Subclassification of Microscopic Vascular Invasion in Hepatocellular Carcinoma.

OBJECTIVE: To investigate whether subclassification of microscopic vascular invasion (MiVI) affects the long-term outcome after curative surgical resection or liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA: The most important factor for TNM staging in HCC is MiVI, which includes all vascular invasions detected on microscopic examination. However, there is a broad spectrum of current definitions for MiVI. METHODS: In total, 412 consecutive patients with HCC who underwent curative surgical resection without any preoperative treatment or gross vascular invasion were histologically evaluated for MiVI. Patients with MiVI were subclassified into 2 groups: microvessel invasion (MI; n = 164) only and microscopic portal vein invasion (MPVI; n = 36). Clinicopathologic features were compared between 2 groups (MI vs MPVI), whereas disease-free survival (DFS) and overall survival (OS) after resection were analyzed among 3 groups (no vascular invasion [NVI] vs MI vs MPVI). These subclassifications were validated in a cohort of 197 patients with HCC who underwent LT. RESULTS: The MPVI group showed more aggressive tumor characteristics, such as higher tumor marker levels (alpha-fetoprotein, P = 0.006; protein induced by vitamin K absence-II, P = 0.001) and poorer differentiation (P = 0.011), than the MI group. In multivariate analysis, both MI and MPVI were independent prognostic factors for DFS (P = 0.001 and <0.001, respectively) and OS (P = 0.005 and <0.001, respectively). In the validation cohort, 5-year DFS was 89%, 67.9%, and 0% in the NVI, MI, and MPVI groups, respectively (P < 0.001), whereas 5-year OS was 79.1%, 55.0%, and 15.4%, respectively (P < 0.001). CONCLUSIONS: Based on subclassification of MiVI in HCC, MPVI was associated with more aggressive clinicopathologic characteristics and poorer survival than MI only. Therefore, the original MiVI classification should be divided into MI and MPVI.

Adjuvant chemotherapy improves overall survival in patients with localized upper tract urothelial carcinoma harboring pathologic vascular invasion: a propensity score-matched analysis of multi-institutional cohort.

OBJECTIVE: Whether adjuvant chemotherapy (AC) for patients with upper tract urothelial carcinoma (UTUC) offers survival benefit is still controversial. To explore the impact of AC on overall survival (OS) of cN0M0 UTUC patients, we conducted a propensity score-matched analysis using the regression model, including pathologic features such as lymphatic and vascular invasion. METHODS: A multi-institutional cohort of 413 UTUC patient record was used. Propensity score matching was performed to reduce bias by potential confounding factors for survival, including pathologic features from the specimen of radical nephroureterectomy (RNU), RESULTS: Ninety-eight patients were identified as pair-matched groups (49 patients in RNU and 49 patients in RNU + AC). Kaplan-Meier curves demonstrated that a 5-year OS rate of 72.7% for patients treated with RNU + AC was significantly higher than 51.6% for those treated with RNU (p = 0.0156). On multivariate analysis, pathologic vascular invasion (HR 3.41, 95% CI 1.24-10.66, p = 0.0166) and administration of AC (HR 0.45, 95% CI 0.19-0.98, p = 0.0438) still remained as the significant predictors for OS. In patients with pathologic vascular invasion (51 of 98 patients), a significantly longer OS in RNU + AC groups was observed (median OS of 30 and 70 months in RNU and RNU + AC groups, respectively: p = 0.0432), whereas there was no significant difference in the OS between RNU (median OS: not reached) and RNU + AC (median OS: not reached) groups in patients without the invasion (p = 0.4549). CONCLUSION: The result indicates a significant benefit for OS by the administration of AC, and pathologic vascular invasion in the specimen of RNU could help the patient selection to better predict the effect of AC.

Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion.

A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ©RSNA, 2020.

Surgical Tips for Inferior Vena Cava Thrombectomy.

PURPOSE OF REVIEW: The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy. RECENT FINDINGS: RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.

Ectopic hepatocellular carcinoma in the adrenal gland with inferior vena cava thrombosis and right atrial extension.

Intravascular tumor extension in the inferior vena cava (IVC) is known to occur with abdominal tumors, such as renal cell, hepatocellular, adrenal cell carcinoma, and Wilm's tumor. We encountered a 53-year-old male patient presenting with pulmonary embolism and a right atrial mass with imaging evidence of an adrenal tumor extending into the IVC, up to the right atrium. The patient underwent surgery for the resection of the tumor using cardiopulmonary bypass by a team of cardiothoracic surgeons and urologists. Histology identified the tumor as hepatocellular carcinoma, which developed as ectopic hepatic tissue in the right adrenal gland.

