Prospective evaluation of 18F-FDG positron emission tomography in the preoperative staging of patients with hepatic colorectal metastases.

Background: Despite considerable advances in preoperative imaging, up to one-third of patients operatively explored for hepatic colorectal metastases are unexpectedly found to harbor unresectable intrahepatic or extrahepatic disease. Methods: The current study is a prospective, blinded study comparing utility of [18F]2-fluoro-2-deoxyglucose positron emission tomography (18F-FDG-PET) to computed tomography (CT) and CT arterial portography (CTAP) as preoperative staging. Results: The 125 planned subjects were enrolled. Findings seen on FDG-PET alone changed therapy for 23 of 125 patients (18%). FDG-PET confirmed other radiologic findings in 16 cases (13%), for an overall influence on therapy in 39 cases (31%). FDG-PET was the most sensitive diagnostic imaging test for extrahepatic cancer; it was 80-90% sensitive for extrahepatic cancer and 70-90% specific. For the 28 cases of unresectable disease due to extrahepatic disease, FDG-PET findings solely changed therapies in 16 cases (57%) and influenced therapy in seven other cases (25%). Of the 21 unresectable cases due to extent of intrahepatic disease, FDG-PET did not solely change therapy in any. Overall, FDG-PET had the lowest sensitivity for hepatic sites compared with CT or CTAP. In particular, small (<1 cm) liver tumors were particularly poorly detected by FDG-PET. The area under the receiver operating characteristic (ROC) curve for small tumors was 0.58 and for patients on chemotherapy it was 0.66, a modest improvement over no imaging. Conclusions: FDG-PET is an important test for preoperative staging of patients with hepatic colorectal metastases, affecting treatment decisions in nearly one-third of patients. The high yield is due mainly to detection of extrahepatic disease. It is therefore recommended in patients with extrahepatic lesions suspected to be disseminated cancer or those with high risk for extrahepatic disease. It is not a good test for identification of small tumors in the liver.

Chemotherapy after portal vein embolization to protect against tumor growth during liver hypertrophy before hepatectomy.

IMPORTANCE: Portal vein embolization improves the safety of liver resection by increasing the size of residual liver, but the embolization may increase tumor growth during the waiting period before definitive hepatectomy. OBJECTIVE: To determine whether the administration of chemotherapy mitigates tumor growth after portal vein embolization (PVE) performed before major hepatectomy for metastatic colorectal cancer. DESIGN, SETTING, AND PARTICIPANTS: Review of prospectively collected data at Memorial-Sloan Kettering Cancer Center was conducted. The database included patients subjected to PVE before major hepatectomy for metastatic colorectal cancer. MAIN OUTCOMES AND MEASURES: Lesions in both the embolized and nonembolized lobes of the liver before and 1 month after PVE were measured and Response Evaluation Criteria in Solid Tumors were applied to assess disease status. Assessment of survival was based on receipt of post-PVE chemotherapy and then stratified by subsequent resectability. RESULTS: Two hundred eight tumors were measured in 64 patients; 53 tumors were in patients undergoing post-PVE chemotherapy. Approximately one-third of the lesions progressed after PVE when no chemotherapy was administered. This did not differ significantly according to whether tumors were ipsilateral or contralateral to the PVE. When chemotherapy was administered, there was a significantly lower rate of progression (18.9%, P = .03). In long-term follow-up, treatment with post-PVE chemotherapy was also independently associated with improved survival (P < .006). CONCLUSIONS AND RELEVANCE: Chemotherapy does not retard growth of the liver after PVE and may prevent cancer progression. Thus, the combination of PVE and chemotherapy may enhance both oncologic and operative safety.

Long-term outcomes following tumor ablation for treatment of bilateral colorectal liver metastases.

