Local surgical resection of hilar cholangiocarcinoma: is there still a place?

In recent decades, surgical treatment of hilar cholangiocarcinoma has moved toward liver surgery in association with biliary resection in order to increase radicality and to achieve better survival. Results of local resection compared with hepatectomy associated with bile duct resection and its actual indications have to be clarified. A systematic review of relevant studies published before December 2007 was performed. Original published studies comparing the results of isolated local excision with those of hepatectomy associated with bile duct resection were identified and the reported results were synthesized. The pathologic data suggest that isolated bile duct resection cannot be adequate: required wide surgical margins; neoplastic extension along perineural sheaths; Segment 1 neoplastic invasion. Considering postoperative outcomes, in the 1990s, local resection had significantly lower mortality rates than liver resection. In recent years, the short-term results of liver surgery have improved significantly, while mortality rates have decreased. The R0 resection rate is significantly higher after associated liver resection. Comparison of survival results between local resection and associated liver surgery is difficult because, in the majority of series, the treatment was planned according to tumor extension. Better long-term outcomes have been reported after liver resection than after isolated bile duct resection, even for Bismuth-Corlette type I-II cholangiocarcinoma. Long-term survivors after local resection have been reported in a few selected patients with Bismuth-Corlette type I Tis-T1 or papillary neoplasm.

Brief Adlerian psychodynamic psychotherapy: theoretical issues and process indicators

Brief psychotherapy is gaining interest worldwide, because of its good cost/effectiveness ratio and proved efficacy. The aim of the paper was to describe the brief Adlerian psychodynamic psychotherapy (B-APP): a brief, psychodynamically oriented psychotherapy referring to the individual psychology (IP). The B-APP theory refers to the following paradigms: 1) the individual represents a psychosomatic unity integrated in the social context; 2) the individual needs to build and regulate the image of the self; 3) bond patterns regulate human relationships and represent the symbolic ''fil rouge'' connecting the elements of the life-style. Its objectives are: 1) an at least partial resolution of the focus problem; 2) a decrease or a non-increase of symptoms; 3) a global increase of quality of life. The results depend on intrapsychic and relational changes. Indications are more relative than absolute. The possibility of identifying a meaningful focus is fundamental. The treatment scheme includes 15 sessions subdivided into 5 phases. B-APP offers a technical approach to brief psychotherapy which is suitable in many fields of psychiatry and liaison medicine such as preventive interventions in at-risk subjects, somatopsychic disorders and liaison psychiatry, personality and eating disorders, and treatment of emotionally disturbed children. It was applied as psychotherapeutic approach in some clinical outcome studies about eating disorders and severe personality disorders displaying a good efficacy.

Liver resection for HCC with cirrhosis: surgical perspectives out of EASL/AASLD guidelines

EASL/AASLD guidelines clearly define indications for liver surgery for HCC: patients with single HCC and completely preserved liver function without portal hypertension. These guidelines exclude from operation many patients that could benefit from radical resection and that are daily scheduled for hepatectomy in surgical centers. Patients with large tumors or with portal vein thrombosis cannot be transplanted or treated by interstitial treatments. In selected cases liver resection may obtain good long-term outcomes, significantly better than non-curative therapies. In cases of multinodular HCC, liver transplantation is the treatment of choice within Milan criteria; patients beyond these limits can benefit from liver resection, especially if only two nodules are diagnosed: even if they have a worse prognosis, survival results after liver surgery are better than those reported after TACE or conservative treatments. EASL/AASLD guidelines excluded from operating patients with portal hypertension but data about this topic are not conclusive and further studies are necessary. Selected patients with mild portal hypertension could probably be scheduled for liver resection and, considering the shortage of donors, listing for transplantation could be avoided. In conclusion, guidelines for HCC treatment should consider good results of liver resection for advanced HCC, and indications for hepatectomy should be expanded in order not to exclude from radical therapy patients that could benefit from it.

