Therapeutic Strategies and Oncological Outcome of Peritoneal Metastases from Lung Cancer: A Systematic Review and Pooled Analysis.

The peritoneum is an unusual site of metastases from lung cancer, and optimal management at the moment remains unclear and mostly based on palliative strategies. Therefore, the aim of the study was to investigate demographic characteristics, management and overall survival of patients with peritoneal metastases from lung cancer (PCLC). A PRISMA-compliant systematic review and pooled analysis was performed searching all English studies published until December 2022. PROSPERO, CRD42022349362. Inclusion criteria were original articles including patients with peritoneal carcinomatosis from lung cancer, specifying at least one outcome of interest. Exclusion criteria were being unable to retrieve patient data from articles, and the same patient series included in different studies. Among 1746 studies imported for screening, twenty-one were included (2783 patients). Mean overall survival was between 0.5 and 5 months after peritoneal carcinomatosis diagnosis and 9 and 21 months from lung cancer diagnosis. In total, 27% of patients underwent first-line or palliative chemotherapy and 7% of them surgery. Management differs significantly among published studies. The literature on PCLC is scarce. Its incidence is low but appears to be substantially rising and is likely to be an underestimation. Prognosis is very poor and therapeutic strategies have been limited and used in a minority of patients. Subcategories of PCLC patients may have an improved prognosis and may benefit from an aggressive oncological approach, including cytoreductive surgery. Further investigation would be needed in this regard.

Laparoscopic versus Open Total Gastrectomy for Locally Advanced Gastric Cancer: Short and Long-Term Results.

BACKGROUND: Laparoscopic gastrectomy for early gastric cancer is widely accepted and routinely performed. However, it is still debated whether the laparoscopic approach is a valid alternative to open gastrectomy in advanced gastric cancer (AGC). The aim of this study is to compare short-and long-term outcomes of laparoscopic (LG) and open (OG) total gastrectomy with D2 lymphadenectomy in patients with AGC. METHODS: A retrospective comparative study was conducted on patients who underwent LG and OG for ACG between January 2015 and December 2021. Primary endpoints were the following: recurrence rate, 3-year disease-free survival, 3-year and 5-year overall survival. Univariate and multivariate analysis was conducted to compare variables influencing outcomes and survival. RESULTS: Ninety-two patients included: fifty-three OG and thirty-nine LG. No difference in morbidity and mortality. LG was associated with lower recurrence rates (OG 22.6% versus LG 12.8%, p = 0.048). No differences in 3-year and 5-year overall survival; 3-year disease-free survival was improved in the LG group on the univariate analysis but not after the multivariate one. LG was associated with longer operative time, lower blood loss and shorter hospital stay. Lymph node yield was higher in LG. CONCLUSION: LG for AGC seems to provide satisfactory clinical and oncological outcomes in medium volume centers, improved postoperative results and possibly lower recurrence rates.

Benefits of minimally invasive surgery in the treatment of gastric cancer.

We read with great interest the article that retrospectively analyzed 814 patients with primary gastric cancer, who underwent minimally invasive R0 gastrectomy between 2009 and 2014 by grouping them in laparoscopic vs robotic procedures. The results of the study highlighted that age, American Society of Anesthesiologists status, gastrectomy type and pathological T and N status were the main prognostic factors of minimally invasive gastrectomy and showed how the robotic approach may improve long-term outcomes of advanced gastric cancer. According to most of the current literature, robotic surgery is associated with a statistically longer operating time when compared to open and laparoscopic surgery; however, looking at the adequacy of resection, defined by negative surgical margins and number of lymph nodes removed, it seems that robotic surgery gives better results in terms of the 5-year overall survival and recurrence-free survival. The robotic approach to gastric cancer surgery aims to overcome the difficulties and technical limitations of laparoscopy in major surgery. The three-dimensional vision, articulation of the instruments and good ergonomics for the surgeon allow for accurate and precise movements which facilitate the complex steps of surgery such as lymph node dissection, esophagus-jejunal anastomosis packaging and reproducing the technical accuracy of open surgery. If the literature, as well as the analyzed study, offers us countless data regarding the short-term oncological results of robotic surgery in the treatment of gastric cancer, satisfactory data on long-term follow-up are lacking, so future studies are necessary.

