RESUMEN
AIM: To determine whether, in a highly selected patient population, medical treatment combined with surgical resection of liver metastases from breast cancer is associated with improved survival compared with medical treatment alone. PATIENTS AND METHODS: Between 1988 and 2007, 100 liver resections for metastatic breast cancer were performed at Institut Curie, 51 of which met the criteria for inclusion in this case-control study. With the exception of bone metastases, patients with other distant metastasis sites were excluded. Surgery was only performed in patients with stable disease or disease responding to medical treatment evaluated by imaging evaluation. Surgical cases were individually matched with 51 patients receiving medical treatment only. All patients had 4 or fewer resectable liver metastases. The study group was matched with the control group for age, year of breast cancer diagnosis, time to metastasis, TNM stage, hormone receptor status and breast cancer tumour pathology. RESULTS: Univariate analysis confirmed a survival advantage for patients lacking bone metastases and axillary lymphadenopathy at the time of breast cancer diagnosis and for surgically treated patients. Multivariate analysis indicated that surgery and the absence of bone metastases were associated with a better prognosis. A multivariate Cox model adapted for paired data showed a RR = 3.04 (CI: 1.87-4.92) (p < 0.0001) in favour of surgical treatment. CONCLUSION: Surgical resection of liver metastases from primary breast cancer appears to provide a survival benefit for highly selected patients.
Asunto(s)
Neoplasias Óseas/secundario , Neoplasias de la Mama/patología , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Adulto , Anciano , Neoplasias de la Mama/tratamiento farmacológico , Neoplasias de la Mama/cirugía , Estudios de Casos y Controles , Femenino , Humanos , Estimación de Kaplan-Meier , Neoplasias Hepáticas/tratamiento farmacológico , Metástasis Linfática , Persona de Mediana Edad , Modelos de Riesgos ProporcionalesRESUMEN
The majority of patients who develop liver metastases in metastatic colorectal cancer (mCRC) has often unresectable disease. Several new methods of nonsurgical ablation have been tested with variable success. Helical tomotherapy (HT), such as intensity-modulated radiation therapy (IMRT) or stereotactic body radiotherapy therapy, is a recent radiation therapy technique which can provide simultaneous and precise targeting of multiple lesions, while sparing normal tissues. We retrospectively assess the feasibility and the tolerance of IMRT with capecitabine followed by hepatic surgery in mCRC patients. This original observation suggests that HT could be safely integrated in the multidisciplinary management of patients with metastatic colorectal cancer as an alternative to surgery or other local ablation therapies.
Asunto(s)
Carcinoma/terapia , Neoplasias Colorrectales/terapia , Neoplasias Hepáticas/terapia , Radioterapia de Intensidad Modulada/métodos , Antineoplásicos/administración & dosificación , Capecitabina , Carcinoma/secundario , Neoplasias Colorrectales/patología , Desoxicitidina/administración & dosificación , Desoxicitidina/análogos & derivados , Femenino , Fluorouracilo/administración & dosificación , Fluorouracilo/análogos & derivados , Hepatectomía , Humanos , Neoplasias Hepáticas/secundario , Persona de Mediana Edad , Recurrencia Local de Neoplasia/terapiaRESUMEN
Targeted therapy has become an indispensable tool in the management of metastatic colorectal cancer (mCRC). The combination of monoclonal antibodies with conventional polychemotherapy has proven its efficacy as the median overall survival now exceeds 24 months: these novel molecules act by targeting circulating vascular endothelial growth factor (VEGF) and the receptor of epidermal growth factor (EGFR). At the present time, no factor has been identified to predict the efficacy of bevacizumab, an inhibitor of circulating VEGF. On the other hand, mutation of the KRAS oncogen has been proven to be a factor of non-response, or even of deleterious response to the use of EGFR, therefore limiting its use to patients whose tumors bear the wild type KRAS oncogen. Treatment toxicity for these molecules is moderate, specific, and is not cumulative with chemotherapy-related toxicity. On the other hand, combined targeted therapy (association of several targeted therapy drugs) has not been shown to be of any benefit. Other biotherapies continue to be developed, but there is not yet a consensus of how to best target the tumor nor which anti-tumoral molecules to use in the treatment of mCRC.