Phase II trial of continuous/metronomic 5-fluorouracil infusion plus long acting Octreotide in advanced neuroendocrine carcinoma

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Background: The administration of cytotoxic drugs on a metronomic schedule has shown antiangiogenetic properties. Well differentiated neuroendocrine carcinomas are notoriously highly vascularized and may be responsive to metronomic chemotherapy. A phase II study was designed to test the activity of protracted 5-fluorouracil (5FU) infusion in association with and long-acting release (LAR) octreotide in patients with advanced/metastatic neuroendocrine carcinoma. Patients and Methods: Twenty-nine patients (pts), with metastatic or locally advanced well differentiated neuroendocrine carcinoma not amenable to surgery with radical intent and not previously submitted to systemic treatments were enrolled. Treatment consisted of 5FU intravenous continuous infusion (200 mg/m2 daily) in association with Octreotide LAR (20 mg once every 4 weeks). 5FU treatment was administered until progression or for a maximum of 9 months. Octreotide LAR was administered until progression. Patients were followed for toxicity, objective response, symptomatic response, biochemical response, time to progression and survival. Results: According to RECIST criteria a partial response was observed in 7 patients (24.1%), a stable disease in 20 pts (69.0%) and a progression disease in only 2 pts (6.9%). A biochemical (chromogranin A) response was observed in 11/25 assessable patients (44.0%), 9/15 symptomatic patients (60.0%) obtained symptom relief. Post-treatment surgery was attempted in three patients, one of them was radically resected. The median time to disease progression was 25 months (range 2–69 months), median overall survival was not reached. Hematologic toxicity was rare and mild [grade 2 neutropenia in 2 pts (6.9%)]. Six cases (20.7%) suffered from grade 2–3 hand-foot syndrome. No patient withdrew from the study because of adverse events. Conclusions: Continuous/metronomic 5FU infusion plus octreotide LAR is well tolerated and shows promising activity in patients with advanced well differentiated neuroendocrine carcinoma. Additional studies with this combination are warranted.

No significant financial relationships to disclose.

Prevention of intrahepatic recurrence by adjuvant (131)iodine-labeled lipiodol after resection for hepatocellular carcinoma in HCV-related cirrhosis

AIM

To evaluate the impact of postoperative injection into the hepatic artery of 131-iodine-labeled lipiodol on disease-free and overall survival rates in patients who underwent liver surgical resection for hepatocellular carcinoma.

METHODS

Ten consecutive patients with HCV (hepatitis C virus)-related cirrhosis who underwent liver surgical resection for hepatocellular carcinoma were treated with adjuvant injection of 131-iodine-labeled lipiodol. They were matched with 20 HCV-positive cirrhotic controls who underwent liver resection alone; patients were paired in terms of age, Child-Pugh class, tumor size, microscopic vascular invasion, tumor histological pattern, presence of satellite nodules and type of surgical resection. Recurrence was defined as the development of a new hypervascularizated nodule in the liver.

RESULTS

No significant differences were found between the two groups in clinical, biologic and histologic characteristics, except a lower platelet count in the control group. None of the treated patients developed an intrahepatic recurrence until the 15th month from liver resection, whereas recurrences occurred in nine of the 20 patients in the control group (p=0.01). From 18 months onwards, recurrences appeared also in the treated patients, and after 36 months of follow-up both recurrence rate and overall survival were not significantly different between the two groups.

CONCLUSIONS

Intrahepatic injection of 131-iodine-labeled lipiodol improves the disease-free survival rate following liver resection of hepatocellular carcinoma in the short term up to 15 months; this advantage fades, however, away after 36 months.

Randomized clinical trial of liver resection with and without hepatic pedicle clamping

BACKGROUND

The purpose of this study was to compare the perioperative outcome of liver resection with and without intermittent hepatic pedicle clamping.

METHODS

Between June 2002 and June 2004, 126 consecutive patients with resectable liver tumours were randomized to undergo resection with (63 patients) or without (63 patients) intermittent hepatic pedicle clamping.

RESULTS

The transection time was significantly higher in the group without hepatic pedicle clamping. The blood loss per cm(2) was similar in the two groups: 2.7 ml/cm(2) in the group with versus 3.2 ml/cm(2) in group without hepatic pedicle clamping (P = 0.425). In the subset of patients with an abnormal liver, there were no differences in blood loss per transection surface: 3.1 ml/cm(2) in the group with versus 2.9 ml/cm(2) in the group without clamping (P = 0.829). The rate of blood transfusions was not higher in the non-clamping group. No differences were observed in the postoperative liver enzyme serum levels, the in-hospital mortality (one patient in each group) or the number of complications.