Immunonutrition reduces complications rate and length of stay after laparoscopic total gastrectomy: a single unit retrospective study.

BACKGROUND: Preoperative immunonutrition (IN) reduces the incidence of postoperative complications in malnourished patients undergoing upper gastrointestinal surgery. However, its effect in norm-nourished patients remains unclear. Furthermore, patients with gastric cancer undergoing laparoscopic total gastrectomy (LTG) are not routinely included in protocols of enhanced recovery after surgery (ERAS). OBJECTIVE: The aim of this study was to investigate the effects of perioperative IN in patients undergoing laparoscopic total gastrectomy (LTG) within an established ERAS pathway. METHODS: A comparative retrospective study of patients undergoing LTG, receiving an immune-enhancing feed plus maltodextrin load the day of surgery (Group A) versus patients who had the same operation but no IN nor fast track management (group B). RESULTS: There were no significant differences in patient demographic characteristics between the two groups but the medium age of patients in group A was older. Thirty-days postoperative complications were respectively 8.7% in Group A and 33.3% in Group B (p 0.04). Mean and median LOS for Group A and B were also significantly different: 7.2 ± 4.4 vs 10.3 ± 5.4 and 7 vs 10 days respectively. CONCLUSION: Preoperative IN associated with ERAS protocol in normo-nourished patient undergoing LTG seems to reduce postoperative complications. Reduction in LOS is possibly associated to the ERAS protocol. Clinical trial registration Clinical trials.gov: NCT05259488.

Thoracic Duct Embolization for Delayed Chyle Leak After Lewis-Tanner Esophagectomy.

BACKGROUND Radical esophagectomy for cancer is a potentially curative treatment that requires two/three-field lymphadenectomy. Serious complications can occur, including chyle leak (CL). CL has an incidence rate of 1-9% and is associated with a higher rate of postsurgical morbidity and mortality. It usually occurs in the early postoperative period; delayed CL is less common and is thought to be due to an occult leak or late diagnosis. CASE REPORT A 54-year-old man with adenocarcinoma of the esophagus underwent Lewis-Tanner esophagectomy after neoadjuvant chemotherapy with FLOT. During en bloc lymphadenectomy, the main thoracic duct was identified, clipped, and divided. The postoperative course was uneventful. One month after hospital discharge, he was readmitted with severe abdominal, scrotal, and lower-limb edema. A chest-abdomen CT scan revealed massive pleural effusion with left shift and compression of the mediastinum. The patient was initially treated with fasting and fat-free total parenteral nutrition, and the drain output was 2800-3000 mL/dL. Lymphoscintigraphy with ethiodized oil eventually revealed a thoracic duct leak, and lymphatic embolization was successfully performed with a 4-mm metallic spiral and glue. Drain output dramatically reduced, and after 11 days the thoracic drain was removed and the patient was safely discharged. CONCLUSIONS Thoracic duct embolization seems be an effective therapy in treating high-output (>1000 mL/dL) CL that has occurred more than 2 weeks after esophagectomy. It can be considered as a first-line treatment due to its simplicity and effectiveness.

GM-CSF suppresses antioxidant signaling and drives IL-1ß secretion through NRF2 downregulation.

GM-CSF is a potent inflammatory cytokine regulating myeloid cell differentiation, hematopoiesis, and various other functions. It is functionally associated with a number of inflammatory pathologies including rheumatoid arthritis and inflammatory bowel disease. GM-CSF has been found to promote NLRP3-dependent IL-1ß secretion, which may have a significant role in driving inflammatory pathologies. However, the molecular mechanisms remain unknown. Here, we show that GM-CSF induces IL-1ß secretion through a ROS-dependent pathway. TNF is required for reactive oxygen species (ROS) generation that strikingly does not promote NLRP3 activation, but instead drives ubiquitylation of IL-1ß, promoting its cleavage through basal NRLP3 activity. GM-CSF regulates this pathway through suppression of antioxidant responses via preventing upregulation of NRF2. Thus, the pro-inflammatory effect of GM-CSF on IL-1ß is through suppression of antioxidant responses, which leads to ubiquitylation of IL-1ß and enhanced processing. This study highlights the role of metabolic regulation of inflammatory signaling and reveals a novel mechanism for GM-CSF to promote inflammation.