Asunto(s)
Neoplasias Colorrectales/tratamiento farmacológico , Neoplasias Colorrectales/patología , Terapia Molecular Dirigida , Inhibidores de la Angiogénesis/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Anticuerpos Monoclonales Humanizados , Antineoplásicos/uso terapéutico , Bevacizumab , Cetuximab , Quimioterapia Combinada , Receptores ErbB/antagonistas & inhibidores , Humanos , Metástasis de la Neoplasia , Panitumumab , Factor A de Crecimiento Endotelial Vascular/antagonistas & inhibidoresRESUMEN
Vascular injury due to penetrating abdominal trauma is a major challenge for trauma teams. Arterial and venous injuries occur with equal frequency. Treatment depends on the hemodynamic status of the patient: under stable conditions, angiography can be envisioned, whereas instability is an indication for immediate surgery; damage control is the most frequent procedure. As persisting on complete surgical exploration may lead to fatal outcome, the surgeon must be prepared to perform perihepatic or pelvic packing and employ endovascular techniques as appropriate. However, the surgeon has to be prepared to deal with uncontrolled hemorrhage, and explore all central retroperitoneal hematomas, retroperitoneal hematoma located in the flanks except when stable in the hemodynamically unstable patient, and those in the pelvis only if the patient is stable. Since it is more critical to control hemorrhage than to avoid end-organ ischemia, vascular ligation is more commonly used than other techniques. However, survival is very low in these severely wounded patients.
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Abdomen/irrigación sanguínea , Abdomen/cirugía , Traumatismos Abdominales/cirugía , Heridas Penetrantes/cirugía , Traumatismos Abdominales/diagnóstico , Diagnóstico por Imagen , Hematócrito , Hematoma/etiología , Hematoma/cirugía , Hemoglobinas/análisis , Hemoperitoneo/etiología , Hemoperitoneo/cirugía , Hemorragia/etiología , Hemorragia/cirugía , Técnicas Hemostáticas , Humanos , Laparotomía , Complicaciones Posoperatorias , Segunda Cirugía , Toracotomía , Traumatología , Procedimientos Quirúrgicos Vasculares , Heridas Penetrantes/diagnósticoAsunto(s)
Adenoma de Células Hepáticas/patología , Carcinoma Hepatocelular/patología , Transformación Celular Neoplásica/patología , Neoplasias Hepáticas/patología , Neoplasias Primarias Múltiples/patología , Dolor Abdominal/etiología , Adenoma de Células Hepáticas/complicaciones , Adenoma de Células Hepáticas/cirugía , Adulto , Carcinoma Hepatocelular/complicaciones , Carcinoma Hepatocelular/cirugía , Colecistectomía , Hepatectomía/métodos , Humanos , Neoplasias Hepáticas/complicaciones , Neoplasias Hepáticas/cirugía , Masculino , Neoplasias Primarias Múltiples/complicaciones , Neoplasias Primarias Múltiples/cirugía , Resultado del Tratamiento , Pérdida de PesoRESUMEN
We report a case of a gaseous gangrene of the thigh, six months after setting a polypropylene monofilament suburethral sling on transobturator position. This rare complication has severely engaged the vital prognosis of a 39-years-old woman, operate for stress urinary incontinence. According to the available data, we discuss the predictive factors of such complications.
Asunto(s)
Gangrena Gaseosa/etiología , Infecciones Relacionadas con Prótesis/etiología , Cabestrillo Suburetral/efectos adversos , Muslo , Incontinencia Urinaria de Esfuerzo/cirugía , Adulto , Femenino , HumanosRESUMEN
OBJECTIVE: To evaluate postoperative and mid-term results of carotid surgery (CS) with somatosensory evoked potentials (SEP) monitoring. METHODS: Between 1998 and 2006, 141 CS in 124 patients were performed under general anesthesia. Selective shunting was based on SEP abnormality. Shunting criteria were: reduction up to 50% of the amplitude or latency increasing up to 10%. Early results and follow-up data are analyzed retrospectively. RESULTS: Shunting rate was 6%, 3 strokes (two transient strokes) occurred and one patient died of perioperative myocardial ischemia. The cumulative stroke and death rate at 30 days was 1.4%. CONCLUSIONS: Intra-operative SEP monitoring with selective shunting may be safely performed in carotid surgery.
