Sarcopenia is an independent risk factor for short-term mortality in patients undergoing transjugular intrahepatic portosystemic shunt.

BACKGROUND: Sarcopenia is common in patients with cirrhosis and is a risk factor for increased mortality. Transjugular intrahepatic portosystemic shunt (TIPS) placement has been utilized in cirrhosis patients with decompensation . We investigated the role of sarcopenia in predicting mortality in patients undergoing TIPS. METHODS: We conducted a single-center retrospective study of 232 patients with cirrhosis who underwent TIPS between January 2010 and December 2015. Sarcopenia was defined by the psoas muscle index (PMI) cutoff value, calculated based on dynamic time-dependent outcomes using X-tile software. Kaplan-Meier analysis demonstrated the difference in survival in the sarcopenia group versus the non-sarcopenia group. . Univariate and multivariate analyses were used to identify the relationship between sarcopenia and post-TIPS mortality during a follow-up period of 1 year. RESULTS: For TIPS indications, 111 (47.84%) patients had refractory ascites, 69 (29.74%) patients had variceal bleeding, 12 (5.17%) patients had ascites, and 40 (17.24%) for other indications. The mean PMI was 4.40 ±â€…1.55. Sarcopenia was defined as a PMI value of <4.36 in males, and <3.23 in females. Sarcopenia was present in 96 (41.38%) of patients. . Kaplan-Meier analysis showed thatsarcopenia is associated with worse survival (log-rank P  < 0.01). Multivariate Cox regression analysis showed that sarcopenia is independently associated with worse survival during the 1-year follow-up period with an hazard ratio of 2.435 (95% CI 1.346-4.403) ( P  < 0.01), after adjusting for age, BMI, indications for TIPS, etiology for cirrhosis, and MELD score and stratified by sex. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in patients undergoing TIPS and should be considered when patients are evaluated as a candidate for TIPS.

Post-traumatic stress disorder in a Canadian population of medical students, residents, and physicians.

BACKGROUND: Physicians encounter stressors with potential long-term psychological consequences. However, a comprehensive picture of post-traumatic stress disorder (PTSD) prevalence and symptomatic work-related event occurrence across practice stages is lacking. OBJECTIVE: To evaluate PTSD prevalence and the occurrence of work-related symptomatic events among physicians and medical learners. METHODS: In 2017, we surveyed 3,036 physicians, residents, and students within the province of Saskatchewan, Canada. Participants completed the Life Events Checklist (LEC) for DSM 4 and the PTSD Checklist for DSM 4-Civilian version (PCL-C). They also reported work-related events that triggered PTSD-like symptoms. The prevalence of a positive PTSD screen (PCL-C ≥ 36) and the proportion identifying a symptomatic work event were determined. The t-test, Chi-square test, and multiple regression were used to evaluate associations between respondent characteristics and these outcomes. RESULTS: Among 565 respondents, 21.2% screened positively, with similarity across career stages. Thirty-nine percent reported a symptom-inducing work event, with many training-related. Although independent PTSD predictors were not identified, partnered residents and surgical residents were more likely to identify a work-related event. Internationally trained practicing physicians were less likely to identify an event. CONCLUSION: Both symptom-inducing work events and PTSD are frequent, broadly based concerns requiring better preventive strategies across career stages.

Direct comparison and reproducibility of two segmentation methods for multicompartment dosimetry: round robin study on radioembolization treatment planning in hepatocellular carcinoma.

