Basis Of Tumor Size Research Articles

Impact of Hepatocellular Carcinoma Tumor Size on Sonazoid Contrast-Enhanced Ultrasound Enhancement Features

The aim of the work described here was to evaluate the impact of hepatocellular carcinoma (HCC) tumor size on Sonazoid contrast-enhanced ultrasound (CEUS) enhancement features, especially in tumors with diameters ≤30 mm and <10 mm. In this retrospective study, we included patients with histopathologically confirmed HCC lesions and divided them into three groups on the basis of tumor size. All patients underwent Sonazoid-enhanced CEUS examinations before surgery. B-mode ultrasound (BMUS) features and CEUS enhancement patterns were evaluated according to current World Federation for Ultrasound in Medicine and Biology Guidelines criteria. The χ2- and Student t-tests were used to compare differences between groups. We included 132 patients with histopathologically confirmed HCC lesions from November 2020 to September 2022. On the basis of tumor size, patients were divided into group 1 (<10 mm, n=5), group 2 (10-30 mm, n=54) and group 3 (>30 mm, n=73). On BMUS, most HCCs appeared heterogeneous but predominantly hypo-echoic (61.4%, 81/132) with ill-defined margins and irregular shapes. Meanwhile, iso-echoic features were more common in small HCCs ≤30 mm (15.3%, 9/59), but a mixed hyper- and hypo-echoic appearance was more common in HCCs >30 mm (17.8%, 13/73) (p=0.003). On Sonazoid-enhanced CEUS, all HCCs presented arterial phase hyperenhancement (APHE) (100.0%, 132/132). Most HCCs >30 mm exhibited heterogeneous hyperenhancement (86.3%, 63/73), whereas nearly one-third of small HCCs ≤30 mm exhibited homogeneous hyperenhancement (35.6%, 21/59) (p=0.003). In the portal venous phase, there was a significantly higher proportion of washout in HCCs >30 mm (84.9%, 62/73) than in small HCCs ≤30 mm (64.4%, 38/59) (p=0.006). During the Kupffer phase, 11 additional hypo-enhanced lesions (mean size: 14.1 ± 4.1 mm, iso-echoic on BMUS), which were also suspected to be HCC lesions, were detected in 5 patients with small HCCs ≤30 mm and 4 patients with HCCs >30 mm. All 5 cases of HCCs <10 mm exhibited APHE and late washout (>60 s). The majority (3/5, 60%) exhibited washout in the portal venous phase (70, 74 and 75 s), one case did so in the late phase (125 s) and another in the Kupffer phase (420 s). Tumor size had a significant impact on the washout features of HCC lesions on Sonazoid-enhanced CEUS. Small HCC lesions ≤30 mm had a higher proportion of relatively late washout in comparison to larger lesions. Sonazoid-enhanced CEUS might be helpful in the detection and characterization of HCC lesions <10 mm.

Laparoscopic and Robotic Technically Major Liver Resections for Lesions Involving Segment 7: A Single Surgeon Experience of 123 Cases

Patients with lesions involving segment 7 have been considered poor candidates for minimally invasive liver resections.This study aims to compare short-term outcomes of laparoscopic liver resections (LLR) and robotic resections (RLR) for tumors involving segment 7. Retrospective analysis of prospective database on operative and postoperative characteristics and surgical outcomes of patients whom underwent a resection of a tumor involving segment 7. Of 555 patients undergoing LLR or RLR between October 2011 and September 2021,123 patiens underwent a technically major minimally invasive resection for tumors involving segment 7(101 LLR and 22 RLR).The type of resection was decided on the basis of tumor size and location.Both groups were comparable for age,sex,ASA score,tumor diameter,and number of patients with additional liver resections outside segment 7.Operative time was similar in both groups (median LRR 150 (70-300)min vs RLR 175 (145-190)min;p=0.25).Blood loss was less in the RLR-group (80 (30-110)cc vs 150(130-190)cc in the LLR;p<0.001).Median hospital stay was shorter for RLR (2 (1-3)days vs 4 (3-6)days for LLR;p<0.001) .There was no significant difference in postoperative complications (LLR:10.9% vs RRL13.6;p=0.72).In RLR less staplers were used (0 (0-0) vs 2 (0-4) for LLR).There was no difference in conversion rate (LLR: 5% vs RLR 0%;p=0.58) or redo-hepatectomies (LLR:17.8% vs 22.7% for RLR;p=0.59).There was no significant difference in R1 resection rate (LLR: 5.2% vs RLR: 0%;p=0.58). This study suggests thar RLR for tumors involving segment 7 can be performed with comparable short-term outcomes as similar LLR. However RLR were associated with less intraoperative blood loss and a shorter hospital stay.

