustrate the emerging utility of FDG-PET/CT in the preoperative detection of malignancy in intraductal papillary mucinous neoplasm.

Pancreatic cysts: a proposed management algorithm based on current evidence.

BACKGROUND: Currently, the management strategy of pancreatic cyst (PC) remains controversial because of the inability to diagnose this type of cyst accurately and the limited knowledge of its natural history. Previously, many clinicians have advocated an aggressive resectional policy. This approach is no longer appropriate, and the number of PCs detected incidentally has increased. This study reviews the present literature and attempts to provide a management algorithm of pancreatic cysts based on currently available evidence. METHODS: A Medline search was conducted to identify studies investigating PC, with particular emphasis placed on studies addressing its diagnosis and management. Additional articles were obtained from the reference lists of key articles and recent reviews. COMMENTS: Based on current evidence, the optimal management of PC remains an art and should be individualized based on the risk-benefit ratio of surgery, which is influenced by multiple factors, such as the patient's potential life expectancy, surgical risk; and malignant potential of the cyst. Our proposed management algorithm is based on an individual's predicted risk-benefit ratio of surgery. Prospective evaluation of the algorithm is needed to determine its integrity.

A study into the risk of exacerbation of chronic hepatitis B after liver resection for hepatocellular carcinoma.

Liver resection is commonly performed for solitary hepatocellular carcinoma (HCC) in well-compensated cirrhotic and noncirrhotic patients. Data concerning exacerbation of chronic hepatitis B (ECHB) post-liver resection are scant. To determine the incidence, risk factors, and clinical outcomes of ECHB in patients who underwent hepatic resection for HCC. The methods consisted of a retrospective review of consecutive patients with chronic hepatitis B virus (HBV) infection who had undergone liver resection for HCC from January 2002 to December 2004. Seventy-seven patients underwent 82 liver resections; the mean age was 58.0 +/- 12.1 years; 87% male; 20% hepatitis B e-antigen positive. Incidence of all causes of postoperative hepatitis was 25.6% (n = 21), and ECHB was 8.5% (n = 7). Both groups had their peak alanine aminotransferases, 231.0 IU/L (74-1,400) and 312 IU/L (147-1,400), respectively, observed at day 84 postresection. Three patients died as a result of ECHB within 4 months postsurgery. One- and 2-year survival rates were poorest for the ECHB group at 42.9 and 21.4%, compared with those with postoperative hepatitis due to other causes at 60.3 and 45.2% and those without postoperative hepatitis at 87.7 and 73.5% (p < 0.001). Liver resection for HCC in patients with chronic HBV infection carries a risk for ECHB, and affected patients have poorer clinical outcomes. There is a need for close monitoring of these patients preoperatively and in the early postoperative period.

A review of mucinous cystic neoplasms of the pancreas defined by ovarian-type stroma: clinicopathological features of 344 patients.

INTRODUCTION: Despite formal definitions of mucinous cystic neoplasms (MCNs) and intraductal papillary neoplasms (IPMNs) by the World Health Organization (WHO) and Armed Forces Institute of Pathology (AFIP), several controversies with regard to MCNs remain. The aim of this review was to determine the clinicopathological features of MCNs defined by ovarian-type stroma (OS) as proposed by the WHO and AFIP and to compare them with MCNs defined by less stringent criteria. METHODS: A MEDLINE search was conducted to identify English-language articles on pancreatic MCNs from 1996 to 2005. Twenty-five studies were identified. The studies were divided into 2 groups: group A included 10 studies with 344 patients whereby the presence of OS was a criteria for the diagnosis of MCNs, and group B, included 15 studies comprising 761 patients whereby the presence of OS was not mandatory for the diagnosis of MCNs. RESULTS: Patients in group A (MCNs as defined by OS) were almost always female (99.7%), with a mean age of 47 (range, 18-95) years. MCNs were located predominantly in the body or tail of the pancreas (94.6%) and had a mean size of 8.7 cm (range, 0.6-35 cm); 76% were symptomatic, 6.8% demonstrated ductal communication, and 27% were malignant. At a mean follow-up of 57.5 (range, 1-264) months and 43 (range, 2-257) months after surgery, 97.9% of benign and 61.9% of malignant neoplasms were disease free, respectively. Patients in group B were older and had a higher proportion of males. Neoplasms were more evenly distributed in the pancreas, were smaller, communicated more frequently with the pancreatic duct, and were composed of a higher proportion of malignant tumors compared with group A. Their clinicopathological features were intermediate between those of group A and patients with IPMN. CONCLUSION: Pancreatic MCNs with OS have unique and distinct clinicopathological features. MCNs should be defined by the presence of OS, as it is the most reliable way of distinguishing MCNs from IPMN. Adoption of "looser" criteria will result in misclassification of some IPMNs as MCNs.