PURPOSE: Investigate reproducibility of two segmentation methods for multicompartment dosimetry, including normal tissue absorbed dose (NTAD) and tumour absorbed dose (TAD), in hepatocellular carcinoma patients treated with yttrium-90 (90Y) glass microspheres. METHODS: TARGET was a retrospective investigation in 209 patients with < 10 tumours per lobe and at least one tumour ≥ 3 cm ± portal vein thrombosis. Dosimetry was compared using two distinct segmentation methods: anatomic (CT/MRI-based) and count threshold-based on pre-procedural 99mTc-MAA SPECT. In a round robin substudy in 20 patients with ≤ 5 unilobar tumours, the inter-observer reproducibility of eight reviewers was evaluated by computing reproducibility coefficient (RDC) of volume and absorbed dose for whole liver, whole liver normal tissue, perfused normal tissue, perfused liver, total perfused tumour, and target lesion. Intra-observer reproducibility was based on second assessments in 10 patients ≥ 2 weeks later. RESULTS: 99mTc-MAA segmentation calculated higher absorbed doses compared to anatomic segmentation (n = 209), 43.9% higher for TAD (95% limits of agreement [LoA]: - 49.0%, 306.2%) and 21.3% for NTAD (95% LoA: - 67.6%, 354.0%). For the round robin substudy (n = 20), inter-observer reproducibility was better for anatomic (RDC range: 1.17 to 3.53) than 99mTc-MAA SPECT segmentation (1.29 to 7.00) and similar between anatomic imaging modalities (CT: 1.09 to 3.56; MRI: 1.24 to 3.50). Inter-observer reproducibility was better for larger volumes. Perfused normal tissue volume RDC was 1.95 by anatomic and 3.19 by 99mTc-MAA SPECT, with corresponding absorbed dose RDC 1.46 and 1.75. Total perfused tumour volume RDC was higher, 2.92 for anatomic and 7.0 by 99mTc-MAA SPECT with corresponding absorbed dose RDC of 1.84 and 2.78. Intra-observer variability was lower for perfused NTAD (range: 14.3 to 19.7 Gy) than total perfused TAD (range: 42.8 to 121.4 Gy). CONCLUSION: Anatomic segmentation-based dosimetry, versus 99mTc-MAA segmentation, results in lower absorbed doses with superior reproducibility. Higher volume compartments, such as normal tissue versus tumour, exhibit improved reproducibility. TRIAL REGISTRATION: NCT03295006.

Gastrointestinal Tract Injury by Yttrium-90 Appears Largely Restricted to Resin Microspheres But Can Occur Years After Embolization.

Radioembolization therapy utilizes yttrium-90 (Y90) impregnated resin (SIR-Spheres) or glass (TheraSpheres) microspheres to selectively target hepatic lesions via transarterial radioembolization. Occasional cases of gastrointestinal tract injury, secondary to nontargeted delivery of microspheres, have been reported, but large descriptive pathology series are lacking. We identified 20 cases of histologically confirmed mucosal injury associated with Y90 from 17 patients and assessed the corresponding clinical and pathologic sequelae. The mucosal biopsies were obtained from 1 to 88 months following Y90 therapy (median: 5 mo). Most cases were gastric (17, 85%), while the remaining were duodenal. Endoscopic ulceration was seen in the majority of cases (16, 80%), and mucosal erythema in the remaining 4. Histologically, a majority (19, 95%) of cases showed rounded, dark blue to purple microspheres measuring 4 to 30 µm, consistent with resin microspheres. A single case with glass microspheres demonstrated 26 µm translucent beads. Histologic evidence of ulceration was appreciated in 14 (70%) cases, and the microspheres were clearly intravascular in 6 (30%). A foreign body giant cell reaction to the microspheres was uncommon (3 cases, 15%). We additionally performed a retrospective review of all gastrointestinal tissue obtained postprocedure from 784 sequential patients treated with Y90 microspheres. Three patients (0.4%) demonstrated the presence of resin microspheres upon histologic examination. No cases involving glass-based Y90 were identified ( P =0.0078), despite the majority of patients having received glass radioembolization (630, 80%). This increased risk of secondary sphere dissemination is likely related to the increased number of particles required per activity for resin versus glass microspheres. We conclude that Y90 microspheres may be encountered in the gastrointestinal tract years after initial liver-targeted therapy and, when present, are often associated with mucosal ulceration. This finding is less likely to be encountered in patients who received Y90 radioembolization utilizing glass microspheres.

