Characterization of microvascularization of liver tumor lesions with high resolution linear ultrasound and contrast enhanced ultrasound (CEUS) during surgery: First results

AIM

Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions.

MATERIAL AND METHODS

Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma). Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue®.

RESULTS

In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation.

CONCLUSION

The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

[Primary hyperparathyroidism: clinical symptoms, diagnostic significance and localisation--a retrospective analysis]

BACKGROUND

The primary hyperparathyroidism (pHPT) is one of the most frequent metabolic diseases. Due to improvement in diagnostics it is a point of interest whether patients with pHPT still suffer from the typical symptoms. Moreover, the question of the best localisation-diagnostics and the most frequent localisation of the adenoma is not yet clarified. New operation strategies and more cost-efficient strategies for diagnostic and therapy could be developed due to the clinically established electrochemiluminescence immunoassay for intraoperative monitoring of intact parathyroid hormone (iPTH).

PATIENTS AND METHODS

121 patients with pHPT were operated and retrospectively evaluated between November 1998 and September 2004. Apart from blood parameters, clinical symptoms were examined. As preoperative localisation techniques the ultrasound, the Tc-SestaMIBI scintigraphy, the CT scan and the MRI were used. The monitoring of the iPTH was performed with a special PTH-assay. The histological slices were estimated by a skilful pathologist.

RESULTS

All patients showed an increased PTH level (> 65 ng / l). Nearly 50 % of the patients suffer from more than one symptom. Gastrointestinal- and neuromuscular symptoms were the most frequent symptoms. The best preoperative diagnostic procedure for localisation of the adenoma of the parathyroid gland, in non preoperated patients, seemed to be the combination of ultrasound and scintigraphy. The most common localisation of the adenoma was caudal, on the left side. Intraoperatively, we recognized in 28 from 34 patients an iPTH decrease of more than 50 % of the base value so that the operation could be finished as minimal invasive unilateral cervical exploration.

CONCLUSION

Patients suffering from pHPT should be treated in a centre with all diagnostic possibilities and surgical experience. Today, the combination of iPTH-monitoring and minimal invasive unilateral cervical exploration should be considered as standard in the surgery of the adrenal gland. Due to our data we recommend an exploration of the left caudal parathyroid gland first if the localisation of the adenoma could not be clarified preoperatively.

Multimodality treatment of peritoneal carcinomatosis from colorectal cancer: first results of a new German centre for peritoneal surface malignancies

BACKGROUND

The presence of peritoneal carcinomatosis arising from colorectal cancer is associated with a poor prognosis. It was the purpose of this study to analyze morbidity, mortality, and survival after major cytoreductive surgery and intraperitoneal chemotherapy.

MATERIALS AND METHODS

Thirty-two patients with peritoneal carcinomatosis were operated between April 2004 and June 2006 with the aim of complete macroscopical cytoreduction. All had a primary colorectal carcinoma. Surgery in these patients was followed by hyperthermic intraperitoneal chemotherapy (HIPEC) consisting of mitomycin C and doxorubicin. Data were analyzed retrospectively.

RESULTS

Of all patients, 16 had appendix and 16 non-appendiceal colorectal carcinoma. A macroscopically complete cytoreduction was achieved in 24 patients by parietal and visceral peritonectomy procedures. All resections were combined with HIPEC. Overall morbidity was 34%. Most frequent surgical complications were intestinal obstruction (4/32), enteric fistula (2/32), pancreatitis (2/32), and bile leakage (2/32). One patient presented grade 4 renal toxicity. There was no hospital mortality. The median follow-up was 12 months. The 1-year overall survival rate is 96%. All patients after complete cytoreduction are still alive.

CONCLUSIONS

Cytoreductive surgery combined with HIPEC is associated with an acceptable morbidity and low mortality. Complete cytoreduction may improve survival, particularly in well-selected patients having a low tumor volume and no extra-abdominal metastases.

[Surgical management of patients with peritoneal carcinomatosis of gastrointestinal origin]

Peritoneal carcinomatosis is found in approximately 15 % of patients with colorectal cancer during the course of their disease, and is associated with a poor prognosis. Even more patients with gastric cancer develop peritoneal seeding. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) have been introduced in the past decade and have led to 5-year survival rates of 30 to 40 % for selected patients with colorectal cancer and peritoneal carcinomatosis. These numbers have been demonstrated by many retrospective analyses and by prospective Phase II studies. The clinical assessment to select patients who will benefit from the combined therapy and achievement of complete macroscopic cytoreduction both play a crucial role. Less favourabale results have been achieved for patients suffering from stage IV gastric cancer with peritoneal seeding. Promising results were demonstrated for postoperative intraperitoneal chemotherapy following curative gastrectomy. Patients with hepatic, biliary and pancreatic cancers and peritoneal carcinomatosis do not benefit from cytoreductive surgery. There is a need for further multicentre, prospective trials analysing the use of hyperthermic intraperitoneal chemotherapy. They should be conducted in the specialised centres by interdisciplinary teams.