Laparoscopic conversion to open surgery in radical nephrectomy and tumor thrombectomy: causal analysis, clinical characteristics, and treatment strategies.

BACKGROUND: We aimed to explore the causal analysis, clinical characteristics and treatment strategies of laparoscopic conversion to open approach (LCTOA) in radical nephrectomy and tumor thrombectomy. METHODS: We included all patients with Mayo level I-III renal tumors with inferior vena cava (IVC) tumor thrombus who underwent laparoscopic radical nephrectomy and tumor thrombectomy as the first choice from May 2015 to July 2019. RESULTS: There were 70 cases of renal tumor with IVC tumor thrombus treated with a laparoscopic approach as the first choice; 31 Mayo level I, 30 Mayo level II, and 9 Mayo level III. A completely laparoscopic approach was performed in 51 cases (72.9%), and 19 cases (27.1%) underwent active or passive LCTOA. The LCTOA group had higher median preoperative serum creatinine (110.0 µmol/L vs 92.0 µmol/L; P = 0.026), longer postoperative hospital stay (9 days vs 7 days; P = 0.008), longer median operation time (374 min vs 311 min; P = 0.017), higher median intraoperative hemorrhage volume (1300 vs 600 ml; P = 0.020), and higher proportion of male patients (94.7% vs 66.7%; P = 0.016) vs the completely laparoscopic group, respectively. Although preoperative serum creatinine and gender were risk factors in the univariate analysis, multivariate analysis revealed no independent risk factors for LCTOA. We divided the reasons for LCTOA into active conversion and passive conversion; 4 (21.1%) cases underwent active conversion, and 15 (78.9%) underwent passive conversion. Most of the patients undergoing passive conversion had multiple concurrent risk factors, among which perirenal adhesion (30.9%), organ invasion (16.4%), and IVC adhesion (25.5%) were the most common. Fourteen (73.7%) cases underwent renal treatment, and 5 (26.3%) cases underwent tumor thrombus treatment. CONCLUSIONS: The LCTOA group had a higher median preoperative serum creatinine concentration, longer hospital stay, longer median operation time, and higher median intraoperative hemorrhage volume. However, none of the predictors in our study was an independent risk factor for LCTOA. Perirenal adhesion, organ invasion, and IVC adhesion were the most common causes of LCTOA. Considering the limitations of this study, studies with large sample sizes are required to validate our conclusions.

Successful emergency endovascular aortic repair for intratumoral hemorrhage in extensive retroperitoneal mass of testicular origin.

BACKGROUND: Metastatic germ cell cancer of the testis is characterized by favorable prognosis since effective treatment methods are available even in cases of extensive disease. Retroperitoneal masses frequently encroach major blood vessels requiring a vascular intervention usually performed in association with the post-chemotherapy retroperitoneal lymph node dissection (RPLND). Reported clinical case describes a successful pre-treatment endovascular surgery for abdominal aortic rupture allowing for full-dose systemic chemotherapy administration, and subsequent radical surgical intervention at primary tumor site as well as metastatic retroperitoneal lymph node dissection including the reconstruction of inferior caval vein. CASE PRESENTATION: Patient presented with left-sided testicular tumor and voluminous retroperitoneal mass with vascular involvement. Soon after the patient had been admitted for the first cycle of cisplatin-based chemotherapy, computed tomographic angiography (CTA) revealed a dorsal aortic wall rupture with active extravasation and irregular pseudoaneurysmatic dilatation of the aorta below the leak area. Retroperitoneal intratumoral hemorrhage associated with the bilateral iliac venous thrombosis required an endovascular repair procedure of infrarenal abdominal aorta. CONCLUSIONS: Following the successful endovascular aortic repair 3 cycles of BEP (bleomycin, etoposide, cisplatin) regimen were administered with subsequent delayed left radical orchiectomy and RPLND associated with vena cava inferior (VCI) resection. Reconstruction of VCI was originally not deemed necessary as collateral blood flow appeared sufficient, however, intraoperative complications resulted in the need for unilateral VCI reconstruction, using the interposed bypass between right common iliac vein and infrarenal segment of VCI. Histopathologic examination of the attained specimen detected no vital cancer structures. The patient remains disease-free 18 months after the RPLND.