Prognostic value of neutrophil-to-lymphocyte ratio in cirrhosis patients undergoing transjugular intrahepatic portosystemic shunt.

BACKGROUND AND AIMS: The neutrophil-to-lymphocyte-ratio (NLR) is used as an inflammatory index and has proven to be an accurate prognostic indicator for decompensated cirrhotics; however, its role in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) has not been evaluated. We examined whether NLR is associated with mortality in decompensated cirrhosis patients undergoing TIPS. METHODS: We performed a retrospective review of 268 decompensated cirrhotics who underwent TIPS from January 2011 to December 2015 at an academic medical center. NLR, patient demographics, manifestations of cirrhosis, TIPS indications and mortality were recorded. Univariate and multivariate Cox regression analyses for prognostic factors associated with 30-day and 90-day post TIPS mortality were performed. RESULTS: A total of 129 (48%) patients received TIPS for refractory ascites with 79 (29%) for variceal bleeding, 14 (5%) for hepatic hydrothorax, and 46 (17%) for other indications. Cirrhosis etiology included hepatitis C (36%), alcohol (28%), nonalcoholic steatohepatitis (20%), or other (15%). Median NLR was 4.42 (IQR 2.75-7.19). Univariate and multivariate analysis showed NLR as an independent predictive factor of 30-day and 90-day mortality. Furthermore, in patients with a Model of End-Stage Liver Disease (MELD) ≤ 15, NLR is superior to MELD/MELD-Na score in predicting 30-day and 90-day mortality. In patients with MELD > 15, MELD/MELD-Na score is superior to NLR. CONCLUSION: Our data indicate that elevated NLR independently predicts 30-day and 90-day mortality. In patients with a MELD ≤ 15, NLR is a better prognostic factor than MELD or MELD-Na in predicting short-term mortality.

An Unsuccessful Randomized Trial of Percutaneous vs Endoscopic Drainage of Suspected Malignant Hilar Obstruction.

Percutaneous transhepatic biliary drainage (PTBD) and endoscopic retrograde cholangiopancreatography (ERCP) are widely accepted but competing approaches for the management of malignant obstruction at the hilum of the liver. ERCP is favored in the United States on the basis of high success rates for non-hilar indications, the perceived safety and superior tissue sampling capability of ERCP relative to PTBD, and the avoidance of external drains that are undesirable to patients. A recent randomized controlled trial (RCT) comparing the 2 modalities in patients with resectable hilar cholangiocarcinoma was terminated prematurely because of higher mortality in the PTBD group.1 In contrast, most observational data suggest that PTBD is superior for achieving complete drainage.2-6 Because the preferred procedure remains uncertain, we aimed to compare PTBD and ERCP as the primary intervention in patients with cholestasis due to malignant hilar obstruction (MHO).

Analysis of dynamic hepatobiliary contrast-enhanced MRI signal intensity after Yttrium-90 radioembolization with glass microspheres for the treatment of hepatocellular carcinoma.

PURPOSE: To analyze hepatobiliary specific contrast agent (HBA) dynamic MRI signal intensity (SI) differences between treated liver (TL) and untreated liver (UL) parenchyma in patients following transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) using yttrium-90 containing glass microspheres. MATERIALS: This was a single institution retrospective study of patients with HCC treated with lobar or segmental TARE who received pre- and post-treatment HBA multiphase MRI within a 3-year period. Patients with prior locoregional therapies or multiple TAREs were excluded. SI was obtained by drawing a 2D ROI on T1-weighted non-contrast, arterial (25 s.), portal venous (60 s.), transitional (180 s.), and hepatobiliary (HB) (1200 s.) phase sequences in the (TL) angiosome and UL. HB phase signal enhancement characteristics were correlated with TARE dose thresholds (< 120 Gy, 120-190 Gy, and > 190 Gy) using the medical internal radiation dose (MIRD) methodology. RESULTS: 282 patients received TARE using glass microspheres during the study period and 58 patients who met inclusion criteria were analyzed. Median dose was 141.5 Gy MIRD [IQR 122.0, 161.5; range 100-540 Gy]). Statistically significant differences were present between treated and non-treated liver on non-contrast (- 28.0, p = 0.003), arterial (38.5, p = 0.013), and HB phases (- 95.8, p ≤ 0.001). Median follow-up time to furthest post-treatment MRI was 6 months (range 3-11 months). There was no significant SI difference on portal venous or transitional phases. HB phase SI changes in the TL compared to UL were significant at all TARE dose thresholds (p < 0.05). CONCLUSIONS: SI differences between treated and untreated liver after TARE are most significant on the HB phase and present at all evaluated dose levels at a median of 6 months after treatment. These findings support the parenchymal ablative potential for TARE and the necessity to consider liver function loss within targeted liver volumes.