Induction Therapy Is Not Associated With Improved Survival in Large cT4 N0 Non-Small Cell Lung Cancers

BackgroundThe eighth edition of the staging manual for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4 N0); previously, such tumors without nodal disease were considered stage IIB (T3 N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared with primary surgery. MethodsThe National Cancer Database was queried for patients with non-small cell lung cancer with tumor size >7 cm who underwent surgical resection from 2010 to 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgical resection (IC group) were compared with patients undergoing primary surgery (PS group). Propensity score matching was performed. ResultsIn total, 1610 patients with cT4 N0 disease on the basis of tumor size >7 cm and no tumor invasion underwent surgical resection: 1346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity score matching, the IC group had a higher rate of pN0 (78.4% vs 66.0%; P < .001) and less lymphovascular invasion (13.9% vs 26.3%; P < .001), but longer postoperative stays (6 days vs 5 days; P < .001) and higher 30-day mortality (3.5% vs 0%; P = .002). Median 5-year survival was similar between the IC and PS groups (53.5% vs 62.2%; P = .075), and IC was not independently associated with survival (hazard ratio, 1.45; P = .146). ConclusionsPatients with cT4 N0 non-small cell lung cancer on the basis of tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either induction chemotherapy or primary surgery. Induction chemotherapy should not be routinely given for this subset of stage IIIA patients.

Risk factors for local tumor progression after RFA of pulmonary metastases: a matched case-control study.

Curative treatment of oligometastatic pulmonary disease aims at eradication of all metastases. Radiofrequency ablation (RFA) has been shown to be an efficient method and the frequency of local tumor progression (LTP) should be minimized. The objective of this study was to determine the morphological and treatment-related risk factors for LTP after RFA of pulmonary metastases. All patients treated with RFA for pulmonary metastases from 2002 to 2014 were reviewed. All LTPs from 2011 to 2014 were individually matched on the basis of tumor size, number, and histology. In total, 48 LTPs and 112 controls were blindly analyzed for morphological factors including vicinity of bronchus and vessels as well as treatment-related factors such as the size of the ablation zone and ablation margins. In the simple regression analysis, the significant predictive variables were ≤ 5-mm distance to a large bronchus (OR = 4.94; p = 0.0095) or large vessel (OR = 7.09; p < 0.001), minimal ablation margin (≤ 5 mm (OR = 42.67; p < 0.001), and a central-peripheral ablation offset/ablation zone size > 0.36 (OR = 13.83; p = 0.013). In the multiple regression model, only a minimal ablation margin ≤ 5 mm remained a significant risk factor for LTP. Only the minimal ablation margin remains significant in the multiple regression analysis; the other factors are presumably surrogates of an insufficient ablation margin. Improvement of lung RFA outcomes can probably be obtained by immediate post RFA evaluation of ablation margins to ensure a minimal ablation margin of at least 5 mm. • A distance < 5 mm to a bronchus or vessel of over 3 mm diameter is associated with insufficient ablation margin and thus risk factors for local tumor progression after pulmonary radiofrequency ablation. • A minimal ablation margin of > 5 mm after pulmonary RFA is associated with significantly less local tumor progression and should be looked for at the end of treatment session before needle removal in order to decrease local tumor progression. • Tumor location, pleural contact, occurrence of intra-alveolar hemorrhage, pulmonary atelectasis, and pneumothorax are not associated with an increased risk of local tumor progression.

