Oncological strategies for locally advanced rectal cancer with synchronous liver metastases, interval strategy versus rectum first strategy: a comparison of short-term outcomes

BACKGROUND

The goal of treatment for patients with synchronous liver metastases (SLM) from rectal cancer is to achieve a complete resection of both tumor locations. For patients with symptomatic locally advanced rectal cancer with resectable SLM at diagnosis, our usual strategy has been the rectum first approach (RF). However, since 2014, we advocate for the interval approach (IS) that involves the administration of chemo-radiotherapy followed by the resection of the SLM in the interval of time between rectal cancer radiation and rectal surgery.

METHODS

From 2010 to 2016, 16 patients were treated according to this new strategy and 19 were treated according RF strategy. Data were collected prospectively and analyzed with an intention-to-treat perspective. Complete resection rate, duration of the treatment and morbi-mortality were the main outcomes.

RESULTS

The complete resection rate in the IS was higher (100%, n = 16) compared to the RF (74%, n = 14, p = 0.049) and the duration of the strategy was shorter (6 vs. 9 months, respectively, p = 0.006). The incidence of severe complications after liver surgery was 14% (n = 2) in the RF and 0% in the IS (p = 1.000), and after rectal surgery was 24% (n = 4) and 12% (n = 2), respectively (p = 1.000).

CONCLUSION

The IS is a feasible and safe strategy that procures higher level of complete resection rate in a shorter period of time compared to RF strategy.

Surgical treatment of liver metastases from colorectal carcinoma in elderly patients. When is it worthwhile?

BACKGROUND

The elderly are under-represented in series of patients operated on for colorectal liver metastases (LM).

OBJECTIVE

To analyse the influence of age on surgery of colorectal LM, and the identification of factors that could be used as exclusion criteria.

PATIENTS AND METHODS

Six hundred and forty-eight patients underwent liver resection between 1990 and 2006. Demographic data, primary tumour related variables, stage of the disease, morbidity, mortality, survival and recurrence were prospectively recorded.

RESULTS

One hundred and sixty of 648 patients (25%) were 70 years old or older. Postoperative mortality was significantly higher in elderly patients (8% vs. 3%, p=0.008). Morbidity was also higher (41% vs. 34%, p=0.008). Survival rate at 1, 3 and 5 years was 88%, 62% and 45% respectively in patients younger than 70 years, and 82%, 48% and 36% in the elderly (p=0.007). Excluding the postoperative mortality, the figures were 90%, 64% and 46%. 90%, 53% and 38% (p=0.061). Disease-free survival rates at 1, 3 and 5 years excluding postoperative mortality were 68%, 32% and 25% in younger patients, compared to 68%, 34% and 30% (p=0.71) in the elderly. Major liver resections increased mortality in the elderly. In the multivariate analyses only a tumour size equal to or more than 10 cm significantly increased the postoperative mortality risk in elderly patients.

CONCLUSIONS

The elderly have a higher mortality. In recent years that difference has been markedly reduced. Excluding the postoperative mortality, the overall survival and disease-free survival are similar between both groups. The criteria to indicate surgery must be the same in both groups.

Serum immunoglobulins (IgG, IgA, IgM) in chronic hepatitis C. A comparison with non-cirrhotic alcoholic liver disease

BACKGROUND/AIMS

Serum immunoglobulin concentrations are commonly elevated in patients with liver cirrhosis. Immunoglobulin class increase may vary depending on the cause of liver disease. Hepatitis C virus is, together with alcohol, a leading cause of chronic liver disease. The present study aimed to evaluate serum IgG, IgA and IgM levels in chronic hepatitis C. Results were compared with those of patients with non-cirrhotic alcoholic liver disease and healthy controls. Special attention was given to cases with minimal liver disease, as an approach to evaluate if the causing agent, independently of liver damage, influences serum immunoglobulin levels.

METHODOLOGY

A total of 274 patients with histologically-proven chronic hepatitis C, 121 alcoholics with non-cirrhotic liver disease (steatosis or alcoholic hepatitis), and 75 healthy controls were studied. Serum IgG, IgA, and IgM were assayed by nephelometry.

RESULTS

Serum IgG was increased in patients with chronic hepatitis C with respect to both alcoholics (p < 0.001) and healthy controls (p < 0.001). IgG levels were similar in alcoholics and in controls. IgA was increased in patients with non-cirrhotic alcoholic liver disease with respect to both chronic hepatitis C patients (p < 0.001) and controls (p < 0.001). IgA values were similar in subjects with chronic hepatitis C and controls. Selective IgG or IgA alteration was present in cases with minimal liver disease (chronic hepatitis C with a Knodell index equal or lower than 3, and alcoholics with liver steatosis, respectively).

CONCLUSIONS

Hepatitis C virus and alcohol are linked to a selective increase of serum IgG and IgA, respectively, even in cases with mild or minimal liver disease.

Acute cholecystitis as a complication following percutaneous ethanol injection of a hepatocellular carcinoma

Percutaneous ethanol injection is a useful option in the treatment of hepatocellular carcinoma which are not amenable to resection or transplantation. We describe a case of cholecystitis and tumour infiltration of the gallbladder after percutaneous ethanol injection, a complication not previously described in literature. The patient was a 70-year-old woman with a history of asymptomatic HCV+ hepatopathy and a 6 cm hepatocellular carcinoma nodule in segment V which had been treated two months before by percutaneous ethanol injection in another center. She attended our center due to febrile syndrome. Imaging studies suggested cholecystitis with an abscess on the wall of the gallbladder, purulent material obtained by means of a CT-guided puncture. Surgery revealed purulent and neoplasic material inside the gallbladder, with tumor invasion of the posterior wall; a partial cholecystectomy was therefore performed and a drainage inserted. The patient showed no post-operative complications and was discharged after seven days.

CONCLUSION

we believe that the percutaneous ethanol injection of hepatocellular carcinomas located close to the gallbladder may occasionally lead to complications in the form of cholecystitis with neoplasic infiltration of the gallbladder. A case of cholecystitis secondary to radiofrequency treatment of a similarly-located tumor has previously been described and, therefore, the use of percutaneous local destructive treatments for tumors close to the gallbladder would seem unadvisable.

Cecal ligation and puncture as a model of sepsis in the rat: influence of the puncture size on mortality, bacteremia, endotoxemia and tumor necrosis factor alpha levels

BACKGROUND

Cecal ligation and puncture is a widely used experimental model of sepsis.

AIM OF THE STUDY

The present study was aimed to evaluate the influence of the size of the cecal puncture on mortality, bacteremia, endotoxemia and plasma TNF-alpha levels.

MATERIALS AND METHODS

Female Sprague-Dawley rats underwent cecal ligation and puncture, divided into the following groups, defined by the diameter of the cecal puncture: 0.5-cm blade incision (n = 25), 13-gauge (n = 25), 16-gauge (n = 25), 18-gauge puncture (n = 25) and 4 punctures with a 22-gauge needle (n = 25). A sham operation was performed in another 25 rats. Three animals of each group were sacrificed 5 h after the procedure for blood cultures as well as determination of plasma endotoxin and TNF-alpha. The remaining animals were followed up for a week after cecal ligation and puncture for evaluation of mortality.

RESULTS

Five hours after cecal ligation and puncture, bacteremia was present in all animals, independently of the puncture size. Endotoxemia and plasma TNF levels tended to increase along with the diameter of the cecal puncture. Mortality gradually increased with the puncture size, from 27% with a 22-gauge needle to 95% with the blade incision.

CONCLUSIONS

The severity of sepsis obtained with cecal ligation and puncture in rats can be easily modulated varying the size of the puncture.