Ablación intraductal por radiofrecuencia en neoplasias biliopancreáticas inoperables con ictericia: experiencia en un hospital comarcal / Intraductal ablation by radiofrequency for inoperable biliopancreatic neoplasms with jaundice: experience at a regional hospital

En la actualidad, el tratamiento de elección en las neoplasias biliopancreáticas inoperables y/o irresecables complicadas con ictericia es la colocación de prótesis metálicas biliares, siendo la complicación más frecuente la obstrucción por crecimiento tumoral. La aplicación de ablación por radiofrecuencia (ARF) es una técnica novedosa mínimamente invasiva que tiene como objetivo la termoablación del tejido tumoral que condiciona la estenosis biliar. La experiencia con ARF es exigua, con escasos estudios retrospectivos de casos clínicos y con un número limitado de pacientes, por lo que los hay pocos datos sobre la dificultad técnica, seguridad y seguimiento a corto-medio plazo. Presentamos tres casos (un colangiocarcinoma y dos adenocarcinomas de cabeza pancreática) con ictericia por estenosis biliar en los que se aplica ARF con sonda ELRA durante la colangiopancreatografía retrógrada endoscópica (CPRE), realizando seguimiento durante diez meses donde se evalúa la dificultad del tratamiento, la eficacia y las complicaciones inmediatas y a medio plazo

The current treatment of choice for inoperable and/or unresectable biliopancreatic neoplasms complicated by jaundice is the placement of metal biliary stents. The most common complication is obstruction due to tumor growth. The application of radiofrequency ablation (RFA) is a new minimally invasive technique for the thermal ablation of the tumor tissue that causes biliary stenosis. Experience with RFA is scarce and there are few retrospective studies of clinical cases with a limited number of patients. Thus, there is little information on technical difficulty, safety and short-medium term monitoring. We present three cases, one cholangiocarcinoma and two pancreatic adenocarcinomas, with jaundice due to biliary stenosis. RFA was used with an ELRA catheter during endoscopic retrograde cholangiopancreatography (ERCP). The patients were monitored for ten months in order to assess the difficulty of treatment, efficacy and immediate and medium-term complications

La papilomatosis biliar difusa puede recidivar después del trasplante hepático en ausencia de focos de carcinoma infiltrante / Tumor recurrence after liver transplantation for diffuse biliary papillomatosis in the absence of invasive carcinoma

La neoplasia papilar intraductal (NPI) o papilomatosis biliar (PB) es una enfermedad recurrente con un alto riesgo de transformación maligna. Cuando la enfermedad afecta de forma difusa a la vía biliar (VB), el trasplante hepático (TH) es la única alternativa terapeútica disponible. Presentamos el caso de un varón de 43 años que debutó con un cuadro de colangitis aguda, siendo diagnosticado de papilomatosis biliopancreática difusa. El paciente fue sometido a una pancreatectomía total en dos tiempos y finalmente, a un TH, descartándose la presencia de focos de carcinoma infiltrante o de afectación ganglionar tanto en el páncreas inicialmente como en el hígado a posteriori. A los dos años de seguimiento, el paciente desarrolló una recidiva hepática multicéntrica cuya biopsia fue compatible con adenocarcinoma de origen biliar. En 2010, Vibert y cols. describieron que en los casos de PB sin presencia de carcinoma infiltrante o afectación ganglionar, el TH era una opción de tratamiento eficaz. Este caso es el primero que describe recidiva de la enfermedad después del TH en ausencia de focos de carcinoma infiltrante y de afectación ganglionar. Cuando la papilomatosis afecta de forma extensa a la VB, es posible que durante el análisis histopatológico pequeños focos de microinfiltración puedan no ser detectados. No obstante, aunque se trata de una enfermedad recidivante, la patogenia es desconocida, y no sabemos si la papilomatosis podría recidivar sobre el injerto después del TH incluso en ausencia de carcinoma infiltrante