Predicting of Sentinel Lymph Node Status in Breast Cancer Patients with Clinically Negative Nodes: A Validation Study.

Simple SummarySentinel lymph node biopsy procedure is time consuming and expensive, but it is still the intra-operative exam capable of the best performance. However, sometimes, surgery is achieved without a clear diagnosis, so clinical decision support systems developed with artificial intelligence techniques are essential to assist current diagnostic procedures. In this work, we evaluated the usefulness of a CancerMath tool in the sentinel lymph nodes positivity prediction for clinically negative patients. We tested it on 993 patients referred to our institute characterized by sentinel lymph node status, tumor size, age, histologic type, grading, expression of estrogen receptor, progesterone receptor, HER2, and Ki-67. By training the CancerMath (CM) model on our dataset, we reached a sensitivity value of 72%, whereas the online one was 46%, despite a specificity reduction. It was found the addiction of the prognostic factors Her2 and Ki67 could help improve performances on the classification of particular types of patients.In the absence of lymph node abnormalities detectable on clinical examination or imaging, the guidelines provide for the dissection of the first axillary draining lymph nodes during surgery. It is not always possible to arrive at surgery without diagnostic doubts, and machine learning algorithms can support clinical decisions. The web calculator CancerMath (CM) allows you to estimate the probability of having positive lymph nodes valued on the basis of tumor size, age, histologic type, grading, expression of estrogen receptor, and progesterone receptor. We collected 993 patients referred to our institute with clinically negative results characterized by sentinel lymph node status, prognostic factors defined by CM, and also human epidermal growth factor receptor 2 (HER2) and Ki-67. Area Under the Curve (AUC) values obtained by the online CM application were comparable with those obtained after training its algorithm on our database. Nevertheless, by training the CM model on our dataset and using the same feature, we reached a sensitivity median value of 72%, whereas the online one was equal to 46%, despite a specificity reduction. We found that the addition of the prognostic factors Her2 and Ki67 could help improve performances on the classification of particular types of patients with the aim of reducing as much as possible the false positives that lead to axillary dissection. As showed by our experimental results, it is not particularly suitable for use as a support instrument for the prediction of metastatic lymph nodes on clinically negative patients.

Intravoxel incoherent motion magnetic resonance imaging for predicting the long-term efficacy of immune checkpoint inhibitors in patients with non-small-cell lung cancer

ObjectivesConventional evaluation of anti-tumor activity on the basis of tumor size is inadequate for immune checkpoint inhibitors (ICIs). We therefore aimed to assess the usefulness of intravoxel incoherent motion magnetic resonance imaging (IVIM-MRI) for evaluation of the therapeutic efficacy of ICIs. Materials and methodsA chest IVIM-MRI was performed before and 2, 4, and 8 weeks after administration of ICIs in patients with advanced non-small-cell lung cancer. Apparent diffusion coefficient (ADC), skewness of ADC (ADCskew), kurtosis of ADC (ADCkurt), true diffusion coefficient (D), pseudodiffusion coefficient (D*), and perfusion fraction (f) were evaluated at each evaluation point and changes from the baseline (Δ). ResultsTwenty patients were enrolled in this study. An increased ADC 8 weeks and decreased ADCkurt and ΔADCkurt 4 weeks after ICIs was associated with objective responses and longer progression-free survival (PFS). A decreased ΔADCskew at 4 weeks was associated with objective responses, disease control, and longer PFS and overall survival. There was no correlation between the efficacy of ICIs and D, D* and f. All of three patients who had pseudoprogression had decreased ΔADCskew at 4 weeks and two of them had decreased ΔADCkurt at 4 weeks. Inversely, all five patients who had progressive disease (PD) did not have increased ΔADCskew at 4 weeks and only one of them had decreased ΔADCkurt at 4 weeks. ConclusionsChanges in histograms of ADC may be useful for predicting long-term efficacy and distinguishing between pseudoprogression and actual PD after ICIs.

Preoperative chemotherapy in colorectal cancer patients with synchronous liver metastasis.

