Simultaneous curative resection of double colorectal carcinoma with synchronous bilobar liver metastases.

Synchronous colorectal carcinoma (SCRC) indicates more than one primary colorectal carcinoma (CRC) discovered at the time of initial presentation, accounts for 3.1%-3.9% of CRC, and may occur either in the same or in different colorectal segments. The accurate preoperative diagnosis of SCRC is difficult and diagnostic failures may lead to inappropriate treatment and poorer prognosis. SCRC requires colorectal resections tailored to individual patients, based on the number, location, and stage of the tumours, from conventional or extended hemicolectomies to total colectomy or proctocolectomy, when established predisposing conditions exist. The overall perioperative risks of surgery for SCRC seem to be higher than for solitary CRC. Simultaneous colorectal and liver resection represents an appealing surgical strategy in selected patients with CRC and synchronous liver metastases (CRLM), even though the cumulative risks of the two procedures need to be adequately evaluated. Simultaneous resections have the noticeable advantage of avoiding a second laparotomy, give the opportunity of an earlier initiation of adjuvant therapy, and may significantly reduce the hospital costs. Because an increasing number of recent studies have shown good results, with morbidity, perioperative hospitalization, and mortality rates comparable to staged resections, simultaneous procedures can be selectively proposed even in case of complex colorectal resections, including those for SCRC and rectal cancer. However, in patients with multiple bilobar CRLM, major hepatectomies performed simultaneously with colorectal resection have been associated with significant perioperative risks. Conservative or parenchymal-sparing hepatectomies reduce the extent of hepatectomy while preserving oncological radicality, and may represent the best option for selected patients with multiple CRLM involving both liver lobes. Parenchymal-sparing liver resection, instead of major or two-stage hepatectomy for bilobar disease, seemingly reduces the overall operative risk of candidates to simultaneous colorectal and liver resection, and may represent the most appropriate surgical strategy whenever possible, also for patients with advanced SCRC and multiple bilobar liver metastases.

Centrally located small unifocal hepatocellular carcinoma between minor conservative liver resection and major hepatectomy. Case reports.

Hepatocellular carcinoma (HCC) is one of the leading cancer in the world, susceptible to potentially curative liver resection (LR) in selected cases. Centrally located HCC (CL-HCC) are sited in central liver segments and may require complex LR because of their relationship to major vascular and biliary structures and deep parenchymal location. Even though extended segment-oriented resections are recommended for oncological reasons, more conservative LR may be indicated in patients with cirrhosis to preserve an adequate function of the future remnant liver (FRL). To extend the indication to LR and to increase the safety of the surgical procedure, preoperative portal vein embolization (PVE) or sequential transarterial embolization/chemoembolization (TAE/TACE) and PVE have been widely used, to induce atrophy of the embolized segments involved by the tumor and compensatory hypertrophy of the FLR. The most appropriate surgical strategy for small uninodular CL-HCC remains controversial, and should be decided according to the features of the tumor at preoperative imaging, the relationship with major intrahepatic vessels and the expected function of the FRL. We report here two cases of elderly cirrhotic patients with unifocal small CL-HCC, where the surgical strategy was decided according to the kind of relationship of the tumor with the hepatic hilum at preoperative imaging. In the first case there was no clear evidence of neoplastic infiltration of the hilar vessels, so that a minor conservative LR was preferred. In the second patient the tumor was suspected to infiltrate the right portal vein, and a major LR was performed after sequential TACE/PVE. KEY WORDS: Centrally located, Future remnant liver, Hepatocellular carcinoma, Liver cirrhosis, Liver resection, Portal vein embolization, Transarterial chemoembolization.

Evolving role of FDG-PET/CT in prognostic evaluation of resectable gastric cancer.