Intraductal papillary neoplasm of the bile duct (IPNB) or biliary papillomatosis (BP) is a premalignant entity with high risk of malignant transformation. When the disease extends widely from the intrahepatic to the extrahepatic biliary tree, liver transplantation (LT) is the only option available. We present the case of a 43-year-old male who was admitted in our hospital with an acute cholangitis. He was diagnosed of diffuse biliary and pancreatic papillomatosis. Firstly, we performed a cephalic pancreaticoduodenectomy, then we completed a total pancreatectomy, and finally, after confirming the absence of foci of carcinoma infiltration or lymph nodes involvement, a LT was performed. Foci of carcinoma infiltration or lymph nodes involvement in the liver were not found. After a two-year follow-up the patient developed liver recurrence and the biopsy showed a biliary adenocarcinoma. In 2010, Vibert et al. published a series of three cases concluding that in the absence of invasive carcinoma and positive lymph nodes, LT can be performed with success. The present case is the first to describe recurrence of the disease after LT in the absence of invasive carcinoma and positive lymph nodes in the literature. When the disease affects widely the entire biliary duct, small micro-invasive foci may not be detected. Nevertheless, although we know that it is a recurrent entity, the pathogenesis is unknown, and we do not know if it is possible that papillomatosis recurs over the new liver

SOX10 is over-expressed in bladder cancer and contributes to the malignant bladder cancer cell behaviors

Purpose. To detect the expression level and significance of SOX10 in human bladder cancer. Methods. Immunohistochemical analyses were performed to assess SOX10 protein level using a bladder cancer tissue microarray (including 59 spots of cancer tissues and 46 spots of paired normal tissues) and 31 specimens and to define the relationship between SOX10 and clinicopathological bladder cancer characteristics in patients. SOX10 protein and mRNA levels in bladder cancer cell lines (T24, 5637, BIU87, EJ) and transitional cell papilloma cell line (RT4) were tested by western blotting and quantitative real-time PCR (q-PCR), respectively. Cell Counting Kit-8 (CCK-8) and colony formation assays were performed to investigate bladder cancer cell proliferation after SOX10 knockdown. The effect of SOX10 on cell migration and invasion was analyzed by Transwell and Matrigel assays. Kaplan-Meier survival curves and Cox regression analyses were used to evaluate SOX10 prognostic significance for bladder cancer patients. The mechanisms by which SOX10 promote bladder cancer progression were examined by western blotting. Results. SOX10 protein was upregulated in 74.4% of bladder cancer tissues compared with adjacent normal tissues (32.6%). SOX10 protein was also upregulated in malignant cell lines. In addition, high SOX10 expression was related with clinical stage (P = 0.008), T stage (P = 0.004), histological grade (P = 0.002) and lymph node metastasis (P = 0.006). Kaplan-Meier survival curves and Cox regression analyses showed that SOX10 functioned as an independent prognostic factor for overall survival. SOX10 knockdown in bladder cancer cells significantly impacted proliferation, migration and invasion, and SOX10 might promote bladder cancer progression by altering β-catenin and Met expression. Conclusion. SOX10 was over-expressed in bladder cancer and promoted malignant bladder cancer cell behaviors. SOX10 has potential as a molecular target for bladder cancer treatment (AU)

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Tratamiento endoscópico de las estenosis malignas de la vía biliar. Puesta al día y puntos más relevantes para la práctica clínica habitual / Endoscopic management of malignant biliary stenosis. Update and highlights for standard clinical practice

En la presente revisión se describen las diferentes indicaciones para la colocación de prótesis biliares en pacientes con neoplasias malignas de la vía biliar. Se profundiza en los accesos a la vía biliar y en la efectividad de los mismos, así como en el uso de las diferentes prótesis en función del tipo de lesión y de la expectativa de sobrevida del paciente. En las lesiones de hilio hepático, algo más complejas, se valoran la utilidad y necesidad de un drenaje uni- o bilateral y el método más apropiado. En conjunto, se trata de una revisión actual de la literatura que puede ayudar al clínico a la toma de decisiones en su práctica diaria y a mejorar y optimizar los resultados en los pacientes (AU)

The present review describes the various indications of biliary stent placement in patients with biliary malignancies. It deals in depth with biliary accesses and their effectiveness, as well as with the use of different stents according to lesion type and expected patient survival. For liver hilum lesions, which are somewhat more complex, the usefulness of and need for unilateral or bilateral drainage is assessed, as it is the most appropriate method. All in all, this is an up-to-date literature review that may help clinicians in their daily decision-making, as well as to improve and optimize patient outcomes (AU)

Is c-Met oncoprotein expression an adverse prognosticator in extrahepatic bile duct cancer treated with curative resection followed by adjuvant chemoradiotherapy?

