Clinical Utility of a Risk-Adapted Protocol for the Evaluation of Coronary Artery Disease in Liver Transplant Recipients.

The prevalence and management of coronary artery disease (CAD) in liver transplantation (LT) candidates are not well characterized. The aims of this study were to evaluate the impact on clinical outcomes of a specifically designed protocol for the management of asymptomatic CAD in LT candidates and to investigate noninvasive risk profiles for obstructive and nonobstructive CAD for 202 LT candidates. Those with high baseline cardiovascular risk (CVR; defined by the presence of classic CVR factors and/or decreased ejection fraction) received coronary angiography and significant arterial stenosis and were treated with percutaneous stents. Patients were followed up after LT until death or coronary event (CE). There were 78 patients who received coronary evaluation (62 direct angiography, 14 computed tomography coronary angiography, and 2 both). Of them, 39 (50%) patients had CAD of any severity, and 6 (7.7%) had significant lesions (5 were amenable to be treated with stents, whereas 1 patient had diffuse lesions which contraindicated the LT). Insulin-dependent diabetes was the only factor related to CAD of any severity (odds ratio, 3.44; 95% confidence interval [CI], 1.00-11.97). A total of 69 patients (46 with coronary evaluation) received LT. The incidence of CEs and overall survival after LT were similar between patients with and without coronary evaluation. Furthermore, no differences occurred between these groups in a multivariate competing risk model (subhazard ratio, 0.84; 95% CI, 0.27-2.61; P = 0.76). In conclusion, the application of an angiographic screening protocol of CAD in a selected high-risk Mediterranean population is safe and effective. The short- and medium-term incidence rates of CEs and death after LT in this population are similar to that observed in low-risk patients.

Solitary extrapleural fibrous tumor with hepatic bilobar metastases: multimodal approach treatment.

BACKGROUND: Solitary fibrous tumor is an unusual fibroblastic mesenchymal neoplasm typically described in the pleura. It may appear anywhere with a varied anatomic distribution and essentially it can develop from any soft tissue or visceral location. Its course is usually indolent and it rarely causes distant metastases, so it has a prolonged survival rate. It sometimes presents itself as a disseminate disease being the liver the most frequently involved location. In these occasions, the management should be discussed in a multidisciplinary tumor committee formed by surgeons, oncologists and radiologists. Surgery remains the gold standard for treatment. CASE REPRESENTATION: We present the case of a woman with a tumor in the left abdominal wall and bilobar massive liver metastases, both locations histologically diagnosed as solitary fibrous tumor. She receives biological treatment for a severe case of Crohn´s disease. Evaluated in a multidisciplinary committee, surgery was recommended for both the primary lesion and the liver metastases. The hepatobiliary surgeons considered a two-stage hepatectomy with portal vein embolization (PVE) as the best strategy. After the first procedure consisting in cleaning the left hepatic lobe followed by PVE the future liver remnant volume (FLRV) was considered inadequate, so the patient was also treated with right transarterial radioembolizacion with yttrium 90 (TARE-Y90) intending a double goal: to treat the tumor and to increased the FLRV. Furthermore, a severe flare of Crohn´s disease forced us to intensify the patient's treatment with the addition of biological agents (infliximab and adalimumab) until complete remission of the symptoms. The second stage of the liver surgery had to be postponed for more than 6 months and could finally be carried out without complications, achieving an R0 resection. The postoperative course was uneventful and the follow up has showed no recurrence to date. CONCLUSION: Solitary fibrous tumours with extensive liver metastases are infrequent but when they appear modern surgical strategies like two stage hepatectomy are the treatment of choice and must be carried out by specialised units. The therapeutic decisions should be guided by a multidisciplinary committee.

Postchemoradiation laparoscopic resection and intraoperative electron-beam radiation boost in locally advanced rectal cancer: long-term outcomes.