Gastric cancer (GC) remains a leading cause of cancer death worldwide. Radical gastrectomy is the only potentially curative treatment, and perioperative adjuvant therapies may improve the prognosis after curative resection. Prognosis largely depends on the tumour stage and histology, but the host systemic inflammatory response (SIR) to GC may contribute as well, as has been determined for other malignancies. In GC patients, the potential utility of positron emission tomography/computed tomography (PET/CT) with the imaging radiopharmaceutical 18F-fluorodeoxyglucose (FDG) is still debated, due to its lower sensitivity in diagnosing and staging GC compared to other imaging modalities. There is, however, growing evidence that FDG uptake in the primary tumour and regional lymph nodes may be efficient for predicting prognosis of resected patients and for monitoring tumour response to perioperative treatments, having prognostic value in that it can change therapeutic strategies. Moreover, FDG uptake in bone marrow seems to be significantly associated with SIR to GC and to represent an efficient prognostic factor after curative surgery. In conclusion, PET/CT technology is efficient in GC patients, since it is useful to integrate other imaging modalities in staging tumours and may have prognostic value that can change therapeutic strategies. With ongoing improvements, PET/CT imaging may gain further importance in the management of GC patients.

Impact of octogenarians on surgical outcome in colorectal cancer.

AIM: Colorectal cancer's (CRC) incidence occupies the second place among malignant tumours in men and the third place in women. The aging of the population raises new questions on the management of CRC in octogenarian patients. The objective of this study was to assess the influence of age (≥80) on treatment and surgical outcome of colorectal cancer. METHOD: In the period between October 1995 and April 2014, a total of 1397 patients underwent emergency and elective surgical interventions for CRC; the first group (Group-Older - GO) was composed of 291 patients 80 years or older (20.9%, of which 46.4% were male). The second group (Group-Younger - GY) included 1106 patients younger than 80 years (79,1%, 57.7% males). RESULTS: Significant differences between the two groups were observed regarding sex (p = 0.001), number of comorbidities (p = 0.001), ASA classification (p < 0.001), emergency presentation (p < 0.001), site of tumor (p = 0.010), need of intraoperative blood transfusions (p < 0.001), 30-days mortality (p < 0.001), 90-days mortality (p < 0.001) and morbidity in accordance with Clavien-Dindo classification (p < 0.001). When combining both elective and emergency procedures, multivariate logistic regression analysis showed that advanced age (≥80 years old) was an independent predictor factor of 30-days mortality (p = 0.023, OR = 2.23) and morbidity (p = 0.088, OR = 1.31), while it was not predictive of 90-days mortality. When considering only elective colorectal surgery, octogenarian age was not found to be a predictive factor of 30-day and 90-day mortality, but predictive of postoperative morbidity. CONCLUSION: Old age (≥80) does not represent a contraindication to CRC elective surgical treatment, in emergency procedures it is associated with an increased risk of postoperative morbidity and mortality.

Successful surgical resection of solitary plasmacytoma of the liver mimicking hepatocellular carcinoma. A case report.

Solitary extramedullary plasmacitomas (SEMP) of the liver are very rare. We report the case of an elderly woman with a huge symptomatic SEMP of the liver mimicking hepatocellular carcinoma (HCC). The patient was a 89-year-old woman who presented with severe abdominal pain and a huge solid mass in the right hypochondrium. The laboratory data on admission revealed normal liver function tests. A multiphasic computed tomography (CT) showed a huge solid mass of the left hemiliver, hypoattenuating on noncontrast images, dishomogeneously hyperenhancing in the late arterial phase, with washout in the portal venous and equilibrium phases. A 18F-FDG positron emission tomography (18F-FDG PET)-CT scan documented a marked FDG uptake within the lesion, without evidence of extrahepatic metastases. We considered the clinical and radiologic findings consistent with the diagnosis of high-grade HCC with areas of intratumoral necrosis preluding to possible tumour rupture. Surgical resection was ultimately considered feasible with a reasonable risk and the patient underwent left hepatectomy with diaphragmatic resection. Pathological examination exhibited an extramedullary plasmacytoma. At immunohistochemical analysis neoplastic cells were positive for CD45, CD38, IRF4, HTPD52, kappa-chain, but negative for lambda- chain; Mib-1 proliferation index was 50%. Subsequent clinical evaluation excluded any sign of multiple myeloma, so that a diagnosis of truly localized SEMP of the liver was finally established. To our knowledge, this is the first case of a solitary extramedullary plasmacitoma of the liver undergoing successful radical liver resection. The patient is alive and well 5 years after surgery without evidence of local recurrence and of systemic disease. KEY WORDS: Extramedullary plasmacytoma, Hepatocellular carcinoma, Liver, Liver resection, Multiple myeloma.