Purpose: To analyze the expression of c-Met, and to investigate correlations between the expression of c-Met, clinicopathologic variables, and survival in patients undergoing curative surgery followed by adjuvant chemoradiotherapy for extrahepatic bile duct (EHBD) cancer. Methods: Ninety EHBD cancer patients who underwent curative resection followed by adjuvant chemoradiotherapy were enrolled. Expression of c-Met was assessed with immunohistochemical staining on tissue microarray. The correlation between clinicopathologic variables and survival outcomes was evaluated using Kaplan-Meier method and Cox proportional hazard model. Results: On univariate analysis, 66 patients (76.7 %) showed c-Met expression. c-Met expression had a significant impact on 5-year overall survival (OS) (43.0 % in c-Met(+) vs. 25.0 % in c-Met(-), p = 0.0324), but not on loco-regional relapse-free survival or distant metastasisfree survival (DMFS). However, on multivariate analysis incorporating tumor location and nodal involvement, survival difference was not maintained (p = 0.2940). Tumor location was the only independent prognostic factor predicting OS (p = 0.0089). Hilar location tumors, nodal involvement, and poorly differentiated tumors were all identified as independent prognostic factors predicting inferior DMFS (p = 0.0030, 0.0013, and 0.0037, respectively). Conclusions: This study showed that c-Met expression was not associated with survival outcomes in EHBD cancer patients undergoing curative resection followed by adjuvant chemoradiotherapy. Further studies are needed to fully elucidate the prognostic value of c-Met expression in these patients (AU)

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Crecimiento endobiliar de las metástasis de carcinoma colorrectal / Intrabiliary growth of colorectal liver metastases

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Biliary tract cancers: SEOM clinical guidelines

Biliary tract cancer (BTC) is an uncommon and highly fatal malignancy. It is composed of three main different entities; Gall bladder carcinoma (GBC), intrahepatic cholangiocarcinoma (iCC) and extrahepatic cholangiocarcinoma (eCC) sharing different genetic, risk factors and clinical presentation. Multidetector-row computed tomography (MDCT) and magnetic resonance cholangio-pancreatography (MRCP) are the more important diagnostic techniques. Surgery is the only potentially curative therapy but disease recurrence is frequent. Treatment with chemotherapy, radiotherapy or both has not demonstrated survival benefit in the adjuvant setting. Cisplatin plus gemcitabine constitutes the gold standard in metastatic disease. New ongoing studies mainly in the adjuvant and neoadjuvant setting along with molecular research will hopefully help to improve survival and quality of life of this disease (AU)

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Hamartoma biliar multiquístico intrahepático: presentación de un caso clínico / Intrahepatic multicystic biliary hamartoma: Presentation of a case report

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Cistoadenocarcinoma biliar / Biliary cystadenocarcinoma

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Colangiocarcinoma hiliar (tumor de Klatskin) / Hilar cholangiocarcinoma (Klatskin tumor)

El colangiocarcinoma es una neoplasia maligna del epitelio de la vía biliar. Su frecuencia de aparición es baja, y su pronóstico es infausto en un breve periodo de tiempo (meses) en la mayoría de los pacientes afectos. La poca especificidad de los síntomas clínicos en su presentación y la infiltración tumoral local en el momento del diagnóstico son factores que suelen impedir la posibilidad de ofrecer una resección quirúrgica radical que sea potencialmente curativa. El caso de una paciente de 52 años afecta de un colangiocarcinoma de la confluencia hiliar (tumor de Klatskin) nos sirve para revisar los aspectos epidemiológicos y clínicos de esta entidad, así como los datos de laboratorio, hallazgos en pruebas de imagen, diagnóstico diferencial y tratamiento potencial de esta infrecuente enfermedad (AU)