Locoregional Therapy Protocols With and Without Radioembolization for Hepatocellular Carcinoma as Bridge to Liver Transplantation.

OBJECTIVE: The objective of this study was to compare posttransplant outcomes in patients undergoing bridging locoregional therapy (LRT) with Y-90 transarterial radioembolization (TARE) based protocol compared with transarterial chemoembolization based protocol for hepatocellular carcinoma (HCC) prior liver transplantation (LT). MATERIALS AND METHODS: Patients listed for LT with HCC within the Milan criteria at our center who had bridging LRT were treated according to transarterial chemoembolization (TACE) based protocol from May 2012 to April 2014 and a TARE based protocol from October 2014 to December 2017. Early posttransplant survival and tumor recurrence were compared between the groups. Tumor response to LRT, microvascular invasion (mVI), and the rate of delisting was also evaluated. RESULTS: One hundred three patients who were listed for LT with HCC within the Milan criteria received LRT. LT was performed in 65 patients, 28 treated with TARE protocol and 37 on TACE protocol. There were no statistical differences in baseline pretransplant characteristics and tumor recurrence. There was a trend toward improved 3-year survival in the TARE group (92.9% vs. 75.7%; P=0.052). The mVI was seen in 1/28 (3.6%) explants in the TARE group compared with 10/37 (27%) in the TACE group (P=0.013). The TARE group also required fewer LRT treatments (1.46 vs. 2.43; P=0.001) despite no difference in time on the transplant list. CONCLUSIONS: Despite requiring fewer LRT treatments, there was significantly less mVI in the explants of patients treated with TARE protocol LRT as a bridge to LT as well as a trend toward improved 3-year survival. Therefore, TARE may be associated with improved tumor control and reduced post-LT recurrence.

Thermal ablation versus wedge or segmental resection in patients with early stage hepatocellular carcinoma: a population survival analysis.

BACKGROUND: The aim of this retrospective review was to evaluate the long-term survival benefits of thermal ablation versus wedge or segmental resection in solitary HCC lesions using tumor size and clinical factors. METHODS: Survival analysis was performed on 43,601 patients from 2004 to 2015 in the National Cancer Database with solitary HCC lesions ≤5 cm with further stratification by tumor size, fibrosis score, and type of resection. RESULTS: In patients with moderate fibrosis or less, survival benefit was seen with one-segment resection over ablation in tumors 1.1-3 cm (HR 0.54, p = 0.03) while tumors of 3.1-5 cm received survival benefit from wedge (HR 0.44, p = 0.04), one (HR 0.28, p = 0.001) and two-segment (HR 0.20, p = 0.001) resections over ablation. In patients with severe fibrosis to cirrhosis, wedge resection demonstrated survival benefit over ablation in patients with tumors 1.1-3 cm (HR 0.48, p = 0.01) with no survival benefit of any resection type in patients with tumors of 3.1-5 cm. CONCLUSION: These findings suggest that the decision to utilize thermal ablation versus resection to extend survival in solitary HCC lesions should include tumor size, fibrosis score, and type of resection.

Learners' experiences of an enhanced surgical skills training program for family physicians.

