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Bile duct carcinomas have a different prognosis and genetic profile depending on their location; intrahepatic/extrahepatic or at the level of the gallbladder. Although in recent years there have been important advances in first-line therapy, second-line therapy in cholangiocarcinoma does not currently have a standard. Therefore at this level, there is an acute need for personalized treatment. The present article is a narrative review that aims to list the newest targeted therapeutic options for this type of cancer, based on identified genetic alterations. The literature selected for analysis includes phase 2 or 3 studies with targeted therapy in this disease and original articles no older than three years that describe the prevalence of the most common gene alterations in this type of cancer. PubMed/Medline, Scopus, and Clarivate-Web of Science databases were searched and keywords such as "cholangiocarcinoma," "biliary cancer," "targeted therapy," "gene amplifications," and "mutations" were used. This narrative review was designed taking into account the SANRA (Scale for the Assessment of Narrative Review Articles) criteria. The conclusions lead to the fact that next-generation sequencing testing is of particular usefulness in cholangiocarcinoma. Bile duct cancers are rich in targetable genetic alterations, and their treatment is in constant change, although much of the current data comes from phase II studies. There is a great need for the current options to be analyzed in phase III studies. Hence, the need of the oncological community to stay informed about targeted treatment options for cholangiocarcinoma is supported by the present article.
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This technical report explores the efficacy and methodology of laparoscopic surgery for treating abdominal echinococcosis, a parasitic infection caused by Echinococcus granulosus. We highlight the zoonotic nature of the disease, which predominantly affects the liver and occasionally other organs, noting the challenge of its asymptomatic progression that complicates timely diagnosis and intervention. We detail our surgical technique using a standard laparoscopy kit to address abdominal hydatid cysts, emphasizing the critical importance of preventing cyst rupture and spillage to avoid recurrence and anaphylactic shock. We discuss considerations for opting for laparoscopy over open surgery, such as reduced postoperative morbidity, faster patient recovery, and lower costs, while also acknowledging limitations like restricted instrument movement and the absence of haptic feedback. We advocate hypertonic saline as the preferred scolicidal agent and strategies to minimize spillage and manage the residual cavity. In conclusion, we assert that laparoscopy offers a viable and effective treatment option for abdominal echinococcosis, emphasizing that optimizing outcomes for this benign condition hinges on careful patient selection and a conservative surgical approach.
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Hydatid cysts are caused by accidental egg ingestion of the Echinococcus granulosus parasite. A 24-year-old female was admitted to our hospital for chronic left lumbar pain. Computed tomography (CT) and abdominal ultrasonography identified an 8/12 cm retroperitoneal cyst. The CT results coupled with enzyme-linked immunosorbent assay tests (positive IgG for Echinococcus granulosus) confirmed that the tumor was a hydatid cyst. Treatment consisted of preoperative chemotherapy with albendazole, intraoperative parasite inactivation, laparoscopic partial cystectomy, and drainage. The drain was removed after three days. Chemotherapy was maintained for two years after surgery. No relapse was observed at the six-month reevaluation. In this article, the diagnostic and therapeutic options and resources are discussed and compared with the published literature.
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Hepatic portal venous gas (HPVG) is an infrequent and life-threatening condition with high morbidity and mortality rates, which consists of the presence of gas in the portal vein and its branches. Improvements in imaging technologies have led to the diagnosis of HPVG in less severe circumstances, which, in turn, has only determined a small amelioration of the prognosis. We present a rare case of HPVG subsequent to paralytic ileus in a patient who attained long-term survival after the surgical treatment was performed. HPVG is considered to be associated with sepsis, parietal/mucosal damage, inflammation of the intraperitoneal organs, and meteorism, which may be found in a variety of pathologies. The severity of this pathology depends on the pre-existing conditions of the patients but also on how quickly a treatment plan is established and applied. As a correct and timely diagnosis is crucial for the increase of the survival rate in HPVG, greater attention shall be paid to the clinical manifestations and the differential diagnosis.