Multifocal intraductal papillary mucinous neoplasm of the pancreas from mild dysplasia to invasive carcinoma A case report.

UNLABELLED: Intraductal papillary mucinous neoplasm (IPMN) is defined as an intraductal mucin-producing neoplasm of the pancreatic ducts. IPMNs may be multifocal, have malignant potential and exhibit a broad histological spectrum ranging from adenoma to invasive carcinoma. The "hyperplasia-dysplasia-carcinoma sequence" in the evolution of IPMNs is considered very similar to the "adenoma-carcinoma sequence" of colorectal tumours. Patients with multifocal IPMN are potential candidates to total pancreatectomy, which still carries significant perioperative risks, especially in the elderly. In selected cases a reasonable alternative to total pancreatectomy is represented by the resection of the dominant tumour leaving deliberately in place the smaller, low-risk tumours. In this context, intraoperative ultrasonography (IOUS) can be useful to define the extent of IPMNs and to plan the surgical strategy. We report the case of a 84-year-old female with multiple IPMNs showing different stages of neoplastic progression up to invasive carcinoma. The patient underwent IOUS-guided distal splenopancreatectomy, while the small multiple branchduct type IPMNs of the head of the pancreas were considered at very low risk of neoplastic progression and were deliberately left in place. The patient is alive without recurrence 96 months after surgery and without evidence of progression of the branch-duct type IPMNs of the head of the pancreas. IOUS-guided pancreatectomy should be considered in selected elderly patients affected by multifocal IPMN evolved to invasive carcinoma without evidence of distant metastases. KEY WORDS: Intraductal papillary mucinous neoplasm, Intraoperative ultrasonography, Pancreatectomy.

One stage curative resection of double intestinal neuroendocrine tumors with thirty-two bilobar liver metastases. A case report.

Neuroendocrine tumours (NETs) of the midgut are often multifocal and have a noticeable attitude to metastasize to locoregional lymph nodes and liver. Surgery is the only curative treatment for metastatic NETs of the midgut, even though only a minority of patients are candidates to radical surgical resection. The optimal timing for surgical resection in case of synchronous presentation of primary intestinal neoplasms and resectable LM is still controversial, especially when LM are multiple and/or involve multiple liver segments. Even though a staged approach with initial intestinal resection followed by liver resection is still preferred, recent studies have shown favourable results for simultaneous procedures, which have the striking advantage of avoiding a second laparotomy, with morbidity and mortality rates comparable to staged resections. We report here the case of a patient with double midgut well-differentiated NET and thirty-two synchronous bilobar LM who received successful simultaneous curative right hemicolectomy and radical but conservative liver resection and radiofrequency thermal ablation with the guidance of intraoperative ultrasonography. He is alive without evidence of recurrence 48 months after surgery.

Laparoscopic appendectomy: Which factors are predictors of conversion? A high-volume prospective cohort study.

Appendicitis represents one of the most frequent condition requiring surgery. In Italy almost 0.2% of the population will be affected by acute appendicitis every year. Laparoscopic appendectomy (LA) has gained acceptance over the past years and despite several meta-analyses, randomized studies and retrospective studies have been conducted, the indications and results are still conflicting especially in cases of complicated appendicitis. The aim of our study is to evaluate which factors are related to conversion to open appendectomy (OA) during laparoscopic appendectomy (LA). MATHERIALS AND METHODS: From September 2011 to May 2013, appendectomy for acute appendicitis was performed on 434 patients in our Surgical Unit at S. Orsola-Malpighi Hospital, Bologna, Italy. Of these, 369 patients (85%) underwent LA. The clinical, demographic, surgical and pathological data of these patients were included in a prospective database. To note, only laparoscopic appendectomies were considered to be included in the analysis. The following factors were analyzed in order to identify which were associated with the conversion: age, sex, body mass index (BMI), previous abdominal surgery, comorbidities, clinical and laboratory parameters including Alvarado score, PCR, intraoperative findings such as anatomy and degree of inflammation. During our study period, laparoscopic appendectomies were performed by different surgeons both residents and attending surgeons. The decision to convert the intervention in an open procedure was taken by the individual surgeon. Regarding the postoperative period, were considered the time of hospitalization and related costs, time of oral intake of liquid and solid, time of passage of stool, readmissions and reoperations. RESULTS: At univariate analysis, the factors significantly related to the conversion were the presence of comorbidities (p < 0.001) and, among these, the presence of arterial hypertension (p = 0.006) or other cardiovascular diseases (p = 0.031) and the history of previous abdominal surgery (p = 0.023). Patients with higher mean age (33.9 ± 15.4 vs. 46.0 ± 19.3, p = 0.001) and higher body mass index (BMI) (23.5 ± 4.3 vs 25.8 ± 4.9 kg/m(2), p = 0.006) had a higher risk of conversion. Multivariate analysis finally showed that factors significantly related to the conversion were the presence of comorbidities (p = 0.029), the presence of an appendiceal perforation (p = 0.003), a retrocecal appendix (p = 0.004), the presence of appendicular abscess (p = 0.023) and the presence of diffuse peritonitis (p = 0.008). CONCLUSION: The majority of patients with acute appendicitis can be successfully managed with laparoscopy. We found that the only preoperative independent factor related to conversion during laparoscopic appendectomy is the presence of comorbidities. Nevertheless surgeons should take into account that presence of peri-appendicular abscess and diffuse peritonitis are both independently related not only to higher rate of conversion but also to higher risk of postoperative complication.