Asunto(s)
Enfermedades de las Arterias Carótidas/cirugía , Potenciales Evocados Somatosensoriales , Monitoreo Intraoperatorio , Derivación Arteriovenosa Quirúrgica , HumanosRESUMEN
In France, the total hospital stay after colorectal resection by laparoscopy or laparotomy varies between 10 and 20 days. For several years, the concept of fast track rehabilitation in colonic surgery has been developed. In addition to a specific surgical and anaesthetic management, this concept relies on postoperative measures, particularly an early food intake and ambulation, which allow a spectacular reduction of the hospital stay to only 2 days. Two remarks temper initial optimism: all patients do not wish a short hospital stay and the wards do not always have the available resources necessary to set up this concept.
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Colectomía/rehabilitación , Cuidados Posoperatorios/métodos , Analgesia/métodos , Analgesia Epidural/métodos , Periodo de Recuperación de la Anestesia , Anestesiología/métodos , Colectomía/métodos , Ingestión de Alimentos , Francia , Motilidad Gastrointestinal , Humanos , Ileus/prevención & control , Laparoscopía , Laparotomía/rehabilitación , Tiempo de Internación , Náusea/etiología , Náusea/prevención & control , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Aceptación de la Atención de Salud , Alta del Paciente , Complicaciones Posoperatorias/prevención & control , Factores de Tiempo , CaminataRESUMEN
OBJECTIVE: Mesenteric panniculitis is a rare disorder characterized by nonspecific inflammation and/or necrosis and/or fibrosis in the adipose tissue of the bowel mesentery. Its signification, primary or associated with other diseases, is a subject of controversy. METHODS: A descriptive and retrospective study of patients with an abdominal CT examination showing features of mesenteric panniculitis and for whom biopsy with immunohistochemical examination was obtained in all cases. RESULTS: Seven patients were enrolled (4 men and 3 women) with a median age of 62,1 years. None of the patients without an identified etiology had a history of abdominal surgery. An associated disease was identified in 4 cases: breast cancer (1), non-Hodgkin's lymphoma based on peripheric lymph nodes biopsy (2) and cryoglobulinemic vascularitis based on renal biopsy (1). In the 3 remaining cases, isolated mesenteric panniculitis was the only abnormality despite thorough imaging and pathologic investigations. CONCLUSION: Except an obvious malignancy context or a history of abdominal surgery, a pathologic examination of the mesenteric panniculitis lesions is necessary, especially to eliminate another mesenteric disorder. Mesenteric panniculitis is often associated with lymphoma.
Asunto(s)
Paniculitis Peritoneal/etiología , Adulto , Anciano , Biopsia , Neoplasias de la Mama/complicaciones , Crioglobulinemia/complicaciones , Femenino , Humanos , Inmunohistoquímica , Lipodistrofia/complicaciones , Linfoma no Hodgkin/complicaciones , Masculino , Persona de Mediana Edad , Paniculitis Peritoneal/patología , Estudios Retrospectivos , Vasculitis/complicacionesRESUMEN
Non-functional paraganglioma have not clinical or biological characteristics, so that the diagnostic is most of the time delayed and made on the occasion of advanced abdominal tumor or symptomatic metastasis management. Hereditary forms, notably those with SDHB mutation, seem to have a poor prognosis. On the other hand, and on the oposite to sporadic forms, they are the only ones to benefit from genetic testing which make possible, if positive, an earlier diagnostic, before apparition of symptoms, recurrence or metastasis. We report a case of non-functional malignant hereditary paraganglioma diagnosed belatedly and we will consider management problems raised by non-functional forms.