Cholangiocarcinoma is a malignant neoplasm of the hepatic bile duct epithelium. The frequency of occurrence is low and has very poor prognosis (short-term survival in months) in most patients affected. The lack of specificity in the clinical symptoms at onset and local tumor infiltration at the time of diagnosis are factors which usually prevent the possibility to offer radical surgical resection as potentially curative. The case of a 52 years old patient suffering from cholangiocarcinoma in the hilar confluence (Klatskin tumor) serves as the basis to review epidemiological and clinical aspects of this entity, as well as laboratory information, findings of imaging tests, differential diagnosis and potential treatment for this uncommon disease (AU)

Hepatocellular and biliary tract carcinomas: SEOM clinical guidelines

While hepatocellular carcinoma (HCC) is a relatively common tumour with an annual incidence in the EU of 8 cases/100,000 inhabitants, bile tract carcinoma (BTC) is much less common, with an incidence of 4 cases per 100,000 inhabitants per year. In both cases, when planning treatment it is essential to perform accurate staging, evaluate hepatic functional reserve and performance status, and obtain the opinion of the patient. The only curative treatment is surgery. However, several interventional radiological techniques can help to achieve local disease control and the alleviation of symptoms. In addition, sorafenib (HCC) and chemotherapy (BTC) may contribute to prolong survival in patients with disseminated disease. Therefore, the therapeutic strategy should always be discussed and planned within a multidisciplinary tumour board (AU)

Síndrome de Mirizzi, una causa infrecuente de ictericia obstructiva / Mirizzi Syndrome, a rare cause of obstructive jaundice

El dolor abdominal es un motivo de consulta muy frecuente en atención primaria. La variabilidad de entidades nosológicas que presenta complica su diagnóstico diferencial. Las principales causas de dolor en hipocondrio derecho son biliares (cólico biliar, colecistitis y colangitis). El síndrome de Mirizzi es una complicación que aparece en aproximadamente el 1% de los pacientes con colelitiasis. Consiste en la impactación de un cálculo en el infundíbulo de la vesícula o el conducto cístico que comprime el conducto hepático común, pudiendo erosionarlo y generar una fístula colecisto-coledociana. Cursa clínicamente como ictericia obstructiva, asociándose frecuentemente a cáncer de vesícula. Se diagnostica mediante ecografía abdominal, confirmándose mediante colangiopancreatografía retrógrada endoscópica, colangiografía percutánea o colangio-resonancia. Su tratamiento es quirúrgico, pudiendo realizarse por vía laparoscópica o abierta en función de su estadio (AU)

Abdominal pain is a common cause of consultation in primary care. The variability in disease conditions with this pain complicates differential diagnosis. The main causes of right upper quadrant pain are bile (biliary colic, cholecystitis and cholangitis). Mirizzi syndrome is a complication that occurs in approximately 1% of patients with cholelithiasis. It consists of the impaction of calculi in the neck of the gallbladder or cystic duct that compresses the common hepatic duct, which may erode and create a cholecystocholedochal fistula. It clinically appears as obstructive jaundice, frequently associated with gallbladder cancer. It is diagnosed by ultrasound, confirmed by endoscopic retrograde cholangiopancreatography, percutaneous cholangiography or resonance-cholangiopancreatography. Treatment is surgical and can be performed by laparoscopic or open surgery, depending on the staging (AU)

Biliary cystadenocarcinoma with mesenchymal stroma

Hepatobiliary cystadenocarcinomas (BCACs) with mesenchymal stroma are a rare cystic lesion. This tumour needs to be distinguished from benign biliary cystadenoma, which is antecedent in most cases. The treatment of choice is radical excision of the mass. The diagnostic evaluation, surgical management, pathological characteristics, treatment and follow-up of one patient with hepatobiliary cystadenocarcinoma with ovarian stroma is described. Preoperative diagnosis of BCACs is often difficult, because their clinical manifestations are similar to those of other hepatic cystic lesions. MRI is suitable for accurate characterisation of cystic biliary lesions, but distinguishing between cystadenoma and cystadenocarcinoma remains difficult on the basis of imaging findings. Complete surgical excision gives a relatively good chance of long-term survival because of the slow growth rate of these tumours (AU)

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