Reconstruction of a complex pelvic perineal defect with pedicled anterolateral thigh flap combined with bilateral lotus petal flap: a case report.

Reconstructing extensive perineal defects represents a challenge, and reconstructive choice requires a careful physical assessment of previous radiotherapy, pre-existing scars, the presence of stomas, and the availability of donor sites. We report a case of a patient affected by an anal carcinoma who underwent a pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. We performed a pedicled anterolateral thigh flap (ALT) combined with bilateral lotus petal flaps (LPF) to reconstruct the pelvic-perineal area. The result was good, and no major post-operative complications were reported. Bilateral LPF, combined with a pedicled ALT, may represent a valid option in pelvic-perineal reconstruction following a wide oncological resection.

Intermittent clamping of the hepatic pedicle in simultaneous ultrasonography-guided liver resection and colorectal resection with intestinal anastomosis: is it safe?

PURPOSE: In patients with colorectal cancer (CRC) and synchronous colorectal liver metastases (CRLM) potentially candidates to combined liver (LR) and colorectal resection (CRR), the extent of LR and the need of hepatic pedicle clamping (HPC) in selected cases are considered risk factors for the outcome of the intestinal anastomosis. This study aimed to determine whether intermittent HPC is predictive of anastomotic leakage (AL) and has an adverse effect on the clinical outcome in patients undergoing combined restorative CRR and LR. METHODS: One hundred six LR have been performed for CRLM in our unit from July 2005. Patients who received CRR with anastomosis and simultaneous intraoperative ultrasonography (IOUS)-guided LR/ablation for resectable CRLM were included in this study. CRR was performed first. Intermittent HPC was decided at the discretion of the liver surgeon. The perioperative outcome was evaluated according to occurrence of AL and overall postoperative morbidity and mortality. RESULTS: Thirty-eight patients underwent simultaneous IOUS-guided LR/ablation and CRR with intestinal anastomosis; 19 underwent intermittent HPC (group ICHPY) while 19 did not (group ICHPN); the mean ± SD (range) duration of clamping in group ICHPY was 58.6 ± 32.2 (10.0-125.0) min. Postoperative results were similar between groups. One asymptomatic AL occurred in group ICHPY (5.2 %). Major postoperative complications were none in group ICHPY and one (5.2 %) in group ICHPN, respectively. One patient in group ICHPY died postoperatively (5.2 %). CONCLUSIONS: This study suggests that intermittent HPC during LR is not predictive of AL and has no adverse effect on the overall clinical outcome in patients undergoing combined restorative colorectal surgery and hepatectomy for advanced CRC.

Treatment strategy for rectal cancer with synchronous metastasis: 65 consecutive Italian cases from the Bologna Multidisciplinary Rectal Cancer Group.