Thermoablation of colorectal liver metastases promotes proliferation of residual intrahepatic neoplastic cells

BACKGROUND

Resection of liver neoplasms is believed to promote growth of residual intrahepatic neoplastic cells. As the effects of radiofrequency thermoablation (RFA) are still unknown, we aimed to compare the influence of RFA versus liver resection on residual intrahepatic neoplastic cells.

METHODS

A primary metastasis was established by injection of syngenic CT-26 coloncarcinoma cells into the right liver lobe of Balb/C mice. Five days later, 3 x 10(5) GFP-transfected CT-26 tumor cells were injected intraportally, and the primary metastasis was treated by resection (group I, n = 7) or RFA (group II, n = 7). The effect of resection/RFA on the growth of single intrahepatic GFP neoplastic cells was evaluated by intravital microscopy 7 days later.

RESULTS

Resection of a primary metastasis enhanced the proliferation of residual intrahepatic neoplastic cells, compared with the control group. RFA led to an increased survival of residual neoplastic cells (5% +/- 2% vs 1% +/- 1% single cells) and significantly promoted the proliferation of neoplastic cells, compared with resection (13% +/- 4% vs 2% +/- 2% micrometastases).

CONCLUSIONS

RFA strongly promotes intrahepatic growth of residual neoplastic cells. On the basis of our findings, RFA should not be recommended as an alternative curative treatment to resection. Furthermore, if RFA is performed as palliative therapy, postinterventional chemotherapy may be advisable to overcome the stimulation of residual neoplastic cells by RFA.

Effect of nitric oxide in ischemia/reperfusion of the pancreas

BACKGROUND

Ischemia/reperfusion injury, and thus graft pancreatitis, remains a major problem in pancreas transplantation. Contradictory results about the role of nitric oxide (NO) in pancreatic ischemia/reperfusion have been reported; however, in none of the reports has a detailed comparison between inhibition of NO synthase and NO supplementation been carried out.

METHODS

Vascular isolation of the pancreatic tail was performed in landrace pigs. After splenectomy catheters placed in the distal part of the splenic vessels allowed collection of the venous effluent and perfusion of the pancreatic tail. Three hours of complete warm ischemia was followed by 6 h of reperfusion. The effect of the NO donor sodium nitroprusside (SNP) and L-arginine was compared to a control group and NO synthase inhibition with L-NAME.

RESULTS

Lipase in the venous effluent of the pancreas was significantly decreased in the SNP and the L-arginine groups. Vascular resistance was markedly elevated in the L-NAME group and reduced in the NO donor groups. Tissue pO2 after reperfusion was only significantly elevated in the SNP group. Granulocyte infiltration and also overall histological tissue injury were most severe in the control group followed by the L-NAME group, the SNP group, and the L-ARG group.

CONCLUSION

The data show that supplementation of nitric oxide is clearly protective in pancreatic ischemia/reperfusion. However, inhibition of NO synthesis does not lead to an equally clear aggravation of tissue injury.

The nitric oxide donor sodium nitroprusside is protective in ischemia/reperfusion injury of the pancreas

BACKGROUND

The role of nitric oxide in the ischemia/reperfusion injury of the pancreas is still unclear. In other organs, protective as well as aggravating effects have been described. We have, therefore, investigated the effect of the nitric oxide donor sodium nitroprusside on pancreatic ischemia/reperfusion injury.

METHODS

In Landrace pigs, after transsection of the pancreas, complete vascular isolation of the pancreatic tail was performed. The tail was subjected to 3 hr of warm ischemia and thereafter reperfusion (6 hr). The animals were divided into a control group (n=7) and a treatment group (n=7) that received 15 mg of sodium nitroprusside after reperfusion intra-arterially into the splenic artery.

RESULTS

The morphological tissue damage and lipase activity in the venous effluent of the pancreas were significantly lower in the treatment group. Partial oxygen tension in the tissue after reperfusion was markedly reduced in the control group, indicating an impairment of microcirculation. In the treatment group, however, partial oxygen tension in the tissue was significantly higher (43 vs. 20 mmHg; P<0.014). Furthermore, total blood flow through the pancreatic tail in the treatment group was found to be significantly higher in the late reperfusion period (14 vs. 9.5 ml/min at 5 hr after reperfusion; P<0.05).

CONCLUSION

There is a marked impairment of pancreatic microcirculation after reperfusion. Sodium nitroprusside counteracts this impairment and has a protective effect on ischemia/reperfusion injury of the pancreas.