The response to preoperative chemotherapy is useful for predicting prognosis in unresectable and resectable disease. However, the prognostic benefit of chemotherapy prior to hepatectomy in patients with colorectal carcinoma and resectable or marginally resectable liver metastases remains unclear. The present study investigated the effect of preoperative chemotherapy on the prognosis of patients with colorectal cancer and resectable or marginally resectable synchronous liver metastasis. A total of 106 patients were retrospectively reviewed, who underwent hepatectomy for colorectal metastasis. The prognosis of 64 patients who received neoadjuvant chemotherapy (NAC) were compared with the 42 patients who did not (non-NAC). Furthermore, a total of 43 patients who responded to chemotherapy were compared with the 21 who did not. Preoperative chemotherapy was administered for 5.7 months, wherein 50 patients (78%) received a single regimen, and 54 (84%) received oxaliplatin. There were more patients with <3 metastases and maximum diameters <5 cm in the non-NAC group. The median survival time was 86.0 and 71.6 months in the NAC and non-NAC groups, respectively (P=0.33). Subgroup analysis on the basis of tumor size and number showed no prognostic differences between the two groups. The median survival time was longer in responders than in non-responders (85 vs. 56 months; P=0.01). However, the median relapse-free survival was equivalent in both groups (16.4 and 10.7 months). Preoperative chemotherapy did not prolong survival. Furthermore, it did not prevent recurrence, even in clinical responders. Therefore, it should not be routinely offered to patients with resectable liver metastasis before their hepatectomy.

Role of FDG PET/CT in the Eighth Edition of TNM Staging of Non-Small Cell Lung Cancer.

Lung cancer is the leading cause of cancer-related mortality in the United States, and accurate staging plays a vital role in determining prognosis and treatment. The recently revised eighth edition of the TNM staging system for lung cancer defines new T and M descriptors and updates stage groupings on the basis of substantial differences in survival. There are new T descriptors that are based on the findings at histopathologic examination, and T descriptors are reassigned on the basis of tumor size and extent. No changes were made to the N descriptors in the eighth edition of the TNM staging of lung cancer, because the four N categories that are based on the location of the diseased nodes can be used to consistently predict prognosis. The eighth edition includes a new M1b descriptor for patients with a single extrathoracic metastatic lesion in a single organ (M1b), because they have better survival and different treatment options, compared with those with multiple extrathoracic lesions (M1c). Examination with fluorine 18 fluorodeoxyglucose (FDG) PET/CT is the standard of care and is an integral part of the clinical staging of patients with lung cancer. To provide the treating physicians with accurate staging information, radiologists and nuclear medicine physicians should be aware of the updated classification system and should be cognizant of the site-specific strengths and limitations of FDG PET/CT. In this article, the eighth edition of the TNM staging system is reviewed, as well as the role of FDG PET/CT in the staging of non-small cell lung carcinoma. ©RSNA, 2018.

Radiologic/histologic discrepancies in tumour identification: The case of a “basketball‐sized” mandibular tumour in a woman from 17th century West Virginia

AbstractObjectivesWhen initially discovered in 1963, techniques did not allow definitive diagnosis of the basketball‐sized mandibular tumour discovered in a woman from the Buffalo site dated to 17th century West Virginia. Her subsequent medical examiners stated that they “can only speculate as to the true nature of the tumor.” An interdisciplinary approach was pursued to assess ability of currently available techniques to resolve this conundrum.Materials and methodsMacroscopic examination, X‐ray, computed tomography (CT), micro‐CT (7‐μ resolution), and epi‐illumination microscopy (100‐μ resolution) were utilized to identify diagnostic criteria that would allow discrimination among the possible etiologies.ResultsMacroscopic examination revealed a 24 by 23 by 19‐cm tumour attached to the right mandible. X‐ray examination revealed intact trabeculae of reduced size but of uniform thickness. CT examination revealed intact trabeculae of decreased size but uniform thickness. Epi‐illumination microscopy confirmed the CT findings. Trabeculae appeared to be intact, uniform in thickness, and with intact connectivity. Micro‐CT revealed significant variation in trabecular thickness with frequent areas of resorption and loss of interconnections.DiscussionOsteosarcoma was considered macroscopically, on the basis of tumour size. However, the small, uniformly sized, intact trabeculae recognized on X‐ray, CT, and with epi‐illumination microscopy presented the pattern anticipated with an osteoblastoma. Micro‐CT, however, falsified that diagnosis, in favour of an osteosarcoma diagnosis. The final consideration is of an osteoblastic osteosarcoma, apparently the first recognized in the archaeologic record. The misleading nature of routine X‐ray, CT, and even microscopy (at 100‐μ resolution) in this case stands as a caveat.