Current highlights on solid pseudopapillary neoplasm of the pancreas.

Solid pseudopapillary neoplasm of the pancreas is a low-grade malignant tumor that predominantly affects young women in their third and fourth decade. Etiology and risk factors are unknown. Clinical symptoms are aspecific and most commonly due to mass effect. Diagnosis is made by computed tomography scan or magnetic resonance imaging and histological characterization is obtained by endoscopic ultrasound-guided fine needle biopsy. Microscopically, these lesions are composed by both solid and pseudopapillary structures with necrotic and hemorrhagic areas. Occasionally, the biological behavior is aggressive with tumor recurrence and distant metastasis. Usually, curative R0 surgical resection is the best option able to provide long term survival even in advanced disease. Unresectable disease is the main predictor of poor prognosis. Chemotherapy and radiotherapy regimens are not well standardized. However, they could be effective in reducing tumor size as neoadjuvant treatment or disease control in palliative setting. Although complete surgical resection provides a cure rate of > 95%, considering young age of the patients and morbidity associated to pancreatic surgery, further studies are needed to better investigate risk factors and responsiveness to hormones in order to allow early diagnosis and follow up strategies that could avoid unnecessary surgery in less aggressive disease.

Synchronous liver and peritoneal metastases from colorectal cancer: Is cytoreductive surgery and hyperthermic intraperitoneal chemotherapy combined with liver resection a feasible option?

Background: Traditionally, synchronous liver resection (LR), cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy for colorectal liver and peritoneal metastases have been contraindicated. Nowadays, clinical practice has promoted this aggressive treatment in selected cases. This study aimed to review surgical and survival results of an extensive surgical approach including CRS with hyperthermic intraperitoneal chemotherapy (HIPEC) and LR. Methods: PubMed, EMBASE, and Web of Science databases were matched to find the available literature on this topic. The search period was limited to 10 years (January 2010-January 2021). A threshold of case series of 10 patients or more was applied. Results: In the search period, out of 114 studies found about liver and peritoneal metastases from colorectal cancer, we found 18 papers matching the inclusion criteria. Higher morbidity and mortality were reported for patients who underwent such an extensive surgical approach when compared with patients who underwent only cytoreductive surgery and HIPEC. Also, survival rates seem worse in the former than in the latter. Conclusion: The role of combined surgical strategy in patients with synchronous liver and peritoneal metastases from colorectal cancer remains controversial. Survival rates and morbidity and mortality seem not in favor of this option. A more accurate selection of patients and more restrictive surgical indications could perhaps help improve results in this subgroup of patients with limited curative options.

Complete mesocolic excision and central vascular ligation in colorectal cancer in the era of minimally invasive surgery.

Since the 19th century, appropriate lymphadenectomy has been considered a cornerstone of oncologic surgery and one of the most important prognostic factors. This approach can be applied to any surgery for gastrointestinal cancer. During surgery for colon and rectal cancer, an adequate portion of the mesentery is removed together with the segment of bowel affected by the disease. The adequate number of lymph nodes to be removed is standardized and reported by several guidelines. It is mandatory to determine the appropriate extent of lymphadenectomy and to balance its oncological benefits with the increased morbidity associated with its execution in cancer patients. Our review focuses on the concept of "complete mesenteric excision (CME) with central vascular ligation (CVL)," a radical lymphadenectomy for colorectal cancer that has gained increasing interest in recent years. The aim of this study was to evaluate the evolution of this approach over the years, its potential oncologic benefits and potential risks, and the improvements offered by laparoscopic techniques. Theoretical advantages of CME are improved local-relapse rates due to complete removal of the intact mesocolic fascia and improved distance recurrence rates due to ligation of vessels at their origin (CVL) which guarantees removal of a larger number of lymph nodes. The development and worldwide diffusion of laparoscopic techniques minimized postoperative trauma in oncologic surgery, providing the same oncologic results as open surgery. This has been widely applied to colorectal cancer surgery; however, CME entails a technical complexity that can limit its wide minimally-invasive application. This review analyzes results of these procedures in terms of oncological outcomes, technical feasibility and complexity, especially within the context of minimally invasive surgery.