BACKGROUND: Twenty percent of rectal cancer patients have synchronous distant metastasis at diagnosis. At present, the treatment strategy in this patient setting is not well defined. This study in one institution evaluates the treatment strategy of three different patient groups. PATIENTS AND METHODS: Between January 2000 and July 2011, 65 patients with M1 rectal cancer were evaluated. Three different groups were defined: rectal cancer with resectable metastatic disease (group A); rectal cancer with potentially resectable metastatic disease (group B), and rectal cancer with unresectable metastatic disease (group C). RESULTS: Group A included 11 patients (16.9%), group B 28 patients (43.1%) and group C 26 patients (40%). Forty-three (66.2%) patients underwent surgery for primary rectal cancer, and 30 (46.2%) patients for metastasis resection (23 liver, 4 lung and 3 ovary). Median overall survival (OS) by group was: 51 (5-86; group A), 32 (24-40; group B) and 16 (7-26; group C) months. Patients undergoing metastasis resection have higher median OS than unresected patients (44 vs. 15 months; p < 0.001). CONCLUSIONS: The treatment strategy in synchronous metastatic rectal cancer must consider the possibility of distant metastasis resection. Long-term survival can be achieved using an integrated approach.

Clinical and instrumental evaluation of pelvic floor disorders before and after bariatric surgery in obese women.

BACKGROUND: Obesity, well known as a risk factor for several diseases, can also lead to pelvic floor dysfunction (PFD). However, scant data are available regarding PFD in obese individuals. Our study was designed to assess the prevalence, severity, and the quality of life (QOL) effect of PFD in obese women before and after bariatric surgery at a university hospital in Italy. METHODS: A total of 100 obese (body mass index [BMI] ≥30 kg/m(2)) women completed 6 validated specific and QOL questionnaires about PFD. The patients were evaluated by physical examination, endoanal ultrasonography, rectal balloon distension test, and dynamic magnetic resonance imaging. Of the 100 patients, 87 were reassessed 12 months after bariatric surgery. RESULTS: The prevalence of PFD was 81%, and 49% of patients reported that their symptoms adversely affected their QOL. Urinary incontinence (UI) was the most common disorder (61%) and was associated with the BMI (P = .04). Fecal incontinence and pelvic organ prolapse symptoms were reported by 24 and 56 patients, respectively. Urogenital prolapse and rectocele was documented in 15% and 74% of patients, respectively. After a mean BMI reduction of 10 kg/m(2), the prevalence of PFD decreased to 48% (P = .02), with a significant improvement in QOL. The prevalence of UI decreased to 9.2% (P = .0001) and was associated with the decrease in postoperative BMI (P = .04). The rate of resolution of the symptoms was 84%, 85%, and 74% for UI, fecal incontinence, and pelvic organ prolapse, respectively. CONCLUSION: In the present sample of obese women, PFD was common and adversely affected their QOL. A clear association was found between the BMI and UI. Weight loss resulted in improved UI, fecal incontinence, and symptoms of pelvic organ prolapse.

Clinically-staged T3N0 rectal cancer: is preoperative chemoradiotherapy the optimal treatment?

BACKGROUND: Preoperative chemoradiotherapy has been widely adopted as the standard of care for stage II-III rectal cancers. However, patients with T3N0 lesions had been shown to have a better prognosis than other categories of locally advanced tumor. Thus, neoadjuvant chemoradiation is likely to be overtreatment in this subgroup of patients. Nevertheless, the low accuracy rate of preoperative staging techniques for detection of node-negative tumors does not allow to check this hypothesis. We analyzed a group of patients with cT3N0 low rectal cancer who underwent neoadjuvant chemoradiotherapy with the purpose of evaluating the incidence of metastatic nodes in the resected specimens. METHODS: Between January 2002 and February 2008, 100 patients with low rectal cancer underwent clinical staging by means of endorectal ultrasound, computed tomography, positron emission tomography, and magnetic resonance imaging. All patients received preoperative 5-fluorouracil-based chemoradiotherapy and surgical resection with curative aim. RESULTS: Of 100 patients with locally advanced rectal cancer, 32 were clinically staged as T3N0M0. Pathological analysis showed the presence of lymph node metastases in nine patients (28%) (node-positive group). In the remaining 23 cases, clinical N stage was confirmed at pathology (node-negative group). Node-positive and node-negative groups differ only in the number of ypT3 tumors (P < .01). CONCLUSIONS: Our results indicate that immediate surgery for patients with cT3N0 rectal cancer represents an undertreatment risk in at least 28% of cases, making necessary the use of postoperative chemoradiotherapy. Preoperative chemoradiotherapy should be the therapy of choice on the grounds of the principle that overtreatment is less hazardous than undertreatment for cT3N0 rectal cancers.