Reclassification as NIFTP: a Retrospective Review in a Single Institution with an Emphasis on Workload.

The aim of this study was to determine the number of cases of papillary thyroid carcinoma (PTC) which could be reclassified as non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in our institute over a 10-year period, document their clinical status and assess the number of slides that had to be reviewed per case to exclude NIFTP. The histopathology reports for thyroid resections for all papillary carcinoma over a 10-year period (2007-2016) were reviewed. Five hundred forty-five histopathology reports were reviewed, and 71 cases were identified as potential cases of NIFTP. Forty-nine (69%) cases had been referred from external departments and the slides were not available for review. Of the remaining 22 (31% of 71) cases, 5 were reclassified as NIFTP. The 17 cases that were not reclassified as NIFTP required review of 114 of 356 slides (median 5.5 slides per case) was required to exclude NIFTP. For the 5 NIFTP cases, 58 slides were reviewed (median 12 slides per case). We found that review of the histology reports alone was adequate for exclusion in most cases, e.g. classic PTC or EVPTC cases with documented lymphovascular invasion or capsular invasion. As a single exclusion criterion is required for exclusion from reclassification as NIFTP, this can be achieved efficiently. Two of the five patients received radioactive iodine [RAI] as per standard treatment at time of diagnosis, on the basis of tumour size. None have recurrent or metastatic disease with mean follow-up of 5.8years.

Tumor Control and Toxicity for Common Stereotactic Body Radiation Therapy Dose-Fractionation Regimens in Stage I Non-Small Cell Lung Cancer

To examine the impact of stereotactic body radiation therapy (SBRT) dose on outcomes in early-stage non-small cell lung cancer in a large single-institution series. We reviewed 600 patients treated from 2003 to 2012 for early-stage non-small cell lung cancer. The SBRT dose was at physician discretion on the basis of tumor size and location. Peripheral tumors were treated to 60Gy in 3 fractions (homogeneous planning), 48-50Gy in 4-5 fractions, or 30-34Gy in 1 fraction. Central tumors were treated to 50Gy in 5 fractions, 60Gy in 8 fractions, or 50Gy in 10 fractions. Patient, tumor, and treatment factors were assessed for their impact on patterns of failure, toxicity, and survival. An SBRT dose of 54-60Gy in 3 fractions was associated with a statistically significant lower rate of local failure (LF) (4.3% at 2years) compared with 30-34Gy in 1 fraction (21%), 48-50Gy in 4-5 fractions (15.5%), and 50-60Gy in 8-10 fractions (13.3%). Lower pre-SBRT hemoglobin and higher positron emission tomography standardized uptake value were also associated with LF. Nodal failure, distant failure, and overall survival were similar between fractionation groups. Pulmonary toxicity (crude rate, any grade) was slightly higher for 3 fractions (5.0%) compared with 1 (3.2%) or 4-5 fractions (3.8%). Chest wall toxicity was also higher for 3 (23.7%) compared with 1 (8.6%) or 4-5 (7.7%) fraction regimens. Although higher biologically equivalent dose SBRT (150-180 Gy10) may be associated with slightly lower LF, it was also associated with mildly increased toxicity and no difference in other patterns of failure or overall survival.