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The primary treatment of breast cancer in sentinel-positive ganglia includes axillary lymphatic nodal dissection. The LAD (lymphatic axillary dissection) has decreased in overall numbers but due to the increasing incidence of breast cancer, it is practised on a daily basis, even though there is a myriad of complications such as numbness of the upper limb and chest wall, movement restriction of the upper limb, and chronic pain which appear due to trauma to the nerves which pass through the axilla. However, the utility in the overall survival or DFS (disease-free survival) of the patient is unquestionable. In our study, through the dissection of cadavers, we exposed the vital structures and the anatomical relations of this region. We aimed to offer a map or technique for the surgeon to follow to decrease the overall morbidity of this procedure.
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Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.
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BACKGROUND: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. METHODS: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. RESULTS: Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. CONCLUSIONS: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.
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Esophageal stenoses of childhood have a broad spectrum of underlying causes. Their treatment is usually minimally invasive by endoscopic means, but sometimes surgery is necessary in refractory cases. Techniques employed in the surgical treatment of esophageal strictures include resection of the stenotic esophageal segment or esophageal substitution procedures. Esophageal anastomosis has always been a challenge in pediatric surgery. Anastomosis complications are linked to anatomical, biological and technical aspects. Mechanical tension between esophageal ends is an important cause of complications including anastomotic leaks or dehiscence. Eleven cases of esophageal stenoses, surgically treated in the Pediatric Surgery Department of Emergency Clinical Hospital for Children 'Marie S. Curie' by a single team in 5 years, were included in the present study. The results showed that, the main causes of esophageal stenosis were represented by corrosive esophageal injury in five cases, complications of esophageal atresia repair in three cases, congenital esophageal stenosis in two cases and chemotherapy-induced esophageal necrosis in acute lymphoblastic leukemia treatment in one case. The authors also designed and presented a device facilitating esophageal anastomosis under tension. Its principle involved temporary absorption of tension at secure points of the two esophageal pouches and reallocating it in equal amounts following anastomosis while decreasing any stretch-related tissue trauma. In conclusion, this auxiliary tool is beneficial for esophageal anastomosis; however, the standard steps of the esophageal anastomosis procedure should still be considered when necessary.
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Background and objective Myxomas are the most common cardiac tumors. This study aimed to analyze the possible risk factors associated with late mortality in this group of patients and assess long-term survival. Methods A retrospective study was conducted among patients who underwent myxomas resection between January 2008 and July 2019 in our service. The patients' preoperative, intraoperative, and postoperative data were analyzed. Multivariate logistic regression was performed to identify predictors of mortality at five years. The Kaplan-Meier curve and Cox proportion-adjusted survival curves were used to assess mortality at five and 10 years. Results A total of 108 patients with cardiac myxomas were identified. All cardiac tumors resected were confirmed as myxomas on histopathological examination. Ninety-six patients presented with left-side myxomas (94 left-atria and two left-ventricle) and 12 with right-side myxomas (11 right-atria, one right-ventricle); 78 of the tumors were capsulated, and 30 were sessile-papillary. The mean dimensions were 37 ±6.1 mm on the left side and 41 ±6.7 mm on the right side. Surgical excision was successful in all cases, with 25% requiring interatrial septum patch repair. Recurrence occurred in 2.77% of the patients. Multivariate logistic regression showed chronic kidney disease (CKD) (OR: 7.96, 95% CI: 1.469-43.125, p=0,016) to be an independent predictor for five-year mortality. The mean follow-up period was 7.13 ±2.965 years, and the Kaplan-Meier curve cumulative proportion survival of patients at five years and 10 years were 100% and 88.8%, respectively. There was no statistically significant difference in late-term survival between patients with and without CKD in the Cox proportion-adjusted survival curve (p=0.275). Conclusions Patients with myxomas have a good long-term prognosis following surgical resection. The multivariate logistic regression showed CKD to be an independent predictor of five-year mortality.