Prehospital Hemorrhage Assessment Criteria: A Concise Review.

OBJECTIVE: Early assessment of the clinical status of trauma patients is crucial for guiding the treatment strategy, and it requires a rapid and systematic approach. The aim of this report is to critically review the assessment parameters currently used in the prehospital setting to quantify blood loss in trauma. DATA SOURCES: Studies regarding hemorrhagic shock in trauma were pooled from PubMed, EMBASE, and Cochrane databases using key words such as "hemorrhagic shock," "vital signs evaluation," "trauma," "blood loss," and "emergency medical service," alone or combined. STUDY SELECTION: Articles published since 2009 in English and Italian were considered eligible if containing data on assessment parameters in blood loss in adults. DATA EXTRACTION: Sixteen articles matching the inclusion criteria were considered in our study. DATA SYNTHESIS: Current prehospital assessment measures lack precise correlation with blood loss. CONCLUSIONS: Traditional assessment parameters such as heart rate, systolic blood pressure, shock index, and Glasgow Coma Scale score often lag in providing accurate blood loss assessment. The current literature supports the need for a noninvasive, continuously monitored assessment parameter to identify early shock in the prehospital setting.

Perforated gastric cancer: a critical appraisal.

Gastric cancer perforation is a life-threatening condition that accounts for less than 5% of all gastric cancer patients and typically requires emergency surgery. However, preoperative diagnosis is difficult and management has a dual purpose: to treat peritonitis and to achieve a curative resection. The optimal surgical strategy is still unclear and prognosis remains poor. A search of the literature was performed using MEDLINE databases (Pubmed, EMBASE, Web of Science and Cochrane) using terms such as "perforated gastric cancer", "perforated gastric cancer and surgery", "perforated gastric tumour" and "gastric cancer perforated". Case reports, other reviews, non-english written papers and papers written before 2010 were excluded. Eight articles published between 2010 and 2020 matched the inclusion criteria for this review. Perforated gastric cancer was more prevalent in elderly males. Distal stomach was most frequently involved. Preoperative diagnosis was uncommon. Mortality rates ranged from 2 to 46%. Patients able to receive an R0 resection demonstrated better long-term survival compared with patients who had simple closure procedures. Laparoscopic procedure was mentioned only in one study. In an emergency situation, curative RO resection should always be offered in patients without multiple adverse factors. A surgical strategy using laparoscopic local repair as first step of surgery to resolve the peritonitis followed by a radical open or laparoscopic gastrectomy with lymphadenectomy could be considered. A balance between emergency and oncological needs should drive the surgical choice on a case by case basis.

Super selective arterial embolization to treat radiation-induced hemorrhagic gastritis: a case report and review of the literature.

Radiation-induced hemorrhagic gastritis (RIHG) is a rare but potentially fatal event following radiotherapy for locally advanced gastric cancer; the treatment of this condition is not standardized. Only few cases of RIHG have been reported, treated with different therapeutic approaches. Here we report the case of a 79-year-old patient who underwent subtotal gastrectomy for gastric cancer, followed by adjuvant chemo-radiotherapy. Approximately 3 months after the end of the treatment, she developed recurrent diffuse bleeding originating from the entire mucosa of the gastric pouch and from a marginal ulcer. As the bleeding was refractory to several endoscopic treatments and surgery was not indicated, the patient underwent two sessions of transcatheter selective arterial embolization, with resolution of bleeding. Arterial embolization has already been reported for the treatment of hemorrhagic cystitis, developing after irradiation of the pelvis for prostate, bladder, rectum, and cervix cancer. However, to our knowledge, it has never been reported as a treatment for hemorrhagic gastritis. Based on this case, we suggest arterial embolization as an option in the management of RIHG, when standard endoscopic treatment fails.