Asunto(s)
Neoplasias Abdominales/genética , Paraganglioma/genética , Adulto , Secuencia de Bases/genética , Exones/genética , Femenino , Humanos , Proteínas Hierro-Azufre/genética , Mutación/genética , Epiplón/patología , Neoplasias Peritoneales/genética , Eliminación de Secuencia/genética , Succinato Deshidrogenasa/genéticaRESUMEN
AIM OF THE STUDY: To determine diagnostic modalities and both immediate and long-term treatment of superior mesenteric venous thrombosis. PATIENTS AND METHODS: Retrospective study from 1997 to 2004 in two institutions concerning patients with superior mesenteric vein thrombosis. RESULTS: Nine patients (all males, mean age=55 years), were included. Abdominal pain (100%), vomiting (44%), and bowel activity disorders (44%) were the most common symptoms. A personal or familial thrombosis history was present in 67% of patients. A genetic predisposing factor of thrombosis was present in 78% of patients. The diagnosis was established with CT-scan in 8 cases with a mean delay of 8 days. Treatment was exclusively medical in 33% of patients and included surgery in 67%. All operated patients underwent resection for bowel infarction and only one had immediate anastomosis. All enterostomies were subsequently closed. No patient died. CONCLUSION: Diagnosis of superior mesenteric vein thrombosis is frequently delayed and relies on CT-scan with intravenous contrast. Prognosis is globally favourable but depends on early application of anticoagulation therapy. In case of surgery, bowel-sparing resection is indicated and enterostomies are often needed. Genetic disorders predisposing to thrombosis are very frequent, that may indicate prolonged even definitive anticoagulation therapy.
Asunto(s)
Oclusión Vascular Mesentérica/diagnóstico , Venas Mesentéricas/patología , Trombosis de la Vena/diagnóstico , Dolor Abdominal/diagnóstico , Enterostomía , Fibrinolíticos/uso terapéutico , Predisposición Genética a la Enfermedad , Humanos , Infarto/cirugía , Enfermedades Intestinales/diagnóstico , Intestino Delgado/irrigación sanguínea , Masculino , Oclusión Vascular Mesentérica/terapia , Persona de Mediana Edad , Estudios Retrospectivos , Trombectomía , Terapia Trombolítica , Factores de Tiempo , Tomografía Computarizada por Rayos X , Trombosis de la Vena/genética , Trombosis de la Vena/terapia , Vómitos/diagnósticoRESUMEN
INTRODUCTION: Leiomyosarcoma of the inferior vena cava is mesenchymal tumor accounting for 95% of primary tumors of the vena cava. Characteristic features include late invasion of adjacent structures and metastases, and delayed diagnosis. OBSERVATION: We report a case of inferior vena cava (IVC) leiomyosarcoma (LMS) found in a 53 year-old man who complained of abdominal pain. Morphologic exams found a very large polycyclic mass in the inferior vena cava involving the middle segment of the vena cava extending from the renal veins to the hepatic veins. An "en bloc" resection of the tumor was achieved. Caval outflow was restored using a ring-reinforced PTFE tube graft, the left renal vein was ligated and not re-implanted, the right renal vein was implanted in a lumbar sub-renal vein using a short prosthesis. Pathological examination documented a grade II leiomyosarcoma of the inferior vena cava and the patient was given adjuvant chemotherapy (anthracycline). One year later, there was no local or regional relapse. COMMENT: We emphasize the importance of restoring caval outflow which provides effective results when used with a ring-reinforced polytetrafluoroethylene (PTFE) prosthesis. Furthermore, the importance of restoring right renal outflow is highlighted because ligature of the renal vein can lead to renal ischemia and nephrectomy which should only be performed in specific cases. The tactical problems of renal and caval revascularisation, including the place of prosthetic replacement, are discussed.