Abstract No. 461 - Prophylactic arterial embolization of renal tumors to reduce hemorrhagic complications following cryoablation

The incidence of hemorrhagic complications following percutaneous cryoablation of renal tumors is non-trivial, occurring in up to 4% of cases. Patients with tumors exceeding 5 cm are at greatest risk for bleeding, and in our practice we routinely embolize large tumors prior to ablation in order to mitigate this risk. Recently, some authors have disputed the utility of pre-embolization in this setting, although data on this subject are sparse. To that end, we aimed to determine the effect of prophylactic tumor embolization on hemorrhagic complications following renal cryoablation. In this single-institution retrospective study, 837 patients underwent renal cryoablation from 2003-2016. A total of 45 patients treated with pre-embolization were identified and matched 1:1 on the basis of primary tumor size to patients who were not pre-embolized. Clinically significant (CTCAE grade 3 + ) hemorrhagic complications were identified through a review of the electronic medical record and relevant imaging. Conditional logistic regression was used to test for a difference in the complication rates while controlling for the matched pair design. 45 pre-embolized patients (mean age 72 ± 12 years; 71% male) were matched to 45 non-embolized controls (71 ± 13 years, 80% male). Mean tumor size was 5.2 ± 1.7 cm (range: 1.7-9.7 cm). Overall, 71% of pairs were matched identically on the basis of tumor size, with 95% matched within 5 mm; the largest difference in size was 9 mm. Three hemorrhagic complications (6.7%) occurred in the pre-embolization group and six (13.3%) in the control group. The odds ratios for developing a hemorrhagic complication were 60% lower in the pre-embolization group; however, the effect was not statistically significant in this sample (OR = 0.40; 95% CI: 0.08–2.06; p = 0.27). While the OR did not reach statistical significance in this sample due to limited power, the magnitude of the effect warrants further investigation given the potential clinical significance of any reduction in hemorrhagic complications. A prospective study, which would benefit from randomization to balance the sample and account for putative confounding variables, is supported by these data.

Lymph node positivity in patients undergoing primary axillary node clearance on the basis of tumour size or multricentricity

Lymph node positivity in patients undergoing primary axillary node clearance on the basis of tumour size or multricentricity

Breast cancer: Determining the genetic profile from ultrasound-guided percutaneous biopsy specimens obtained during diagnostic workups

ObjectivesTo evaluate the possibility of determining the genetic profile of primary malignant tumors of the breast from specimens obtained by ultrasound-guided percutaneous biopsies during the diagnostic imaging workup. Material and methodsThis is a retrospective study in 13 consecutive patients diagnosed with invasive breast cancer by B-mode ultrasound-guided 12 G core needle biopsy. After clinical indication, the pathologist decided whether the paraffin block specimens seemed suitable (on the basis of tumor size, validity of the sample, and percentage of tumor cells) before sending them for genetic analysis with the MammaPrint® platform. ResultsThe size of the tumors on ultrasound ranged from 0.6cm to 5cm. In 11 patients the preserved specimen was considered valid and suitable for use in determining the genetic profile. In 1 patient (with a 1cm tumor) the pathologist decided that it was necessary to repeat the core biopsy to obtain additional samples. In 1 patient (with a 5cm tumor) the specimen was not considered valid by the genetic laboratory. The percentage of tumor cells in the samples ranged from 60% to 70%. In 11/13 cases (84.62%) it was possible to do the genetic analysis on the previously diagnosed samples. ConclusionIn most cases, regardless of tumor size, it is possible to obtain the genetic profile from tissue specimens obtained with ultrasound-guided 12 G core biopsy preserved in paraffin blocks.