Interleukin-34 Stimulates Gut Fibroblasts to Produce Collagen Synthesis.

BACKGROUND AND AIM: The mechanisms underlying the formation of intestinal fibrostrictures [FS] in Crohn's disease [CD] are not fully understood, but activation of fibroblasts and excessive collagen deposition are supposed to contribute to the development of FS. Here we investigated whether interleukin-34 [IL-34], a cytokine that is over-produced in CD, regulates collagen production by gut fibroblasts. METHODS: IL-34 and its receptor macrophage colony-stimulating factor receptor 1 [M-CSFR-1] were evaluated in inflammatory [I], FS CD, and control [CTR] ileal mucosal samples by real-time polymerase chain reaction [RT-PCR], western blotting, and immunohistochemistry. IL-34 and M-CSFR-1 expression was evaluated in normal and FS CD fibroblasts. Control fibroblasts were stimulated with IL-34 in the presence or absence of a MAP kinase p38 inhibitor, and FS CD fibroblasts were cultured with a specific IL-34 antisense oligonucleotide, and collagen production was evaluated by RT-PCR, western blotting, and Sircol assay. The effect of IL-34 on the wound healing capacity of fibroblasts was evaluated by scratch test. RESULTS: We showed enhanced M-CSFR-1 and IL-34 RNA and protein expression in FS CD mucosal samples as compared with ICD and CTR samples. Immunohistochemical analysis showed that stromal cells were positive for M-CSFR-1 and IL-34. Enhanced M-CSFR-1 and IL-34 RNA and protein expression was seen in FS CD fibroblasts as compared with CTR. Stimulation of control fibroblasts with IL-34 enhanced COL1A1 and COL3A1 expression and secretion of collagen through a p38 MAP kinase-dependent mechanism, and wound healing. IL-34 knockdown in FS CD fibroblasts was associated with reduced collagen production and wound repair. CONCLUSIONS: Data indicate a prominent role of IL-34 in the control of intestinal fibrogenesis.

Minimal Open Access Ileocolic Resection in Complicated Crohn's Disease of the Terminal Ileum.

The objective of this study was to evaluate the possibility to undertake an ileocolic resection in complex Crohn's disease using a minimal open abdominal access using standard laparoscopic instruments. The incision was carried out over the previous McBurney scar, with a mean length of 6 cm. Seventy-two patients with complicated Crohn's disease underwent IC resection in the considered period; 12 patients had a McBurney scar due to a previous appendectomy and represented the group of study. Feasibility and safety of the procedure were evaluated. Clinical data and outcome were compared with a control arm of 15 patients who had a standard laparoscopic IC resection, pooled out from our database among those who had a McBurney incision as service incision. Mean operative time and postoperative stay were significantly shorter in the study group. Blood loss and operative costs were also lower in the study group but did not reach statistical significance. Minimal open access ileocolic resection (MOAIR) through a small McBurney incision seems safe and feasible in complex Crohn's disease. Some advantages over standard laparoscopic surgery could be found in surgical outcomes and costs.

Cadherin-11 Is a Regulator of Intestinal Fibrosis.