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Next-generation sequencing (NGS) is a fast and relatively inexpensive method to sequence a large number of genes with crucial importance in cancer medicine. Nowadays, NGS is frequently used in diagnostic and therapeutic decisions in oncology; however, recently, it was demonstrated that only a few cancer sites actually benefit from this assessment. Moreover, the association of a mutant gene with a targeted drug is not always as predicted during in-vitro trials and is often not associated with tumor response. To predict the efficacy of such an association several classification systems have been developed. The present review aims to analyze the most important tumor agnostic treatment trials and assess how they shape selecting cancer patients for NGS. Moreover, it aims to determine how mutation-drug associations can be classified by their targetability and level of evidence of efficacy in non-small-cell lung cancer.
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BACKGROUND/AIM: Currently, the impact of diabetes mellitus (DM) on rectal cancer patients is complex and just partly elucidated. The purpose of this study was to investigate the impact of diabetes mellitus on rectal cancer patients focusing on tumor differentiation grade, neoadjuvant chemoradiotherapy (NACRT) response, disease-free (DFS) and overall (OS) survival. PATIENTS AND METHODS: Our study's population consisted of a group of 53 patients diagnosed with locally advanced rectal cancer, who underwent NACRT, followed by radical oncological surgery. This patient population was further divided into two groups according to diabetes presence. RESULTS: Downstaging rates, local control, DFS, and OS were lower in the DM subgroup compared to the non-DM locally advanced rectal cancer patients. CONCLUSION: The presence of DM at the time of diagnosis of locally advanced rectal cancer patients may be a negative predictive factor for response to neoadjuvant therapy, distant metastases, and local recurrences rates.
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Diabetes Mellitus , Neoplasias Retais , Quimiorradioterapia , Diabetes Mellitus/epidemiologia , Intervalo Livre de Doença , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia/epidemiologia , Estadiamento de Neoplasias , Prognóstico , Neoplasias Retais/diagnóstico , Neoplasias Retais/epidemiologia , Neoplasias Retais/terapia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Viral hepatitis C represents a significant liver pathology worldwide, with a detrimental impact on national health systems. The present study aimed to correlate the levels of serum α-fetoprotein (AFP) with prognostic tools such as Fibroscan®, the presence of mixed cryoglobulinemia, and various demographic and standard biochemical markers, in patients with chronic hepatitis C, unrelated to hepatocellular carcinoma (HCC). A clinical study was designed considering three study groups: Hepatitis C virus (HCV) group including 35 patients with chronic hepatitis C and detectible viral load; sustained viral response (SVR) group including 20 HCV patients without detectable virus load 12 weeks after therapy cessation; a control group represented by 37 healthy volunteers. It was observed that serum AFP was moderately increased in the HCV and SVR groups and was positively correlated with aspartate transaminase (AST), alkaline phosphatase (AP), and γ-glutamyl transferase (GGT). The incidence of mixed cryoglobulinemia was increased in the HCV group, and the degree of fibrosis assessed by Fibroscan® was increased in both the HCV and SVR groups. In conclusion, the data revealed that a moderate increase in AFP levels could be present in patients with HCV even in the absence of HCC, unrelated to viral load or therapy response and that there was a linear positive correlation between serum levels of AFP and the degree of hepatic cytolysis and cholestasis. Additionally, mixed cryoglobulinemia was present in HCV patients with patent viral load, decreasing in those with SVR after therapy cessation unrelated to any renal impairment, while the degree of fibrosis was increased in HCV-infected patients, with no reversibility 12 weeks after successful therapy.