BACKGROUND: Family Physicians with Enhanced Surgical Skills (FPESS) have sustained rural operative care, including local access to caesarean section, in many communities across rural Canada and internationally. The contemporary role of FPESS within the health system, however, has not been without challenges. The 12-month Prince Albert Enhanced Surgical Skills (ESS) program intakes two learners a year and is one of only two accredited programs in Canada offering a scope of surgical practice beyond operative delivery. METHODS: This paper highlights the results of an evaluation of graduates' experiences of training and the post-training environment. Graduates were practicing in Western and Northern Canada after completing the ESS training program, specifically in British Columbia, Alberta, Manitoba, and the Northwest Territories. RESULTS: Findings suggest the overall success of the program in meeting learners' needs. There was a close match between the training curriculum and post-training practice. CONCLUSION: The findings from the post training experience suggest that sustainability of ESS is linked to 1) creating pathways to privileges between the ESS community and the Health Authorities, 2) building functional and trusting relationships with surgical specialists, and 3) creating a web of accessible effective rurally appropriate surgical Continuing Professional Development (CDP). Ongoing CPD is identified as essential in increasing the comfort of FPESS.

Safety of Radioembolization in the Setting of Angiographically Apparent Arterioportal Shunting.

PURPOSE: To retrospectively analyze adverse events (AE) in patients with hepatocellular carcinoma (HCC) treated with yttrium-90 radioembolization in the setting of angiographically apparent arterioportal shunts (APSs). MATERIALS AND METHODS: Thirty-two patients with HCC underwent radioembolization with APSs from January 2011 to September 2016, totaling 34 administrations using resin (6) and glass (28) microspheres. APSs were graded angiographically as segmental (9), ipsilobar (15), contralobar (7), or main portal (2), according to portal perfusion. Tumors were categorized as solitary (9), multifocal (7), or infiltrative (16). Both unilobar (25) and bilobar (7) disease was treated. Child Pugh Score was A (22), B (10), or C (2), with a median Model for End-Stage Liver Disease (MELD)/Na-MELD of 8/8.5. Median procedure dose was 132.6 Gy. AEs were graded using Combined Terminology Criteria for Adverse Events (CTCAE) version 4.0. Tumor response was assessed using the modified Response Evaluation Criteria in Solid Tumors (mRECIST). RESULTS: CTCAE grade ≥3 AEs were observed in 22% of patients. Barcelona Clinic Liver Cancer (BCLC) C patients with nonsegmental shunts who received lobar administrations had a grade ≥3 AE rate of 38% compared with the remaining cohort, which was 12% (P = .076). No events were reported in patients with segmental shunts (P = .023). Imaging analysis revealed mRECIST complete response (17), partial response (13), stable disease (3), and progressive disease (1). Overall survival at 6 months and 12 months was 72% and 57%, respectively. CONCLUSIONS: Radioembolization in the setting of APS may have a higher AE profile than reported literature when BCLC-C patients with nonsegmental shunts receive lobar administrations. Segmental shunts are generally well tolerated.

Non-surgical management of patients with intrahepatic cholangiocarcinoma in the United States, 2004-2015: an NCDB analysis.