IMPORTANCE: Ablative therapies extend the capability of delivering potentially curative treatment for bilateral hepatic colorectal metastases. OBJECTIVE: To compare the long-term effectiveness of ablation with that of resection in patients with bilateral hepatic colorectal metastases. DESIGN: Review of a prospective database of 2123 operative cases of hepatic colorectal metastases. SETTING: A large institution with expertise in ablation and resection. PATIENTS: Patients with bilateral colorectal liver metastases undergoing operation with a curative intent. A total of 141 patients had been treated with bilateral resection (BR) and 95 had undergone ablation. INTERVENTIONS: Radiofrequency or microwave ablation alone or in combination with resection (A/R) compared with BR. MAIN OUTCOMES AND MEASURES: We compared tumor characteristics and operative and postoperative outcomes using χ2 or Wilcoxon tests as appropriate and assessed overall survival differences between the 2 groups using the log-rank test. RESULTS: During the study, 141 patients were treated with BR and 95 patients with A/R. The A/R group was a significantly poorer prognostic group than the BR group as judged by the Clinical Risk Score (P < .01). There was no difference in median operative time (A/R: 280 minutes, BR: 282 minutes; P = .52), but a lower blood loss (A/R: 300 mL, BR: 500 mL; P < .01) and a shorter length of stay (A/R: 7 days, BR: 9 days; P < .01) was achieved in the A/R group. Long-term outcome was not significantly different between the groups (5-year overall survival, A/R: 56%, BR: 49%; P = .16). CONCLUSIONS AND RELEVANCE: Treatment of bilateral, multiple hepatic metastases with combined resection and ablation was associated with improved perioperative outcomes without compromising long-term survival compared with bilateral resection. Ablative therapies extend the capability of delivering potentially curative treatment for bilateral hepatic colorectal metastases.

Postoperative venous thromboembolism predicts survival in cancer patients.

OBJECTIVES: To determine whether a postoperative venous thromboembolism (VTE) is associated with a worse prognosis and/or a more advanced cancer stage and to evaluate the association between a postoperative VTE and cancer-specific survival when known prognostic factors, such as age, stage, cancer type, and type of surgery, are controlled. CONTEXT: It is unknown whether oncology patients who develop a venous thromboembolism after a complete curative resection are at the same survival disadvantage as oncology patients with a spontaneous VTE. METHODS: A retrospective case control study was conducted at Memorial Sloan-Kettering Cancer Center. Years of study: January 1, 2000, to December 31, 2005. Median follow-up: 24.9 months (Interquartile range 13.0, 43.0). All cancer patients who underwent abdominal, pelvic, thoracic, or soft tissue procedures and those who developed a VTE within 30 days of the procedure were identified from a prospective morbidity and mortality database. Overall survival (OS) was calculated for the entire cohort. In the matched cohort, OS and disease-specific survival (DSS) were calculated for stages 0 to 3 and stages 0 to 2. RESULTS: A total of 23,541 cancer patients underwent an invasive procedure and 474 (2%) had a postoperative VTE. VTE patients had a significantly worse 5-year OS compared to no-VTE patients (43.8% vs 61.2%; P < 0.0001); 205 VTE patients (stages 0-3) were matched to 2050 controls by age, sex, cancer type, stage, and surgical procedure. In this matched analysis, VTE patients continued to demonstrate a significantly worse prognosis with an inferior 5-year OS (54.7% vs 66.3%; P < 0.0001) and DSS (67.8% vs 79.5%; P = 0.0007) as compared to controls. The survival difference persisted in early stage disease (stage 0-2), with 5-year DSS of 82.9% versus 87.3% (P = 0.01). CONCLUSIONS: Postoperative VTE in oncology patients with limited disease and a complete surgical resection is associated with an inferior cancer survival. A postoperative VTE remains a poor prognostic factor, even when controlling for age, stage, cancer type, and surgical procedure further supporting an independent link between hypercoagulability and cancer survival.

Comparison of hepatocellular carcinoma in American and Asian patients by tissue array analysis.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide. Although some epidemiologic and etiologic differences between Asian and Western HCC are known, detailed comparative studies with pathologic correlations have not been performed. METHODS: Paraffin sections of resected HCC specimens from Memorial Sloan-Kettering Cancer Center and Korea University Medical Center were used to construct tissue microarrays. Immunohistochemical staining of microarray sections was performed using antibodies against markers of proliferation and regulators of cell cycle. Patient data were correlated with staining results. RESULTS: When comparing both cohorts, significant differences were found in expression of p53 and MDM2. In the Asian group, more frequent positive staining for p53 (24%) was observed compared with the American group (9%; P = 0.037). For MDM2, 26% of American cases stained positive compared with 2% of Asian cases (P = 0.0003). No significant differences were found in expression of Ki67, p21, p27, cyclin D1, or bcl2. Female gender, vascular invasion, and lack of viral hepatitis infection correlated with positive MDM2 staining. CONCLUSION: These data likely correlate with differences in molecular pathogenesis of HCC based on racial and regional differences. These findings may have implications in choice of molecular targeted therapies based on patient ethnicity.