Cáncer de mama: determinación del perfil genético a partir de la biopsia percutánea ecoguiada diagnóstica

ObjectivesTo evaluate the possibility of determining the genetic profile of primary malignant tumors of the breast from specimens obtained by ultrasound-guided percutaneous biopsies during the diagnostic imaging workup. Material and methodsThis is a retrospective study in 13 consecutive patients diagnosed with invasive breast cancer by B-mode ultrasound-guided 12 G core needle biopsy. After clinical indication, the pathologist decided whether the paraffin block specimens seemed suitable (on the basis of tumor size, validity of the sample, and percentage of tumor cells) before sending them for genetic analysis with the MammaPrint® platform. ResultsThe size of the tumors on ultrasound ranged from 0.6cm to 5cm. In 11 patients the preserved specimen was considered valid and suitable for use in determining the genetic profile. In 1 patient (with a 1cm tumor) the pathologist decided that it was necessary to repeat the core biopsy to obtain additional samples. In 1 patient (with a 5cm tumor) the specimen was not considered valid by the genetic laboratory. The percentage of tumor cells in the samples ranged from 60% to 70%. In 11/13 cases (84.62%) it was possible to do the genetic analysis on the previously diagnosed samples. ConclusionIn most cases, regardless of tumor size, it is possible to obtain the genetic profile from tissue specimens obtained with ultrasound-guided 12 G core biopsy preserved in paraffin blocks.

Role of PET/CT in Gastrointestinal Stromal Tumors

The first accurate description of mesenchymal neoplasms of the gastrointestinal tract (GIT) was in 1941. With the advent of immuno-histochemical analysis a definition of a new entity among gastrointestinal mesenchymal tumors called the gastrointestinal stromal tumors (GISTs); which particularly express the kit (CD117) protein; a growth factor trans-membrane receptor with tyrosine kinase activity(1 ) . Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal tumors of the gastrointestinal tract(2). GISTs are usually found in the stomach or small intestine but can occur anywhere along the gastrointestinal tract and rarely have extra-gastrointestinal involvement. Approximately 50-70% of GISTs originate in the stomach. The small intestine is the second most common location, with 20-30% of GISTs arising from the jejuno-ileum. Less frequent sites of occurrence include the colon and rectum (5-15%) and esophagus (<5%). Primary pancreatic, omental, or mesenteric GISTs have been reported but are very rare (3). Surgery remains the mainstay of therapy for patients with primary GIST who do not have evidence of metastasis and should be the initial therapy if the tumor is technically resectable with acceptable risk of morbidity. Regarding patients with a positive microscopic margin on final pathologic analysis, the management is still not well defined. There is no evidence that those patients with complete resection of all macroscopic disease, but still have microscopically positive margins, need to undergo re-excision. Lymphadenectomy is usually unnecessary because lymph node metastases are rare with GIST and sarcomas in general (4). There are different schemes for classification of GISTs on the basis of tumor size and mitotic count into very low risk, low risk, intermediate risk, and high risk. Alternatively, they are classified

Does tumor size limit application of laparoscopic surgery to ovarian tumors?

Abstract Objective We have found laparoscopic surgery to be both feasible and safe for large ovarian tumors, which at one time would have been managed strictly by conventional laparotomy. The aim of this study was to evaluate the potential risks and the outcomes of laparoscopic surgery for ovarian tumors on the basis of tumor size. Materials and methods From among 1248 cases of adnexal tumor treated at our institution between June 2005 and June 2014, we identified 1196 cases of preoperatively diagnosed benign ovarian tumor treated by laparoscopic surgery. We divided the cases into three groups according to the diameter of the tumor: ≤ 5cm (Group A, n = 355), 6–9 cm (Group B, n = 688), and ≥10 cm (Group C, n = 153) and investigated the incidences of perioperative complications and the rates at which laparotomy was converted to open surgery. Results Median operation time was 59 minutes, 7 minutes, and 73 minutes ( p p n = 4, n = 7, and n = 4, respectively), did not differ significantly between groups nor did the rate of conversion to laparotomy ( n = 1, n = 2, and n = 2, respectively). Tumor size was not a prognostic indicator of perioperative complications (Hazard Ratio (HR), 0.96; 95% confidence interval, 0.79–1.16; p = 0.652). Conclusion Operation time and estimated blood loss were shown to increase with the size of an ovarian tumor. However, we found no relation between tumor size and the perioperative complication rate or the rate of conversion to open surgery. Thus, we conclude that tumor size is not a factor limiting application of laparoscopic surgery to ovarian tumors.