[Resection of retroperitoneal leiomyosarcoma followed by replacement of cavarenal segment of inferior vena cava]. / Udalenie zabryushinnoi leiomiosarkomy s rezektsiei i protezirovaniem kavarenal'nogo segmenta nizhnei poloi veny Klinicheskoe nablyudenie.

The authors reported a rare clinical case of successful surgical treatment of young female with retroperitoneal leiomyosarcoma followed by lesion of the cavarenal segment of inferior vena cava, left renal vein. Clinical and morphological features of disease, postoperative outcomes and prognostic factors in patients with retroperitoneal leiomyosarcoma are discussed.

Safety, Diagnostic Accuracy, and Effects of Endoscopic Ultrasound Fine-Needle Aspiration on Detection of Extravascular Migratory Metastases.

BACKGROUND & AIMS: Tumor cells can migrate via diminutive perivascular cuffing to distant sites along blood vessels to form extravascular migratory metastases (EVMM). These metastases usually are identified during surgery or autopsies. We aimed to evaluate the feasibility and safety of endoscopic ultrasound fine-needle aspiration (EUS-FNA) of perivascular soft-tissue cuffs to detect EVMM. We compared findings from EUS with those from noninvasive cross-sectional imaging (reference standard) of patients who underwent EUS-FNA to assess suspected EVMM and studied the effects on pancreatic tumor staging and determination of resectability. METHODS: We performed a retrospective analysis of 253 patients (mean age, 62 ± 12 y) who underwent EUS-FNA of 267 vessels for evaluation of suspected EVMM, from April 2001 through May 2018. EUS findings were compared with those from computed tomography (CT) and magnetic resonance imaging (MRI) as the reference standard. Lesions were considered to be malignant based on cytology analysis of FNA samples, histology analyses of surgical or biopsy specimens, or vascular abnormalities detected by CT or MRI that clearly indicate EVMM. RESULTS: Thirty patients were found to have benign lesions. The remaining 223 patients who had malignancies (166 with pancreatic ductal adenocarcinomas [PDACs]), underwent further analyses. A median of 4 FNAs (range, 1-20 FNAs) were obtained from 4-mm perivascular soft-tissue cuffs (range, 2-20 mm). FNA and cytology analysis showed malignant cells in 163 vessels (69.4%) from 157 patients (70.4%). CT or MRI did not detect EVMM in 44 patients (28%) with malignancies, including 24 patients (24%) with newly diagnosed PDAC. Detection of EVMM by EUS-FNA resulted in upstaging of 15 patients and conversion of 14 patients with PDAC from resectable (based on CT or MRI) to unresectable. No adverse events were reported during a follow-up period of 3.9 months (range, 0-117 mo). CONCLUSIONS: EUS-FNA and cytologic analysis of perivascular soft-tissue cuffs can detect EVMM that were not found in 28% of patients by CT or MRI. Detection of EVMM affects tumor staging and determination of tumor resectability.

Hepatocellular carcinoma with inferior vena cava and right atrial tumor thrombus: A case report.

This is a case report of a 45-year-old patient admitted with the symptom of bilateral leg swelling. Ultrasonography revealed a hyperechoic mass in the right lobe of the liver, which invaded the right hepatic vein (RHV) and extended into the inferior vena cava (IVC) and right atrium (RA). Based on the high alpha-fetoprotein (AFP) level and the ultrasonography findings, the patient was diagnosed as having hepatocellular carcinoma (HCC) with a RHV, IVC, and RA tumor thrombus and secondary Budd-Chiari syndrome (BCS). HCC with a tumor thrombus extending into the IVC and RA has rarely been observed, and as a cause of secondary BCS, this type of HCC has been even more rarely reported.

Lymphovascular invasion as a poor prognostic indicator in thoracic esophageal carcinoma: a systematic review and meta-analysis.