Simple measurement of intra-abdominal fat for abdominal surgery outcome prediction.

OBJECTIVE: To assess the effect of increasing body mass index, intra-abdominal fat, and outer abdominal fat on outcome in patients undergoing major hepatectomy. DESIGN: Cohort study. SETTING: Memorial Sloan-Kettering Cancer Center. PARTICIPANTS: We studied patients aged 19 to 86 years undergoing major hepatic resection between June 18, 1996, and November 6, 2001. Complications were extracted from a prospective database at a tertiary cancer center. INTERVENTION: A total of 349 patients were grouped according to body mass index for analysis. Preoperative abdominal computed tomographic scans were examined and measurements of perinephric fat (as a surrogate for intra-abdominal fat) and outer abdominal fat taken at uniform anatomical locations. MAIN OUTCOME MEASURES: We compared 30-day mortality and morbidity figures, length of stay, and operating times. RESULTS: Body mass index had an influence on operative time (P = .02) but no significant effect on mortality, frequency of any complications, frequency of severe complications, or length of stay (P = .80, P = .89, P = .16, and P = .81, respectively). Outer abdominal fat had no significant effect on any of the 5 outcome measures. Perinephric fat measurements had a significant effect on most outcome measures (P = .004 for mortality, P = .003 for frequence of complications, P < .001 for frequence of severe complications, and P = .001 for length of stay). CONCLUSIONS: Outer appearances of obesity do not correlate with poor outcomes for major upper abdominal operations. A simple measurement of perinephric fat, as a surrogate for intra-abdominal fat, on preoperative imaging gives a more useful risk assessment for patients undergoing major upper abdominal operations.

Kinetics of liver volume changes in the first year after portal vein embolization.

OBJECTIVE: To determine the time course of liver hypertrophy after portal vein embolization (PVE). DESIGN: In a cohort study, computed tomography volumetrics were calculated for livers during a 1-year period after PVE. SETTING: Tertiary liver cancer treatment center. PATIENTS: Ten patients who were subjected to PVE and were found subsequently to not be candidates for liver resection. INTERVENTION: Right PVE. MAIN OUTCOME MEASURES: Left and right liver volumes. RESULTS: The left liver continued growing for the entire first year after PVE, while the right liver continued to atrophy. The total volume remained remarkably constant. CONCLUSION: Early PVE during administration of a course of neoadjuvant therapy would be beneficial for enhanced growth of the liver before liver resection.

Combined blunt-clamp dissection and LigaSure ligation for hepatic parenchyma dissection: postcoagulation technique.

BACKGROUND: Blunt-clamp dissection allows for visualization of intrahepatic vessels and individual ligation of major blood or bile vessels. Recently, many instruments have been developed for "precoagulation" of liver parenchyma before sharp transection, but suffer from the possibility of injuring major blood and biliary vessels that are not well-visualized, along with high cost. In this article, we describe a "postcoagulation" technique combining clamp dissection and sealing of vessels under direct vision using a tissue-sealing device. STUDY DESIGN: Clinical evaluation of 400 patients from 2 centers subjected to liver resection using this technique. RESULTS: There were no cases complicated by hemorrhage. There was an incidence of 1.8% for bile leaks. This low incidence of biloma formation was seen even with the high incidence (49%) of abnormal parenchyma encountered in this cohort. CONCLUSIONS: Combining the clamp-crushing method with use of the LigaSure device (Valleylab) allows identification of intraparenchymal vessels followed by sealing. This method of parenchymal transaction optimizes ease of use with confidence in vessel ligation.

Use of helical CT is associated with an increased incidence of postoperative pulmonary emboli in cancer patients with no change in the number of fatal pulmonary emboli.