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Riñón/irrigación sanguínea , Leiomiosarcoma/diagnóstico , Neoplasias Vasculares/diagnóstico , Vena Cava Inferior/cirugía , Prótesis Vascular , Humanos , Leiomiosarcoma/cirugía , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Venas Renales/cirugía , Neoplasias Vasculares/cirugíaRESUMEN
Frequently found in kidney, angiomyolipoma is a rare mesenchymal tumor when diagnosed in the liver and usually benign composed of proliferative blood vessels, fatty tissue and smooth muscle. We report the case of a 67-year-old woman who underwent a left hepatectomy for a 4th segment tumor unidentified after imaging and fine needle biopsy. Final anatomopathologic examination revealed an epithelioïd hepatic angiomyolipoma with signs of malignant behaviour as vascular and lymphatics embolus and invaded left portal vein thrombosis. During the subsequent 24-month follow-up, no recurrence was observed. A review of the literature found only two cases of malignant hepatic angiomyolipoma with fatal issue, however, their incidence must be underrated because of their scarcity and the difficulty of their diagnosis, which needs immunohistochemical confirmation with HMB 45 in particularly. Advances in imaging and anatomopathology in particular with the concept of PEComa (Perivascular-Epithelioïd Cell) as the unifying feature should lead to the recognition of the various variant patterns and cell types. The latter which are important for a correct diagnosis, in order to obtain reliable data about frequency, possible malignant behaviour and therefore consensus management for hepatic angiomyolipoma.
Asunto(s)
Angiomiolipoma/cirugía , Neoplasias Hepáticas/cirugía , Anciano , Biopsia con Aguja Fina , Femenino , Estudios de Seguimiento , Hepatectomía , Humanos , Ganglios Linfáticos/patología , Células Neoplásicas Circulantes/patología , Vena Porta/patología , Tomografía Computarizada por Rayos X , Trombosis de la Vena/patologíaRESUMEN
Cryopreserved arterial allografts are used in vascular surgery to treat infected arterial prosthesis. This treatment reduces mortality and morbidity compared to conventional surgery. We observed a case of early rupture of the allograft with the death of the patient due to a misdiagnosis. Recent findings show that cases of rupture have been described, and that current cryopreservation protocols may be the cause of degeneration. To avoid a sudden death for the patient, this complication must be known to diagnose quickly and treat surgically before a final haemorrhagic shock.
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Arterias/trasplante , Criopreservación , Complicaciones Posoperatorias/diagnóstico , Prótesis Vascular , Resultado Fatal , Fiebre/etiología , Humanos , Complicaciones Posoperatorias/microbiología , Complicaciones Posoperatorias/patología , Complicaciones Posoperatorias/terapia , Rotura Espontánea , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/patología , Trasplante HomólogoRESUMEN
The authors report two cases of adenocarcinomatous dedifferentiation of a recurrent mature teratoma arising 3 and 20 years after the initial resection. This is a rare event, occurring after macroscopically or microscopically incomplete resection of a mature teratoma. The nature of this recurrence was difficult to determine prior to histological examination. However, PET scan suggests the diagnosis of malignant teratoma in the presence of increased uptake by the lesion. These tumours have a poor prognosis. Treatment consists of complete resection of the tumour mass. The possibility of long-term malignant dedifferentiation of a teratoma therefore requires prolonged and regular life-long surveillance of patients presenting a mature teratoma after chemotherapy for non-seminomatous germ cell tumour of the testis.
Asunto(s)
Adenocarcinoma/patología , Transformación Celular Neoplásica/patología , Neoplasias Primarias Secundarias/patología , Neoplasias Retroperitoneales/patología , Teratoma/patología , Neoplasias Testiculares/cirugía , Adulto , Humanos , MasculinoRESUMEN
Soft tissue infections are uncommon but prognosis is severe (20 to 50%). Management consists in surgical debridement, antibiotic therapy against anaerobic and aerobic bacteria, and appropriate intensive care. When available, hyperbaric oxygen therapy is an integral part of the treatment. We report the case of 56-year-old female patient with diabetes (150 kg) was hospitalized in our unit a few days after surgical treatment of a buttocks abscess for clinical signs of peripheral gas gangrene. Surgical exploration showed necrotizing soft tissue infection with fasciitis. Adequate therapy using antibiotics, surgery daily and hyperbaric oxygen was given. Therapy had to be adapted to the patient's obesity. Outcome was good with recovery and few sequelae, allowing transfer to a medical ward.