BACKGROUND: Surgical resection is the standard of care for intrahepatic cholangiocarcinoma (ICC), but only a minority of patients are managed surgically. Other modalities, including external beam radiation (XRT), radiofrequency ablation (RFA), and radioactive implants (RIs) have been employed with significant heterogeneity of prognosis reported in the literature. The aim of this study was to evaluate the demographics of patients with ICC managed non-surgically and compare prognosis in patients managed surgically to those that underwent XRT, RFA, or RI. METHODS: All patients diagnosed with ICC from 2004 to 2015 in the National Cancer Database (NCDB) were reviewed. Patient demographics, treatments, and survival outcomes were analyzed. RESULTS: Of the 6,140 patients with ICC, 4,374 (71%) did not undergo surgery. Patients managed non-surgically were typically older, treated at community centers, more likely to have severe fibrosis or cirrhosis, and present with higher stage disease. The strongest association to receipt of XRT, RI, or RFA modalities was treatment at an academic center. Increased clinical stage was associated with decreased use of RFA; a significantly higher proportion of patients with stage IV disease were given no local therapy. RFA associated with a statistically significant survival benefit over no local therapy only in stage I disease (2.1 vs. 0.7 years, P=0.012) as well as XRT over no local therapy (1.7 vs. 0.7 years, P=0.009). No survival benefit was realized for any treatment in stage II disease. Patients with stage III disease had a survival benefit from XRT versus no local therapy (0.9 vs. 0.6 years, P=0.029) and RI over no local therapy (1.2 vs. 0.6 years, P=0.013). Patients with stage IV disease only demonstrated survival benefit from RI over no local therapy (0.9 vs. 0.3 years, P=0.014). CONCLUSIONS: The majority of patients with ICC in the United States continue to be managed non-surgically. RFA was associated with improved survival only in stage I disease. XRT was associated with improved survival in stage I & III disease, while RI was associated with improved survival in stage III and IV disease.

Safety and initial efficacy of radiation segmentectomy for the treatment of hepatic metastases​.

BACKGROUND: Hepatic metastatectomy and ablation are associated with prolonged survival, but not all lesions are anatomically amenable to these therapies. We evaluated safety and initial efficacy of segmental ablative transarterial radioembolization, or radiation segmentectomy (RS), as a treatment for hepatic metastases. METHODS: A single institution retrospective analysis was performed of patients with hepatic metastases, determined unamenable to resection by a multidisciplinary tumor board, treated with RS from 2015-2017. Safety parameters evaluated were pre and post procedure liver chemistry, MELD score, ALBI grade, platelet count, and adverse events using both Common Terminology Criteria for Adverse Events (CTCAE) v 4.0 and Clavien Dindo (CD) classifications. Initial efficacy was evaluated using RECIST, mRECIST, and PERCIST criteria. RESULTS: Ten patients underwent between 1-3 RS treatments. There was no clinical treatment toxicity or significant post-treatment change in liver chemistry, MELD, or ALBI score. One patient had a CTCAE Grade 1/CD Grade 1 adverse event. All patients showed partial or complete imaging response at initial assessment (1-3 months). Seven patients demonstrated disease control at a mean of 7.1 months post treatment. Three patients developed out of field disease progression. One RS was technically unsuccessful. CONCLUSIONS: Early evaluation of segmental radioembolization suggests a safe treatment option for select patients with hepatic metastases. Initial efficacy as definitive radiotherapy with minimal toxicity is promising in anatomic locations unamenable to resection or alternative means of ablation.

Percutaneous transhepatic vs. endoscopic retrograde biliary drainage for suspected malignant hilar obstruction: study protocol for a randomized controlled trial.

BACKGROUND: The optimal approach to the drainage of malignant obstruction at the liver hilum remains uncertain. We aim to compare percutaneous transhepatic biliary drainage (PTBD) to endoscopic retrograde cholangiography (ERC) as the first intervention in patients with cholestasis due to suspected malignant hilar obstruction (MHO). METHODS: The INTERCPT trial is a multi-center, comparative effectiveness, randomized, superiority trial of PTBD vs. ERC for decompression of suspected MHO. One hundred and eighty-four eligible patients across medical centers in the United States, who provide informed consent, will be randomly assigned in 1:1 fashion via a web-based electronic randomization system to either ERC or PTBD as the initial drainage and, if indicated, diagnostic procedure. All subsequent clinical interventions, including crossover to the alternative procedure, will be dictated by treating physicians per usual clinical care. Enrolled subjects will be assessed for successful biliary drainage (primary outcome measure), adequate tissue diagnosis, adverse events, the need for additional procedures, hospitalizations, and oncological outcomes over a 6-month follow-up period. Subjects, treating clinicians and outcome assessors will not be blinded. DISCUSSION: The INTERCPT trial is designed to determine whether PTBD or ERC is the better initial approach when managing a patient with suspected MHO, a common clinical dilemma that has never been investigated in a randomized trial. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT03172832 . Registered on 1 June 2017.