BACKGROUND: Multidetector computed tomography (MDCT) scanning technology has increased the ease with which pulmonary emboli (PE) are evaluated. Our aim was to determine whether the incidence and severity of postoperative PE have changed since adoption of multidetector computed tomography. STUDY DESIGN: A prospective postoperative morbidity and mortality database from a single institution was used to identify all cancer patients who experienced a PE within 30 days of thoracic, abdominal, or pelvic operations. The incidence, type (central, segmental, and subsegmental), and severity of PE were examined. RESULTS: A total of 295 PE were documented among 47,601 postoperative cancer patients. The incidence of PE increased yearly from 2.3 per 1,000 patients in 2000 to 9.3 per 1,000 patients in 2005 (p < 0.0001). This corresponded to an increasing number of CT scans of the chest performed (6.6 CT scans per 1,000 postoperative patients in 2000 versus 45 in 2005; p < 0.0001). The increased incidence was because of a 7.8% (CI, 4.0 to 11.7) and 5.4% (CI, 4.1 to 6.7) average annual increase in segmental and subsegmental PE, respectively. There was no change in the number of central (0.1%; CI, -1.0 to 1.12) PE. Overall incidence of fatal PE was 0.4 and did not change during the time period (p = 0.3). A central PE was more commonly associated with hypoxia, ICU admission, and 30-day mortality (33% versus 5% for peripheral; p = 0.02). CONCLUSIONS: Chest CT scans are being performed more frequently on postoperative cancer patients and have resulted in an increased diagnosis of peripheral PE. The clinical significance of, and optimal treatment for, diagnosed subsegmental PE are incompletely defined.

Combined portal vein embolization and neoadjuvant chemotherapy as a treatment strategy for resectable hepatic colorectal metastases.

OBJECTIVES: The objectives of this study are 1) to determine whether the future liver remnant will grow after portal vein embolization (PVE) in patients with colon cancer on concurrent chemotherapy and 2) to determine whether recovery after extended hepatectomy is improved after PVE. PURPOSE: Neoadjuvant chemotherapy followed by hepatic resection is an increasingly used therapeutic strategy for curative treatment for colorectal metastases. However, such chemotherapy may result in steatosis, liver damage, and compromised liver regeneration and recovery. This study aims to determine whether PVE can be used during neoadjuvant therapy to enhance growth of future residual liver and to improve postoperative recovery. METHODS: From September 1999 to September 2004, 100 patients with colorectal metastases to the liver were subjected to PVE as preparation for extended hepatic resection, 43 of whom were embolized during neoadjuvant chemotherapy. Liver growth was examined by computed tomography volumetric analysis. Clinical outcomes of the 71 patients subsequently resected were compared with 100 consecutive patients subjected to extended resection without PVE (controls). RESULTS: After a median wait of 30 +/- 2 days after PVE, patients on neoadjuvant chemotherapy experienced a median contralateral (nonembolized) liver growth of 22% +/- 3% compared with 26% +/- 3% for those without chemotherapy (P = NS). The number of patients with <5% growth was also similar: 4 of 43 versus 6 of 57 (P = NS). Comparison of patients resected after PVE to a simultaneous cohort of 100 consecutive patients subjected to extended resection without prior PVE demonstrated a lower fresh frozen plasma requirement (P = 0.01), a lower peak bilirubin (P = 0.002), and a shorter length of stay (P = 0.03). Mortality was similar (0% vs. 2%). CONCLUSIONS: Liver growth occurs after PVE even when cytotoxic chemotherapy is administered. No major complications occurred with PVE. Patients requiring major hepatic resection should be considered for PVE during neoadjuvant chemotherapy to improve subsequent recovery after resection.

18F-FDG PET scanning correlates with tissue markers of poor prognosis and predicts mortality for patients after liver resection for colorectal metastases.

UNLABELLED: (18)F-FDG PET has proven invaluable in the staging of patients with metastatic colorectal cancer. The aim of the current study was to determine whether this biologic scan would correlate with other cellular characteristics and the clinical behavior of tumors. METHODS: Ninety patients with resectable colorectal cancer metastatic to the liver underwent (18)F-FDG PET before hepatectomy. At surgery, tumors were harvested and prepared for assessment by histology and immunohistochemistry. Expression of Ki67 (a marker for cell proliferation), GLUT1 and GLUT3 (markers for glucose transportation), p53 and p27 (markers for cell cycle control), and BCL-2 (a marker for apoptosis) was assessed by a pathologist who was unaware of the PET results and the clinical outcome. Patients were followed to determine outcome. Survival analysis was performed comparing patient outcome in groups segregated according to standardized uptake values (SUVs) greater or less than 5, 7, or 10. RESULTS: Maximum SUV correlated with GLUT1 (P=0.03), Ki67 (P=0.026), and p53 (P=0.024) but did not correlate with p27, BCL-2, or GLUT3. Survival was significantly longer for patients with a low SUV than for patients with a high SUV, with P values of 0.014, 0.025, and 0.0095 for SUV cutoffs of 5, 7, and 10, respectively. CONCLUSION: (18)F-FDG PET is a biologic scan that predicts prognosis in patients with metastatic colorectal cancer. It is uncertain if this ability is due to cellular glucose metabolism or to a correlation with other cellular characteristics of aggressive tumors.

