RESUMO
Background: Although minimally invasive surgery (MIS) of the liver is increasingly widespread, its role in the treatment of colorectal liver metastasis (CRLM) remains uncertain. In this setting, the role of robotic-assisted surgery (RAS) has not been significantly evaluated yet. The aim of this study was to report our experience with RAS for treatment of CRLM. Material and Methods: Prospectively collected surgical and oncologic data on all of the robotic-assisted liver resections for CRLM performed at our centre were retrieved from the institutional database and retrospectively analysed. Intra-operative ultrasound (US) was obtained with a dedicated robotic probe using the TilePro™ function. Results: Twenty patients underwent robotic-assisted resection of CRLM between May 2012 and April 2018. Six patients (30%) had multiple synchronous CRLM resections (median = 2; range 2-4). The tumour size averaged 3.0 ± 1.8 cm. All of the lesions were removed using a parenchymal-sparing approach, with R0 resection margins. Mean hospital stay was 4.7 ± 1.8 days. The mean follow-up was 22.5 ± 19.5 months. During the study period, there were no local recurrences, while 9 patients (45%) developed new systemic metastasis. All patients are still alive as of September 2018 with 1- and 3-year disease-free survival of 89.5% and 35.8%, respectively. Conclusions: In our experience, RAS for CRLM surgical treatment was feasible and played a positive role even in patients with multiple metastases and previous or synchronous surgery. RAS seemed to be oncologically effective in this setting, as no patients experienced local relapse in the treated area.
RESUMO
BACKGROUND: Ampullary adenocarcinomas (AACs) are heterogeneous tumors currently classified into three important sub-classes (SC): Intestinal (INT), Pancreato-Biliary (PB) and Mixed-Type (MT). The different subgroups have similar clinical presentation and are treated by pancreatoduodenectomy with curative intent. However, they respond differently to chemotherapy and have different prognostic outcomes. The SC are often difficult to identify with conventional histology alone. The clinical outcome of all three remains unclear, particularly for MT. AIM: To identify two main subtypes of AACs, using an immunohistochemical (IHC) score based on CDX2, CK7 and CK20. METHODS: Tissue samples from 21 patients who had undergone resection of AAC were classified by HE histology and IHC expression of CDX2, CK7 and CK 20. An IHC score was obtained for each marker by counting the number of positive cells (0 = no stained cells; 1 < 25%; 2 < 50% and 3 > 50%) and their intensity (1 = weak; 2 = moderate and 3 = strong). A global score (GS) was then obtained by summation of the IHC scores of each marker. The MT tumors were grouped either with the INT or PB group based on the predominant immuno-molecular phenotype, obtaining only two AACs subtypes. The overall survival in INT and PB patients was obtained by Kaplan-Meier methods. RESULTS: Histological parameters defined the AACs subtypes as follows: 15% INT, 45% PB and 40% MT. Using IHC expression and the GS, 75% and 25% of MT samples were assigned to either the INT or the PB group. The mean value of the GS was 9.5 (range 4-16). All INT samples had a GS above the average, distinct from the PB samples which had a GS score significantly below the average (P = 0.0011). The INT samples were identified by high expression of CDX2 and CK20, whereas PB samples exhibited high expression of CK7 and no expression of CK20 (P = 0.0008). The INT group had a statistically significant higher overall survival than in the PB group (85.7 mo vs 20.3 mo, HR: 8.39; 95%CI: 1.38 to 18.90; P = 0.0152). CONCLUSION: The combination of histopathological and molecular criteria enables the classification of AACs into two clinically relevant histo-molecular phenotypes, which appear to represent distinct disorders with potentially significant changes to the current therapeutic strategies.