[Synchronous adenocarcinoma of the sigmoid colon and multifocal intraductal papillary mucinous neoplasm of the pancreas in an elderly patient]. / Adenocarcinoma del colon e neoplasia papillare intraduttale mucinosa multifocale sincrona del pancreas in un paziente anziano: caso clinico e revisione della letteratura.

Intraductal papillary mucinous neoplasms are a well-recognized pathologic entity of the pancreas that is being reported with increasing frequency. These tumours carry a relatively favourable prognosis and are frequently associated with extrapancreatic malignancies. The combination of advanced age and co-existence of two neoplasms challenges the planning of the best treatment option. A 78-year-old man presented with rectal bleeding which led to the diagnosis of a stenosing adenocarcinoma of the sigmoid colon. No metastatic lesions were present but a 30 mm intraductal papillary mucinous neoplasm with mural nodules was detected in the uncinate process of the pancreas. Small diffused dilations of the side branches were present in the body and tail of the gland. A two-stage procedure was planned: an R0 sigmoid resection was undertaken first with an uneventful postoperative course. Forty-five days later a pancreaticoduodenectomy was performed and the postoperative course was again uneventful apart from delayed gastric emptying. Histology showed a combined-type intraductal papillary mucinous neoplasm with foci of non-invasive carcinoma. The patient is still alive without evidence of cancer recurrence 33 month after the pancreatico-duodenectomy. The co-existence of a potentially malignant pancreatic tumour with an extra-pancreatic overt malignancy in elderly patients poses difficulties in the attempt to cure the patient with minimal morbidity. In the present case we considered a staged surgical procedure with the aim of reducing the perioperative risk, since the excision of the pancreatic neoplasm required a pancreaticoduodenectomy in an elderly patient.

[Echo-guided spleen-preserving resection of the pancreas tail for pancreatic intraductal papillary mucinous neoplasms]. / Resezione della coda del pancreas "spleen preserving" ecoguidata per neoplasia intraduttale mucinosa (IPMN) del pancreas.

Intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are a distinct entity with malignant potential, which may recur after surgical excision. Limited pancreatectomies have been recently proposed for non-invasive tumours. We report our technique of intraoperative US-guided resection of non-invasive IPMNs located in the tail of the pancreas with spleen and splenic vessel preservation. Following adequate exposure of the distal pancreas, a thorough ultrasonographic examination of the parenchyma is accomplished to define the features of the neoplasia, its relationship with the main pancreatic duct and splenic vessels and to mark the transection line with electrocautery. Dissection begins at the inferior edge of the pancreatic tail and proceeds in a lateral to medial direction up to the transection line. The main pancreatic duct is identified and sutured, the parenchyma is then closed and the suture line is reinforced with a fibrinogen/thrombin-coated collagen patch. Patient 1 was a 63-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 28 mm with moderate dysplasia at histology, and was discharged 9 days after surgery. Patient 2 was a 60-year-old male who underwent intraoperative US-guided resection of the pancreatic tail for an IPMN of the pancreatic tail measuring 30 mm with carcinoma in situ at histology, and was discharged 9 days after surgery. Limited distal pancreatic resection with spleen and splenic vessel preservation is an adequate surgical technique for non-invasive IPMN of the tail of the pancreas. Intraoperative ultrasonography is crucial in planning "radical but conservative" pancreatic resection.

[Efficacy, impact on survival and cost of intensive follow-up after curative resection for colorectal cancer aim]. / Il follow-up intensivo degli operati per cancro colon-rettale.