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Despite the development of imagistic methods, the differential diagnosis of a right atrial mass may be difficult to be established, the most common pathologies which should be taken in consideration being represented by thrombus, tumors, prominent crista terminalis, or vegetation of infectious endocarditis. In this study, we present the case of a 63-year-old man with chronic kidney disease, in hemodialysis (HD) with a silicone central venous catheter (CVC) with the incidental transthoracic echocardiography (transthoracic echocardiogram, TTE) finding of a tumoral mass of 35x26 mm in the right atrium (RA), not related with the catheter, which was diagnosed as right atrial myxoma and underwent surgical excision. After reviewing the histopathology probe, the diagnosis of right atrial thrombus was confirmed. In conclusion, differentiating intracardiac right atrial masses (RAMs) could may prove challenging. In our patient, clinical presentation and the preoperative investigations could not differentiate the right atrial thrombus from a myxoma, and only the postoperative histopathology diagnosis was able to guide correct diagnosis.
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Thyroid cancer accounts for 1% of all malignancies, and is becoming increasingly common worldwide. The literature reports a prevalence of ~50% of thyroid nodules detected during autopsies in subjects with unknown thyroid pathology. An extended retrospective study of 526 autopsy cases was performed to identify the prevalence of thyroid carcinoma, among various types of thyroid nodules identified incidentally. Tissue samples were taken from thyroid nodules, for investigation of the presence of thyroid carcinoma, along with their macroscopic and microscopic features by means of histopathology and immunohistochemistry (IHC) methods. Histopathological diagnosis of malignancy was found in 51 cases of analyzed thyroid samples. Systematic detailed studies demonstrated that a thyroid gland, apparently normal on macroscopic examination, may be the site of pathological manifestations, sometimes presenting carcinomatous findings. Among thyroid carcinomas, the highest frequency was that of papillary microcarcinomas, which have a long evolution, and are incidentally detected during autopsies. Papillary microcarcinoma is an extremely common incidental finding and the vast majority of these tumors pursue a benign course. Furthermore, it is therefore necessary to create national screening programs for the early detection of thyroid carcinoma.
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Background: Breast cancer represents the most common type of neoplasm in women around the world. Breast reconstruction following mastectomy has become a demanding procedure in the treatment of patients suffering from breast cancer. Their major role is to improve the quality of life of women, leading to better aesthetic outcomes. Based on each type of reconstruction, the complications following surgery and the duration of hospital stay, the financial implications slightly vary. Methods: Our study included 168 female patients who underwent immediate or delayed breast reconstruction after mastectomy. We assessed the clinical management of each of these cases and we evaluated the average final cost of the treatment after the reconstruction, focusing on the reconstructive method used, the complications that occurred and the number of days of hospitalization. Results: The total cost of care in breast reconstruction surgery depends on the type of reconstructive procedure used, which consequently affects the duration of hospitalization of the patients. The expenses also depend on the materials that are used: the type of implant/expander or the use of ADM. Costs were higher in patients who underwent breast reconstruction using a latissimus dorsi flap associated with an implant, in comparison to reconstruction using a free flap. Conclusions: Breast reconstruction represents a crucial process in the management of women who underwent mastectomies following cancer and presumes variable financial resources, depending on the chosen reconstructive method.
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Neoplasias da Mama , Mamoplastia , Neoplasias da Mama/cirurgia , Feminino , Humanos , Mastectomia , Qualidade de Vida , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Independent Cushing's adrenocorticotropic hormone (ACTH) syndrome can have several causes, including adrenal carcinoma or simple adrenal hyperplasia. Although the distinction between malignant and benign can be effectively made through imaging investigations, in the situation where there are bilateral formations, their hormonal activity is impossible to appreciate via non-invasive techniques. The present study includes the presentation of a clinical case on the basis of which a literature review was made. The clinical case pertains to a 32-year-old patient with ACTH-independent Cushing's syndrome and bilateral adrenal tumor formations leading to the utility of adrenal venous sampling to avoid bilateral adrenalectomy. A literature review was subsequently conducted focusing on articles pertaining to the PICO criteria in order to describe: The diagnosis of adrenal tumor masses, the decision on the type of surgery and most importantly, the impact of adrenal venous sampling in avoiding surgical resection. These interventions severely limit the patients' quality of life.