Safety and efficacy of preoperative portal vein embolization with polyvinyl alcohol in 58 patients with liver metastases.

OBJECTIVE: The objective of our study was to evaluate the safety and efficacy of transhepatic lobar portal vein embolization (PVE) using polyvinyl alcohol (PVA) particles to induce contralateral lobar hypertrophy in patients with liver-only metastases and normal underlying liver function. MATERIALS AND METHODS: Fifty-eight consecutive patients with small predicted future liver remnants (FLRs) underwent PVE with PVA particles to induce hypertrophy of the contralateral hemi-liver before surgical resection of liver metastases. Total liver, right hemi-liver, and left hemi-liver volumes were calculated before and after embolization using a 3D workstation. RESULTS: Eight patients underwent left PVE; 47, right PVE; and three, right and segment IV PVE. There were no major complications of the procedure. The mean increases in the ratio of the FLR to the total estimated liver volume after right, right and segment IV, and left PVE were 9%, 10%, and 3%, respectively; the corresponding mean hypertrophy ratios were 24.3%, 31.9%, and 1.5%, respectively. CONCLUSION: Right PVE using PVA particles alone as the embolic agent is safe and effective in achieving left hemi-liver hypertrophy. In contrast, left PVE did not induce significant right hemi-liver hypertrophy in this patient population.

Citation characteristics of basic science research publications in general surgical journals.

BACKGROUND: Basic science research (BSR) publications in general surgical (GS) journals are an important "translational bridge" for practicing surgeons and surgical trainees. The purpose of this study is to characterize the BSR publications in GS journals and to analyze their citation frequencies. METHODS: In 1996, all (224) BSR publications in the five highest rated U.S. GS journals (by impact factor) were reviewed, characterized, and their citation frequencies were compared to BSR publications in non-GS journals. RESULTS: On average, a BSR publication from these journals is cited 32 times (range 1-141, median 11). Half of the publications were cited more than 10 times in 6 years and 22% were cited twice, or more, within 1 year of publication. One in four publications were cited twice or more in journals with an impact factor greater than five. Citation frequencies of BSR publications in GS journals were related to the journal impact factor (P = 0.07), and to having a basic scientist (i.e., Ph.D.) as one of the authors (P < 0.01). Citation characteristics of BSR publications in GS journals were similar to those of BSR publications in non-GS journals with similar impact factors. CONCLUSIONS: We found that BSR publications in the U.S. GS journals studied had significant citation frequencies.

Left-handed surgeons: are they left out?

BACKGROUND: Left-handedness has been considered a simple inconvenience by some or something as convoluted as "the sinister," the Latin word for the left, by others. One in ten medical personnel is left-handed. The perceptions of left-handed surgeons regarding their laterality related inconveniences are unknown. OBJECTIVES: To determine the perceptions of left-handed surgeons and the way it has affected their surgical training and career. DESIGN AND SETTING: Web-based survey of left-handed surgeons. PARTICIPANTS: Left-handed surgeons in 2 boroughs of New York City, Manhattan and Brooklyn. METHODS: Distribution and completion of the survey. MAIN OUTCOME MEASURE: Career-oriented concerns of left-handed surgeons. RESULTS: Three percent of left-handed surgeons received laterality related mentoring during medical school. Ten percent of the programs mentored left-handed surgical residents, and 13% of the programs provided left-handed instruments during surgical residency. Laparoscopy and laparoscopic instruments did not eliminate the problems associated with instrument handling to left-handed surgeons. Ten percent of the left-handed surgeons expressed concerns when asked whether they would be comfortable being treated by another left-handed surgeon when they are the patients themselves. CONCLUSIONS: This study reveals the perceptions of left-handed surgeons in adapting to a right-handed world. Early laterality related mentoring in medical school and during surgical residency with provision of left-handed instruments might reduce the inconveniences of left-handed surgeons learning.