AIM OF THE STUDY: This retrospective study was aimed at establishing the efficacy, impact on survival and cost of an intensive follow-up program. METHODS: Data from 790 patients who underwent resections for primary colorectal carcinoma were prospectively entered into a data-base. Four hundred fifty-six patients who had radical surgery were followed-up with a 5-year preestablished schedule. Median follow-up was 42 months (range 2-108). RESULTS: Seventy-four adenomas, 7 metachronous carcinomas, 11 extra-colonic carcinomas and 96 recurrences (13 locoregional recurrences, 68 metastases and 15 cases of combined recurrences) were detected. Thirty-eight (39.6%) of 96 recurrences were amenable to salvage therapy and 23 relapses (24.0%) were radically resected. The median survival of patients who had recurrences was 38 months. The 5-year overall survival was significantly better in patients underwent radical surgery than those who were not treated with curative resection (60.0% vs 7.5%, p < 0.0001). Radical re-operations were performed in 2 (4.8%) of the 42 symptomatic patients and in 21 (38.9%) of the 54 cases with asymptomatic relapses. Median overall survival of patients with asymptomatic recurrences was significantly higher than those with syntomatic relapses (20 vs 6 months, p < 0.0001). The follow-up program used showed an efficacy of 4.6% and led to an expense, based on the exclusive cost of the visits and tests included, of 2087,10 Euro for colonic cancer and 2519.90 Euro for rectal cancer. CONCLUSIONS: Our intensive follow-up program after curative colorectal cancer surgery allowed to detect a quite large number of asymptomatic recurrences with a benefit in term of radical re-operation and overall survival.

[Hepatocellular carcinoma with neoplastic thrombosis of the common hepatic duct]. / Carcinoma epatocellulare con trombosi neoplastica del dotto epatico comune: caso clinico e revisione della letteratura.

Biliary tract involvement in patients with hepatocellular carcinoma usually occurs in advanced stages and is due to tumour compression or infiltration. In a few cases, however, a tumour thrombus may grow into the biliary ducts (bile duct thrombosis). Identification of this condition is important because surgical treatment may be beneficial in selected cases. A 69-year-old man came from another hospital after repeated sessions of radiofrequency thermoablation and alcoholisation of 3 nodules of hepatocellular carcinoma. At admission to our unit, the nodule in S5-S8 was still viable and a neoplastic thrombus had invaded the right and common bile ducts. S5-S8 sub-segmentectomy, S6 wedge resection and removal of the tumour thrombus were performed. Seventeen months later the tumour thrombus recurred in the hepatic ducts without evidence of intrahepatic recurrence and was again removed. Eight months later a large metastatic lymph node appeared at the hepatic hilum, without evidence of liver recurrence or distant metastases, and the patient underwent lymphadenectomy. Eighteen months after the last procedure the patient is alive without recurrence. The appearance of bile duct thrombosis in the natural history of hepatocellular carcinoma does not necessarily entail an unfavourable prognosis. An early diagnosis is crucial to select the appropriate treatment. Biliary decompression with removal of tumour debris and blood clots and curative resection of the hepatocellular carcinoma can result in effective palliation and occasional long-term survival. Also in the presence of intrabiliary, hepatic or limited extrahepatic recurrence, surgical exeresis is the best therapeutic choice in selected cases.

Real time contrast enhanced ultrasonography in detection of liver metastases from gastrointestinal cancer.

BACKGROUND: Contrast enhanced ultrasound (CEUS) is an imaging technique which appeared on the market around the year 2000 and proposed for the detection of liver metastases in gastrointestinal cancer patients, a setting in which accurate staging plays a significant role in the choice of treatment. METHODS: A total of 109 patients with colorectal (n = 92) or gastric cancer prospectively underwent computed tomography (CT) scan and conventional US evaluation followed by real time CEUS. A diagnosis of metastases was made by CT or, for lesions not visible at CT, the diagnosis was achieved by histopathology or by a malignant behavior during follow-up. RESULTS: Of 109 patients, 65 were found to have metastases at presentation. CEUS improved sensitivity in metastatic livers from 76.9% of patients (US) to 95.4% (p <0.01), while CT scan reached 90.8% (p = n.s. vs CEUS, p < 0.01 vs US). CEUS and CT were more sensitive than US also for detection of single lesions (87 with US, 122 with CEUS, 113 with CT). In 15 patients (13.8%), CEUS revealed more metastases than CT, while CT revealed more metastases than CEUS in 9 patients (8.2%) (p = n.s.). CONCLUSION: CEUS is more sensitive than conventional US in the detection of liver metastases and could be usefully employed in the staging of patients with gastrointestinal cancer. Findings at CEUS and CT appear to be complementary in achieving maximum sensitivity.