BACKGROUND: In selected patients with rectal cancer, laparoscopic surgery is as safe as open surgery, with similar resection margins and completeness of resection. In addition, recovery is faster after laparoscopic surgery. We analyzed long-term outcomes in a group of patients with locally advanced rectal cancer (LARC) treated with preoperative therapy followed by laparoscopic surgery and intraoperative electron-beam radiotherapy (IOERT). METHODS AND MATERIALS: From June 2005 to December 2010, 125 LARC patients were treated with 2 induction courses of FOLFOX-4 (oxaliplatin 85 mg/m(2)/d1, intravenous leucovorin at 200 mg/m(2)/d1-2, and an intravenous bolus of 5-fluorouracil 400 mg/m(2)/d1-2) and preoperative chemoradiation (4,500-5,040 cGy) followed by total mesorectal excision (laparoscopic, 35 %; open surgery, 65 %) and a presacral boost with IOERT. RESULTS: Patients in the laparoscopic surgery group lost less blood (median 200 vs 350 mL, p < 0.01) and had a shorter hospital stay (7 vs 11 days; p = 0.02) than those in the open surgery group. Laparoscopic procedures were shorter than open surgery procedures (270 vs 302 min; p = 0.67). Postoperative morbidity (32 vs 44 %; p = 0.65), RTOG grade ≥3 acute toxicity (25 vs 25 %; p = 0.97), and RTOG grade ≥3 chronic toxicity (7 vs 9 %; p = 0.48) were similar in the laparoscopy and open surgery groups. The median follow-up time for the entire cohort of patients was 59.5 months (range 7.8-90); no significant differences were observed between the groups in locoregional control (HR 0.91, p = 0.89), disease-free survival (HR 0.80, p = 0.65), and overall survival (HR 0.67, p = 0.52). CONCLUSIONS: Postchemoradiation laparoscopically assisted IOERT is feasible, with an acceptable risk of postoperative complications, shorter hospital stay, and similar long-term outcomes when compared to the open surgery approach.

Tumores sacropélvicos primarios y secundarios. Tratamiento con cirugía radical y radioterapia intraoperatoria / Primary and secondary sacropelvic tumors. Treatment with radical surgery and intraoperative radiation therapy (IORT)

Introducción. La resección sacropélvica es el tratamiento de elección de los tumores primitivos o secundarios de los huesos pélvicos. Sin embargo, es una técnica compleja asociada a una elevada tasa de recidiva local. Para optimizar el control local y la supervivencia proponemos la asociación de radioterapia intraoperatoria (RIO) a la cirugía radical. Pacientes y método. Desde 1997-2002 hemos evaluado a 17 pacientes, de los que 15 fueron operados. En 13 casos se realizó sacrectomía (siete por invasión de cáncer de recto, tres por cordomas sacros, uno por histiocitoma maligno, uno por neurofibrosarcoma y uno por condrosarcoma). En 2 pacientes se llevó a cabo una escisión subtotal del ilion izquierdo y del pubis por sarcomas de la región. En 7 casos se practicaron procedimientos asociados (3 exenteraciones pélvicas completas, 2 posteriores y 2 resecciones intestinales). En todos los casos se aplicó un componente de RIO sobre el área de resección, con dosis entre 10-12,5 Gy. Resultados. Un paciente murió (6,5 por ciento) en el postoperatorio inmediato por infarto agudo de miocardio. Las complicaciones mayores incluyeron dos reoperaciones y 7 infecciones o retraso en la curación de la herida pelviperineal. El seguimiento medio ha sido de 26 meses (rango, 6-60 meses). Dos pacientes presentaron una recaída sistémica con metástasis a distancia, sin recidiva local, a los 41-48 meses de la cirugía. Los otros 13 pacientes siguen vivos, sin evidencia de enfermedad, a los 6-60 meses de la intervención quirúrgica. Conclusiones. La invasión tumoral sacropélvica no debe ser considerada como signo de inoperabilidad. La prolongada supervivencia con control de los síntomas locales en el 86 por ciento de nuestros pacientes sometidos a cirugía radical y RIO avalan esta terapia multimodal. El presente artículo contribuye a la descripción de las indicaciones de resección sacropélvica, los tiempos técnicos y los resultados a medio plazo. Consideramos que la RIO durante la cirugía radical ha sido de gran importancia para el control local de la enfermedad. Según nuestro conocimiento, ésta es la primera descripción en España de una serie clínica de resección sacropélvica asociada a radioterapia intraoperatoria (AU)