BACKGROUND AND AIMS: Although the mechanisms underlying the formation of intestinal fibrostrictures in Crohn's disease [CD] are not fully understood, activation of fibroblasts and excessive collagen deposition are supposed to contribute to the development of such complications. Here, we investigated the role of cadherin-11 [CDH-11], a fibroblast-derived protein that induces collagen production in various organs, in intestinal fibrosis. METHODS: CDH-11 expression was evaluated in inflammatory [I] and fibrostricturing [FS] CD mucosal samples, ulcerative colitis [UC] mucosal samples, and ileal and colonic control samples, by real-time polymerase chain reaction, western blotting, and immunohistochemistry. CDH-11 expression was evaluated in normal and in CD intestinal fibroblasts stimulated with inflammatory/fibrogenic cytokines. FS CD fibroblasts were cultured either with a specific CDH-11 antisense oligonucleotide [AS], or activating CDH-11 fusion protein and activation of RhoA/ROCK, and TGF-ß pathways and collagen production were evaluated by western blotting. Finally, we assessed the susceptibility of CDH-11-knockout [KO] mice to colitis-induced intestinal fibrosis. RESULTS: CDH-11 RNA and protein expression were increased in both CD and UC as compared with controls. In CD, the greater expression of CDH-11 was seen in FS samples. Stimulation of fibroblasts with TNF-α, interleukin [IL]-6, IFN-γ, IL-13, and IL-1ß enhanced CDH-11 expression. Knockdown of CDH-11 in FS CD fibroblasts impaired RhoA/ROCK/TGF-ß signalling and reduced collagen synthesis, whereas activation of CDH-11 increased collagen secretion. CDH-11 KO mice were largely protected from intestinal fibrosis. CONCLUSIONS: Data show that CDH-11 expression is up-regulated in inflammatory bowel disease [IBD] and suggest a role for this protein in the control of intestinal fibrosis.

Surgical treatment of intraperitoneal metastases from lung cancer: two case reports and a review of the literature.

BACKGROUND: Peritoneal metastases are often reported in several abdominal tumors. Peritoneal diffusion from extra-abdominal tumors is thought to be rare. Lung cancer is one of the most common cancers in the world with early metastases and it is associated with poor prognosis in advanced stages. Peritoneal metastases from lung cancer are uncommon and the real mechanism of its diffusion to the peritoneum is unknown. However, its clinical behavior is similar to any other peritoneal metastasis from abdominal tumors. CASE PRESENTATION: We present two Caucasian patients (a 44-year-old man and a 59-year-old man) with bowel obstruction from peritoneal metastases from non-small cell lung cancer who successfully underwent emergency cytoreductive surgery and had a good prognosis and survival. CONCLUSIONS: In our patients with isolated peritoneal metastases from lung cancer, cytoreduction showed good prognosis with acceptable morbidity. This treatment option might be considered in highly selected cases to improve survival. Strict follow-up is mandatory to allow early diagnosis of peritoneal diffusion.

Coding in surgery: impact of a specialized coding proforma in hepato-pancreato-biliary surgery.

BACKGROUND: Coding inaccuracies in surgery misrepresent the productivity of hospitals and outcome data of surgeons. The aim of this study was to audit the extent of coding inaccuracies in hepato-pancreato-biliary (HPB) surgery and assess the financial impact of introducing a coding proforma. METHODS: Coding of patients who underwent elective HPB surgery over a 3-month period was audited. Codes were based on International Classification of Diseases 10 and Office of Population and Census Surveys-4 codes. A coding proforma was introduced and assessed. New human resource group codes were re-assigned and new tariffs calculated. A cost analysis was also performed. RESULTS: Prior to the introduction of the coding proforma, 42.0% of patients had the incorrect diagnosis and 48.5% had missing co-morbidities. In addition, 14.5% of primary procedures were incorrect and 37.6% had additional procedures that were not coded for at all. Following the introduction of the coding proforma, there was a 27.5% improvement in the accuracy of primary diagnosis (P < 0.001) and 21% improvement in co-morbidities (P = 0.002). There was a 7.2% improvement in the accuracy of coding primary procedures (P = not significant) and a 21% improvement in the accuracy of coding of additional procedures (P < 0.001). Financial loss as a result of coding inaccuracy over our 3-month study period was £56 073 with an estimated annual loss of £228 292. CONCLUSION: Coding in HPB surgery is prone to coding inaccuracies due to the complex nature of HPB surgery and the patient case-mix. A specialized coding proforma completed 'in theatre' significantly improves the accuracy of coding and prevents loss of income.

Resection margin influences the outcome of patients with bilobar colorectal liver metastases.