The ability to further stratify patients with esophageal carcinoma (EC) in the same stage into high-risk patients by the presence of lymphovascular invasion (LVI) may permit refinement of multi-modality therapy. However, the role of LVI in the prognosis of EC is not definite. A meta-analysis was conducted to investigate the relationship between LVI and EC prognosis. We searched PubMed, Embase, Web of Science, and Cochrane Library databases for studies on the association between LVI and prognosis of EC. Only studies with patient survival data related to LVI were included. The effect size for this analysis was the hazard ratio (HR) with 95% confidence intervals (CI) for overall survival (OS) and recurrence-free survival (RFS). Thirty-five studies with 9876 patients were included according to the defined inclusion and exclusion criteria. LVI was a poor indicator for the OS (HR = 1.64, 95% CI: 1.44-1.87, P < 0.001) and RFS (HR = 1.79, 95% CI: 1.38-2.34, P < 0.001). However, the heterogeneity was medium in OS (I2 = 61.2%, P < 0.001) and extreme in RFS (I2 = 77.5%, P < 0.001). In subgroup analysis, heterogeneity was originated from the staining method and proportion of early disease (stage (I + II)). We concluded that LVI was a poor prognostic indicator in patients with EC, especially in those studies with the IHC staining method and a high proportion of early disease (stage (I + II)).

The value of combined vein resection in pancreaticoduodenectomy for pancreatic head carcinoma: a meta-analysis.

BACKGROUND: Although pancreaticoduodenectomy with vein resection (PDVR) is widely performed in selected patients with indications, its benefits remain controversial. In this meta-analysis, we evaluate the safety and efficacy of PDVR in comparison to standard pancreaticoduodenectomy (PD). METHODS: We searched PubMed, Embase, and Cochrane as well as the Chinese National Knowledge Infrastructure, Weipu, and Wanfang databases for studies that evaluate the value of PVDR. The data of the patients who underwent PD or PDVR were analyzed using Review Manager and STATA software. RESULTS: In comparison with the PD group, the PDVR group had a lower R0 resection rate and higher rates of complications such as biliary fistula, reoperation rate, delayed gastric emptying, cardiopulmonary abnormalities, hemorrhage, in-hospital mortality, 30-day mortality. The blood loss, duration of operation, total hospital stay is higher in PDVR group. CONCLUSIONS: Compared to standard PD, PDVR was associated with a greater risk of some specific complications and increase the mortality rate, total hospital stay time, combine with vein resection have a lower R0 resection rate. Therefore, combine with vascular resection for pancreatic cancer needs to be carefully selected by the surgeon.

Successful operative treatment of uterine leiomyoma with extensive intravenous extension to the IVC, right heart, and pulmonary arteries.

INTRODUCTION: Intravenous extension of benign uterine leiomyomata ('fibroids'), in the absence of discrete metastatic disease has rarely been reported. 'Fibroids' remain one of the most common premenopausal uterine pathologies. METHODS AND RESULTS: We report the diagnosis and multidisciplinary led operative management of a 52-year-old woman with a histologically benign, but biologically aggressive, uterine leiomyoma with intravenous extension to the inferior vena cava (IVC), right heart and pulmonary arteries. CONCLUSIONS: Total abdominal hysterectomy and bilateral salpingo-oophorectomy combined with exploration of the sub-hepatic IVC and heart under deep hypothermic circulatory arrest achieved its successful macroscopic clearance.

Chromosomal Aberrations Associated with Sequential Steps of the Metastatic Cascade in Colorectal Cancer Patients.

BACKGROUND: Genomic information can help to identify colorectal tumors with high and low metastatic potential, thereby improving prediction of benefit of local and/or systemic treatment. Here we investigated chromosomal aberrations in relation to the different stages of the metastatic cascade: dissemination of tumor cells into the mesenteric vein, metastatic outgrowth in the liver, intravasation of the peripheral blood circulation, and development of further distant metastasis. METHODS: Peripheral and mesenteric blood from colorectal cancer patients (n = 72) were investigated for circulating tumor cells, and DNA extracted from their primary tumors was subjected to array comparative genomic hybridization profiling. The results were validated with an independent set of primary colorectal tumors (n = 53) by quantitative reverse transcription PCR. RESULTS: Mesenteric intravasation and liver metastasis were correlated with losses of chromosomes 16p (72%), 16q (27%), and 19 (54%), gain along 1q31 (45%) and 20q (60%), tumor cell infiltration into the peripheral blood circulation, and further distant metastasis with gain of chromosome 8q (59%) and 12 (47%, P < 0.01). Chromosome 12 gain was associated with poor overall survival in the initial (2.8 vs >7 years) and validation cohort (3.3 vs >6 years). The prospective study presented here is a hypothesis-generating study and confirmation with larger cohorts is required. CONCLUSIONS: This is the first study that investigated colorectal cancer in its different stages of metastasis in correlation with copy number changes of the primary tumor. This information might be helpful to identify patients with limited metastatic spread who may profit from liver metastasis resection and may lead to the discovery of new therapeutic targets.Microarray data have been deposited in NCBI's Gene Expression Omnibus and are accessible through GEO Series accession number GSE82228.

Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: A Japanese nationwide survey.

Because of the rarity of hepatic vein tumor thrombus (HVTT) compared with portal vein tumor thrombus (PVTT) in patients with hepatocellular carcinoma, little is known about this disease entity. The aim of this study was to evaluate the prognosis of each treatment modality for HVTT through an analysis of data collected in a Japanese nationwide survey. We analyzed data for 1,021 Child-Pugh A hepatocellular carcinoma patients with HVTT without inferior vena cava invasion registered between 2000 and 2007. Of these patients, 540 who underwent liver resection (LR) and 481 who received other treatments were compared. Propensity scores were calculated, and we successfully matched 223 patients (49.0% of the LR group). The median survival time in the LR group was 2.89 years longer than that in the non-LR group (4.47 versus 1.58 years, P < 0.001) and 1.61 years longer than that in the non-LR group (3.42 versus 1.81 years, P = 0.023) in a propensity score-matched cohort. After curative resection, median survival times were similar between patients with HVTT in the peripheral hepatic vein and those with HVTT in the major hepatic vein (4.85 versus 4.67 years, P = 0.974). In the LR group, the postoperative 90-day mortality rate was 3.4% (16 patients). In patients without PVTT, the median survival time was significantly better than that in patients with PVTT (5.67 versus 1.88 years, P < 0.001). CONCLUSION: LR is associated with a good prognosis in hepatocellular carcinoma patients with HVTT, especially in patients without PVTT. (Hepatology 2017;66:510-517).

Session 2: Extramural vascular invasion and extranodal deposits: should they be treated the same?

Professor Nagtegaal has already highlighted that lymph nodes are probably not responsible for the development of liver metastases. If they are not, then is there another mechanism? Professor Haboubi addresses the question of extranodal deposits - their frequency and their importance in the development of metastatic disease. The experts review the evidence and discuss whether this information will alter treatment decisions and staging systems in the future.

Modified ante situm liver resection without use of cold perfusion nor veno-venous bypass for treatment of hepatic lesions infiltrating the hepatocaval confluence.

PURPOSE: Treatment of malignancies invading the hepatic veins/inferior vena cava is a surgical challenge. An ante situm technique allows luxation of the liver in front of the situs to perform tumor resection. Usually, cold perfusion and veno-venous bypass are applied. Our experience with modified ante situm resection relying only on total vascular occlusion is reported. METHODS: Retrospective analysis on an almost 15-year experience with ante situm resection without application of cold perfusion or veno-venous bypass RESULTS: The ante situm technique was applied on eight patients. Five individuals were treated due to intrahepatic cholangiocellular cancer and one case each for mixed cholangio-/hepatocellular carcinoma, colorectal liver metastasis, and pheochromocytoma. Trisectorectomy (n = 4), left hemihepatectomy, right hepatectomy, atypical resection, or mesohepatectomy (each n = 1) were performed, combined with dissection of suprahepatic/retrohepatic vena cava/hepatic veins. Venous reconstruction was achieved by reimplantation of hepatic veins with/without vascular replacement using allogeneic donor veins or PTFE grafts. Median total vascular occlusion of the liver was 23 min. Severe morbidity occurred in three patients (Dindo-Clavien > 3A). R0 status was achieved in six cases with a median overall survival of 33.5 months. CONCLUSIONS: Ante situm liver resection can be applied without cold perfusion nor veno-venous bypass with acceptable morbidity and mortality. However, this procedure remains challenging even for the experienced hepato-pancreato-biliary surgeon.

Evaluation of vascular invasion in patients with musculoskeletal tumors of lower extremities: use of time-resolved 3D MR angiography at 3-T.