CONCLUSION

This study showed clearly that liver resection without hepatic pedicle clamping is safe, even in patients with a diseased liver.

Improvements for determining the modulation transfer function of charge-coupled devices by the speckle method

We present and evaluate two corrections applicable in determining the modulation transfer function (MTF) of a charge-coupled device (CCD) by the speckle method that minimize its uncertainty: one for the low frequency region and another for the high frequency region. The correction at the low-spatial-frequency region enables attenuation of the high power-spectral-density values that arise from the field and CCD response non-uniformities. In the high-spatial-frequency region the results show that the distance between the CCD and the aperture is critical and significantly influences the MTF; a variation of 1 mm in the distance can cause a root-mean-square error in the MTF higher than 10%. We propose a simple correction that minimizes the experimental error committed in positioning the CCD and that diminishes the error to 0.43%.

Cryptosporidium outbreak linked to interactive water feature, UK: importance of guidelines

A need for national guidelines relating to interactive water features was highlighted following three outbreaks of cryptosporidiosis in the United Kingdom, all of which were related to public water features. In August 2003 the Health Protection Agency South West of England was notified of an outbreak of cryptosporidiosis associated with an interactive water feature designed for water play within an adventure park. The water feature was implicated following samples with a high coliform count and the presence of faecal coliforms. A case was defined as any child (younger than 16 years of age) who had visited the park during August and who subsequently had gastrointestinal symptoms and a faecal sample positive for cryptosporidium. Seventy one children were identified in the cohort. This outbreak of cryptosporidiosis was characterised by a very high attack rate (89%), relatively severe in duration (median 8 days) and had a relatively high hospital admission (16% of cases). The epidemic curve was consistent with a point source of infection, which corresponded to the date 80% of the cohort visited the park. This outbreak has similarities to two other cryptosporidiosis outbreaks reported in England in 2003 that involved public water features. These outbreaks raise issues about the operation and maintenance of water-based recreational attractions that very often involve children. The paper reflects on the basic control measures that can be taken and highlights the need for guidelines, especially since such attractions are becoming increasingly common. The Pool Water Treatment Advisory Group in United Kingdom has now produced guidelines.

Cryptosporidium outbreak linked to interactive water feature, UK: importance of guidelines

A need for national guidelines relating to interactive water features was highlighted following three outbreaks of cryptosporidiosis in the United Kingdom, all of which were related to public water features. In August 2003 the Health Protection Agency South West of England was notified of an outbreak of cryptosporidiosis associated with an interactive water feature designed for water play within an adventure park. The water feature was implicated following samples with a high coliform count and the presence of faecal coliforms. A case was defined as any child (younger than 16 years of age) who had visited the park during August and who subsequently had gastrointestinal symptoms and a faecal sample positive for cryptosporidium. Seventy one children were identified in the cohort. This outbreak of cryptosporidiosis was characterised by a very high attack rate (89%), relatively severe in duration (median 8 days) and had a relatively high hospital admission (16% of cases). The epidemic curve was consistent with a point source of infection, which corresponded to the date 80% of the cohort visited the park. This outbreak has similarities to two other cryptosporidiosis outbreaks reported in England in 2003 that involved public water features. These outbreaks raise issues about the operation and maintenance of water-based recreational attractions that very often involve children. The paper reflects on the basic control measures that can be taken and highlights the need for guidelines, especially since such attractions are becoming increasingly common. The Pool Water Treatment Advisory Group in United Kingdom has now produced guidelines.

Clinical and pharmacokinetic phase II study of pegylated liposomal doxorubicin and vinorelbine in heavily pretreated recurrent ovarian carcinoma

BACKGROUND

This multicenter phase II study evaluated feasibility, clinical efficacy, toxicity and pharmacokinetics of the combination of pegylated liposomal doxorubicin (PLD) and vinorelbine (VNR) in patients with platinum-paclitaxel pretreated recurrent ovarian cancer.

PATIENTS AND METHODS

All patients received prior treatment with platinum and paclitaxel. Thirty-two heavily pretreated (median number of chemotherapy regimens two, range one to six) ovarian cancer patients received treatment with PLD 30 mg/m(2) and VNR 30 mg/m(2) every three weeks for six cycles. Ten patients entered the pharmacokinetic study, five receiving the PLD-VNR and five the VNR-PLD sequence.