Angiosomal radiopathologic analysis of transarterial radioembolization for the treatment of hepatocellular carcinoma.

PURPOSE: To assess the radiopathologic correlation following Yttrium-90 transarterial radioembolization (TARE) of hepatocellular carcinoma (HCC) using variable radiodosimetry to identify imaging surrogates of histologic response. METHODS: Twelve patients with HCC underwent ablative (≥ 190 Gy) and/or non-ablative (< 190 Gy) TARE delivered in a segmental, lobar, or combined fashion as a surgical neoadjuvant or bridge to transplantation. Both targeted tumor and treatment angiosome were analyzed before and after TARE utilizing hepatocyte-specific contrast-enhanced MRI or contrast-enhanced CT. Responses were graded using EASL and mRECIST criteria. Histologic findings including percent tumor necrosis and adjacent hepatic substrate effects were correlated with imaging features. RESULTS: Complete pathologic necrosis (CPN) was observed in 7/12 tumors post-TARE. Ablative and non-ablative dosing resulted in CPN in 5/6 and 2/6 tumors, respectively. Hyperintensity on T2-weighted imaging, the absence of hepatocyte-specific gadolinium contrast uptake, and plateau or persistent enhancement kinetics in the angiosome correlated with CPN and performed similarly to EASL and mRECIST criteria in predicting CPN. CONCLUSIONS: The absence of hepatocyte-specific contrast uptake, increased signal on T2-weighted sequences, and plateau or persistent enhancement in the angiosome may represent MRI surrogates of CPN following TARE of HCC. These findings correlated with EASL and mRECIST response criteria. Further investigation is needed to determine the role of these findings as possible adjuncts to conventional imaging criteria.

Neoadjuvant transarterial radiation lobectomy for colorectal hepatic metastases: a small cohort analysis on safety, efficacy, and radiopathologic correlation.

Colorectal cancer patients have a high incidence of liver metastasis (ml-CRC). Surgical resection is the gold standard for treatment of hepatic metastasis but only a small percent of patients are traditional candidates based on disease extent and adequate size of the future liver remnant (FLR). Interventions such as portal vein embolization (PVE) and associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) are performed to increase FLR for operative conversion. Limitations to PVE include intrahepatic disease progression, portal vascular invasion, and utilization with concurrent chemotherapy. ALPPS is associated with a high morbidly and mortality. Radiation lobectomy (RL) with yttrium-90 (Y-90) delivers transarterial ablative brachytherapy to the future hepatectomy site which generates FLR hypertrophy similar or greater than PVE. Early results indicate that RL is safe, effective, and may offer unique benefits by providing cytoreduction of hepatic metastases which extends FLR hypertrophy time and allows FLR surveillance to gauge disease biology. A retrospective analysis of four patients with ml-CRC treated with RL prior to hepatectomy was performed to evaluate initial safety, efficacy, FLR hypertrophy, and radiopathologic correlation. Adverse events after RL and hepatectomy were evaluated. Imaging findings were analyzed for efficacy defined as FLR hypertrophy and disease control. Radiopathologic correlation was performed after histologic analysis. RL was well tolerated without major adverse events or hepatic decompensation. FLR hypertrophy ranged from 24.9% to 119% at mean follow-up of three months. The majority of complications were related to surgical instrumentation of the FLR due to upstaging at time of surgery. Hepatectomy specimen histology demonstrated complete pathologic response in 50% of patients, 50% radiopathologic concordance rate, and no significant hepatic fibrosis. Initial experience with neoadjuvant RL for ml-CRC is safe and provides both durable disease control and FLR hypertrophy with concurrent chemotherapy. A 50% complete pathologic response rate raises the possibility of definitive chemoradiation in poor surgical candidates. Prospective investigation is required.

A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills.

SUMMARY: Rural western Canada relies heavily on family physicians with enhanced surgical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a "community of practice" section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the training and evaluation of the ESS skill set.