Background Time-resolved angiography with stochastic trajectories (TWIST) sequence makes considerable progress in temporal and spatial resolution, which presents high potential in evaluation of vascular diseases. Purpose To assess magnetic resonance imaging (MRI) using TWIST MR angiography (MRA) sequence in the assessment of vascular invasion for bone and soft-tissue tumors in comparison to computed tomography angiography (CTA) as the reference standard. Material and Methods Thirty-three patients with lower extremity musculoskeletal tumors were imaged with conventional MR and TWIST MRA. CTA was performed 48 h later. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of the femoral artery were calculated. Vascular invasion as determined by MRA and CTA was separately analyzed. Vascular invasion by MRA and CTA were analyzed with kappa coefficients to determine agreement between the imaging methods. Results Seven cases of bone and 26 cases of soft tissue tumors were examined. SNR and CNR of the femoral artery were excellent for TWIST MRA (mean ± SD values of 317 ± 80 and 276 ± 76, respectively). Based on the TWIST sequence, the vessels were free of tumor in 16 cases. Vascular displacement was found in 11 cases and vascular stenosis in six cases. The MRA findings conflicted with CTA findings in only one case. The kappa value was 0.953 ( P < 0.01). In five cases, vascular malformations were found with TWIST MRA but not CTA. Conclusion TWIST MRA enables accurate delineation of anatomical structures and tumor arterial involvement, providing reliable preoperative imaging information with respect to lower extremity musculoskeletal tumors.

Remote malignant intravascular thrombi: EUS-guided FNA diagnosis and impact on cancer staging.

BACKGROUND AND AIMS: Malignant vascular invasion usually results from gross direct infiltration from a primary tumor and impacts cancer staging, prognosis, and therapy. However, patients may also develop a remote malignant thrombi (RMT), defined as a malignant intravascular thrombus located remote and noncontiguous to the primary tumor. Our aim was to compare EUS, CT, and magnetic resonance imaging (MRI) findings of RMT and to explore the potential impact on cancer staging. METHODS: Patients with RMT were identified from a prospectively maintained EUS database. Retrospective chart review was performed to obtain EUS, CT/MRI, clinical, and outcome data. RESULTS: A median of 3 FNAs (range, 1-8) was obtained from RMT in 17 patients (60 ± 14.1 years, 56% men) between April 2003 and August 2016, with the finding of malignant cytology in 12 patients (70.6%; 10 positive, 2 suspicious). CT/MRI detected the RMT in 5 patients (29.4%), 4 of whom had positive or suspicious EUS-FNA cytology. Among the 8 newly diagnosed pancreatic adenocarcinoma (PaC) patients, CT did not detect the RMT in 5 (63%), of whom 3 patients had positive or suspicious intravascular EUS-FNA cytology. For newly diagnosed PaC patients (n = 8), the EUS-FNA diagnosis of a biopsy specimen-proven RMT upstaged 3 patients (37.5%) and converted 2 patients (25%) from CT resectable to unresectable disease. No adverse events were reported. The mean follow-up was 18.9 ± 27.7 months. CONCLUSIONS: Our study demonstrates the ability and potential safety of intravascular FNA to detect radiographically occult RMT, which substantially impacts cancer staging and resectability.

Routinely reported 'equivocal' lymphovascular invasion in prostatectomy specimens is associated with adverse outcomes.

OBJECTIVE: To evaluate the significance of routinely reported 'equivocal' lymphovascular invasion (LVI) in prostatectomy specimens of patients with clinically localized prostate cancer. MATERIALS AND METHODS: Prospectively collected data from men who underwent prostatectomy for clinically localized prostate cancer were retrospectively reviewed. Rates of adverse pathological features and biochemical recurrence (BCR) were compared between tumours positive, negative or 'equivocal' for LVI. Multivariable Cox regression analysis was performed to identify independent predictors of BCR. RESULTS: Of 1 310 consecutive cases, LVI was present definitively in 82 (6.3%) and equivocally in 43 (3.3%) cases. Similar to definitive LVI, equivocal LVI was significantly associated with other adverse pathological features, including advanced stage, higher Gleason grade and positive surgical margins. BCR occurred more frequently in patients with tumours that were equivocal (61%) or positive for LVI (71%) than in patients with negative results (14.7%). In addition, patients with both definitive and equivocal LVI had a significantly shorter BCR-free survival time compared with those with negative LVI. Multivariable Cox regression analysis indicated that the presence of either definitive or equivocal LVI were independent predictors of disease recurrence (hazard ratio [HR] 3.32, 95% confidence interval [CI] 2.3-4.8; P <0.001 vs HR 1.66, 95% CI 1.05-2.65; P = 0.032, respectively). CONCLUSION: In this single-institution study, equivocal LVI had a similar association with adverse pathological features and rate of BCR to that of definitive LVI. If our observations are validated in an independent cohort, consideration should be given to the inclusion of equivocal LVI as part of routine pathological reporting.