RESULTS

In 30 patients evaluated for response and toxicity, the overall response rate was 37% and 10% of patients achieved stable disease. Median time to progression and overall survival were 5.5 months (range 1-10) and 9 months (range 2-16), respectively. Toxicity was generally mild and reversible. VNR AUC(tot) and plasma levels were considerably higher in the PLD-VNR sequence.

CONCLUSIONS

The PLD-VNR regimen exhibits significant activity in heavily pretreated patients, is well tolerated and is associated with encouraging survival. Preliminary pharmacokinetic results suggest the PLD-VNR sequence for further clinical applications. This regimen should be considered as a treatment option in patients with chemotherapy-resistant ovarian cancer.

First measurement of the transverse spin asymmetries of the deuteron in semi-inclusive deep inelastic scattering

First measurements of the Collins and Sivers asymmetries of charged hadrons produced in deep-inelastic scattering of muons on a transversely polarized 6LiD target are presented. The data were taken in 2002 with the COMPASS spectrometer using the muon beam of the CERN SPS at 160 GeV/c. The Collins asymmetry turns out to be compatible with zero, as does the measured Sivers asymmetry within the present statistical errors.

[Parenchyma sparing: evolution of the resective surgical approach of hepatic metastasis from the colorectum]

Liver surgery for colorectal metastasis has moved toward a parenchymal sparing strategy in order to reduce postoperative liver failure, to resect an higher number of metastases and to allow a future re-resection. Patients undergone hepatectomy in our Department before and after 1999 were retrospectively compared. In the recent years surgery became more aggressive: a higher number of patients with multiple and bilateral lesions were treated. Short-term results improved in the recent series. After 1999, the rate of wedge resections was significantly increased with the same oncological radicality and with improved long-term results. Moreover, parenchymal sparing strategy allowed a higher re-resection rate in patients with liver recurrence.

[Glutamatergic neurotransmission, depression and antidepressants]

Depression is a psychiatric disorder that affects 20% of the population. Despite the efforts aimed to identify the mechanisms underlying its behavioral and affective symptoms, no consensus has been reached. In the last years two new theories, the glutamatergic and the genomic ones, have been proposed. Upon the first, the exposition to stressful stimuli increases hippocampal glutamatergic neurotransmission and triggers excitotoxic changes. The second one postulates that depression is closely correlated with neuronal atrophy due to a decrease in BDNF. The aim of this work is to review recent findings about the glutamatergic neurotransmission and its implication in animal models of depression, depressed patients and in both conditions after the antidepressant treatment. We also tried to identify possible links between these observations and the genomic theory.

Laparoscopic identification of pelvic nerves in patients with deep infiltrating endometriosis

BACKGROUND

Nerve sparing is suggested for cancer surgery, but no experience is available for deep endometriosis. The aim of this study was to laparoscopically identify the pelvic nerves in the posterior pelvis.

METHODS

A total of 24 patients operated for deep endometriosis were considered. During surgery and on videotapes of the procedures, we evaluated single- or double-sided resection of the uterosacral ligaments and other structure's visualization of the inferior hypogastric and the splanchnic nerves. The most important objective criteria for resection of the nerves was urinary retention after surgery, which was compared to surgical resection on the videotapes.

RESULTS

Visualization of the inferior hypogastric nerves was possible in 20 of 22 patients (90.1%). Eight of the 24 patients had at least one inferior hypogastric nerve resected (33.3%). In seven patients (29.2%) resection of the uterosacral ligaments was bilateral, and in three of these the nerves were resected. Postoperatively, the median residual urine volume after the first spontaneous voiding was 40 ml (range, 20-400). Seven of eight patients (29.2%) with resection of the nerves had urinary retention and self-catheterization at discharge. The difference in urinary residuum after first voiding between patients undergoing self-catheterization and patients released without the catheter was significant ( p < 0.01). The median time to resume the voiding function in patients with self-catheterization was 18 days (range, 9-45).

CONCLUSIONS

Nerve visualization is possible by means of laparoscopic surgery for deep endometriosis in a high rate of patients. Careful technique is necessary, but the laparoscopic approach may help. Even single-sided radical dissection can induce important urinary retention.