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Anastomotic leaks (ALs) remain the most severe complication in digestive surgery, as well as the most consumptive in terms of human and financial resources. There is an abundance of international research which has focused on identifying and correcting risk factors, and on individualized surgical management as well. The most frequent risk factors are male sex, obesity, diabetes, advanced malignant disease, ASA score, perioperative blood loss or perioperative transfusion, long operation time, emergency operation and altered nutritional status. The aim of the present study was to measure the preoperative serum calcium level and to find a possible correlation between calcium levels and the risk of AL occurrence. A retrospective analysis of medical records for 122 patients who underwent surgical gut resection with anastomosis for different pathologies was carried out. Preoperative serum calcium level and the occurrence of AL was noted. The results revealed that the average value of total blood calcium was 8.78 mg/dl, without a significant difference in sex groups. Hypocalcemia was identified in 44 patients (36.1%). AL was identified in 8 patients (6.6%), with a statistically insignificant difference between male and female patients. The average value of blood calcium in the AL patient group was 8.07 mg/dl, while in patients without AL the average value was 8.83 mg/dl. Hypocalcemia, defined as a serum calcium level below 8.5 mg/dl, was observed in 7 of the 8 patients presenting with AL (87.5%) and 37 patients who did not present with AL (32.5%), a significant difference with which to consider and include hypocalcemia in the group of risk factors for AL (P=0.001). In conclusion, preoperative low serum calcium level can represent a risk factor for AL in digestive surgery.
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Obesity is a worldwide pandemic health issue. Obesity is associated with the pathogenesis of type 2 diabetes, hypertension, dyslipidemia, cardiovascular diseases, cancer, and kidney diseases. This systemic disease can affect the kidneys by two mechanisms: Indirectly through diabetes mellitus (DM) and hypertension and directly through adipokines secreted by adipose tissue. Obesity is a risk factor for chronic kidney disease (CKD), which is associated with an increased risk of morbidity and mortality among the adult population. Increased visceral adipose tissue leads to renal glomerular hyperfiltration and hyperperfusion, which may lead to glomerular hypertrophy, proteinuria, and CKD development. Adipokines are hormones produced by fat tissue. They are involved in energy homeostasis, sugar and fat metabolism, reproduction, immunity, and thermogenesis control. Hormones and cytokines secreted by adipose tissue contribute to the development and progression of CKD. Decreased serum or urinary adiponectin levels are specific in diabetic and non-diabetic CKD patients, while leptin presents increased levels, and both are associated with the development of glomerulopathy. Excessive adipose tissue is associated with inflammation, oxidative stress (OS), insulin resistance and activation of the renin angiotensin-aldosterone system (RAAS). Therefore, adipose tissue dysfunction plays an important role in the development of CKD.
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Renal cell carcinoma (RCC) accounts for over 90% of all renal malignancies, and mainly affects the male population. Obesity and smoking are involved in the pathogenesis of several systemic cancers including RCC. The phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signalling pathway regulates cell growth, differentiation, migration, survival, angiogenesis, and metabolism. Growth factors, hormones, cytokine and many extracellular cues activate PI3K/AKT/mTOR. Dysregulation of this molecular pathway is frequently reported in human cancers including RCC and is associated with aggressive development and poor survival rate. mTOR is the master regulator of cell metabolism and growth, and is activated in many pathological processes such as tumour formation, insulin resistance and angiogenesis. mTOR inhibitors are used at present as drug therapy for RCC to inhibit cell proliferation, growth, survival, and the cell cycle. Temsirolimus and everolimus are two mTOR inhibitors that are currently used for the treatment of RCC. Drugs targeting the PI3K/AKT/mTOR signalling pathway may be one of the best therapeutic options for RCC.
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Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.