AIM: To evaluate the outcome of patients with bilobar colorectal liver metastases (CRLM) and identify clinico-pathological variables that influenced survival. METHODS: Patients with bilobar CRLM were identified from a prospectively maintained hepatobiliary database during the study period (January 2010-June 2014). Collated data included demographics, primary tumour treatment, surgical data, histopathology analysis and clinical outcome. Down-staging therapy included Oxaliplatin- or Irinotecan- based regimens, and Cetuximab was also used in patients that were K-RAS wild-type. Response to neo-adjuvant therapy was assessed at the multi-disciplinary team meeting and considered for surgery if all macroscopic CRLM were resectable with a clear margin while preserving sufficient liver parenchyma. RESULTS: Of the 136 patients included, thirty-two (23.5%) patients were considered inoperable and referred for palliative chemotherapy, and thirty-four (25%) patients underwent liver resection. Seventy (51.4%) patients underwent down-staging therapy, of which 37 (52.8%) patients responded sufficiently to undergo liver resection. Patients that failed to respond to down-staging therapy (n = 33, 47.1%) were referred for palliative therapy. There was a significant difference in overall survival between the three groups (surgery vs down-staging therapy vs inoperable disease, P < 0.001). All patients that underwent hepatic resection, including patients that had down-staging therapy, had a significantly better overall survival compared to patients that were inoperable (P < 0.001). On univariate analysis, only resection margin significantly influenced disease-free survival (P = 0.017). On multi-variate analysis, R0 resection (P = 0.030) and female (P = 0.036) gender significantly influenced overall survival. CONCLUSION: Patients undergoing liver resection with bilobar CRLM have a significantly better survival outcome. R0 resection is associated with improved disease-free and overall survival in this patient group.

Same day arterial embolisation followed by hepatic resection for treatment of giant haemangioma.

Cavernous haemangiomas are the most common tumour of the liver; they are benign in nature and have an incidence of up to 7.3% at autopsy. Occasionally, they may cause symptoms necessitating intervention. We report the case of a woman who presented with non-specific abdominal pain and evidence of a giant hepatic haemangioma on abdominal imaging. She underwent selective hepatic arteriography with transcatheter arterial embolisation followed by same-day left hemi-hepatectomy, making an uneventful recovery. We discuss the management of giant hepatic haemangiomas and present same day transcatheter arterial embolisation prior to hepatic resection as a safe and viable treatment strategy in selected cases.

Restaging oesophageal cancer after neoadjuvant therapy with (18)F-FDG PET-CT: identifying interval metastases and predicting incurable disease at surgery.

OBJECTIVES: It is unknown whether restaging oesophageal cancer after neoadjuvant therapy with positron emission tomography-computed tomography (PET-CT) is more sensitive than contrast-enhanced CT for disease progression. We aimed to determine this and stratify risk. METHODS: This was a retrospective study of patients staged before neoadjuvant chemotherapy (NAC) by (18)F-FDG PET-CT and restaged with CT or PET-CT in a single centre (2006-2014). RESULTS: Three hundred and eighty-three patients were restaged (103 CT, 280 PET-CT). Incurable disease was detected by CT in 3 (2.91 %) and PET-CT in 17 (6.07 %). Despite restaging unsuspected incurable disease was encountered at surgery in 34/336 patients (10.1 %). PET-CT was more sensitive than CT (p = 0.005, McNemar's test). A new classification of FDG-avid nodal stage (mN) before NAC (plus tumour FDG-avid length) predicted subsequent progression, independent of conventional nodal stage. The presence of FDG-avid nodes after NAC and an impassable tumour stratified risk of incurable disease at surgery into high (75.0 %; both risk factors), medium (22.4 %; either), and low risk (3.87 %; neither) groups (p < 0.001). Decision theory supported restaging PET-CT. CONCLUSIONS: PET-CT is more sensitive than CT for detecting interval progression; however, it is insufficient in at least higher risk patients. mN stage and response (mNR) plus primary tumour characteristics can stratify this risk simply. KEY POINTS: • Restaging (18) F-FDG-PET-CT after neoadjuvant chemotherapy identifies metastases in 6 % of patients • Restaging (18) F-FDG-PET-CT is more sensitive than CT for detecting interval progression • Despite this, at surgery 10 % of patients had unsuspected incurable disease • New concepts (FDG-avid nodal stage and response) plus tumour impassability stratify risk • Higher risk (if not all) patients may benefit from additional restaging modalities.