Total laparoscopic management of lesions involving liver segment 7.

Until recently, laparoscopic resection of tumors involving segment 7 (s7) of the liver was seen as a relative contraindication. We analyzed our experiences with laparoscopic resection of tumors in s7. Retrospective analysis of prospective database on operative and postoperative characteristics and surgical outcomes of patients in whom the intention was to remove tumors located in s7 of the liver laparoscopically. We defined two groups: those with laparoscopic metastasectomy of s7 (s7 group) and those undergoing laparoscopic right posterior sectionectomy (RPS group). Of 400 patients undergoing laparoscopic liver resection, 20 patients (5%) underwent total laparoscopic resections of tumors in s7 (7 metastasectomy of s7 and 13 RPS). The type of resection was decided on the basis of tumor size and location. Median age was 70years (range 46-82), and the indication for surgery was mainly CRLM (n=13, 65%) and HCC (n=4, 20%). There was 1 (5%) conversion. Mean operative times were 252min (±69) for s7 and 271min (±102) for RPS. The mean intraoperative blood loss was 400mL (±493) for s7 and 625mL (±363) for RPS. A Pringle maneuver was used in 86% of patients in s7 group and 75% of patients in RPS group. Mean total hospital stay was 4.6days (±2.5) in s7 and 6.9days (±7.8) for RPS. The overall R0 resection rate was 95% (s7 100%, RPS 92%). Although resection of lesions in s7 is technically demanding, a laparoscopic approach can be performed safely and effectively in experienced hands.

Preoperative ultrasound features as prognostic factors for patients with hepatocellular carcinoma.

Ultrasound is the most common imaging tool used to scan the tumours of hepatic carcinoma patients. However, very few studies have been performed to evaluate ultrasound imaging features for predicting tumour prognosis. Therefore, the goal of the current study was to evaluate preoperative ultrasound characteristics as prognostic factors that could affect survival rate after liver resection for hepatocellular carcinoma (HCC). A total of 104 HCC patients who underwent resection were retrospectively reviewed with regard to their clinical data, preoperative ultrasound characteristics, and survival rate. Preoperative ultrasound parameters included cirrhosis, tumour site, size, echo pattern, portal vein thrombosis, intra-tumour blood flow signal, peak systolic velocity (V max), and resistance index (RI). The Kaplan-Meier method was used to calculate survival. Pre-resection prognostic factors were assessed using univariate log-rank test and a multivariate Cox proportional hazards model. The median survival was 37months. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 78.85, 53.85, and 26.92%, respectively, and the overall survival (OS) rates at 1, 3, and 5years were 85.58, 69.23, and 46.15%, respectively. On univariate analysis, shorter survival was associated with mixed echo pattern, larger tumour size, portal vein thrombus, affluent flow signal, and higher V max. Application of the Cox multivariate proportional hazards model indicated that tumour size and blood flow signal in the tumours were independent prognostic factors. The overall survival for HCC patients undergoing hepatic resection can be stratified on a sonographic basis of tumour size and intra-nodular vasculature. These prognostic factors may be useful to determine appropriate treatment for HCC patients.

Prolapsed Gastric Gastrointestinal Stromal Tumor: A Rare Cause of Biliary Obstruction and Acute Pancreatitis

77-year-old woman presented with abdominal Apain and early satiety. Computed tomography of the abdomen (Figure A) showed a 6-cm submucosal mass (white arrow) on a stalk (black arrow) arising from the gastric fundus as well as several benignappearing liver lesions. Esophagogastroduodenoscopy (Figure B) demonstrated the same non-friable, nonobstructing gastric mass (white arrow) and its stalk (black arrow). While biopsy results were pending, the patient presented to the emergency department with acutely worsening abdominal pain, nausea, vomiting, and jaundice. Laboratory evaluation was significant for the following: alanine aminotransferase 83 U/L, aspartate aminotransferase 117 U/L, total bilirubin 4 mg/dL, and lipase 5315 U/L. Computed tomography imaging (Figure C) showed that the aforementioned mass had prolapsed into the duodenum (white arrow) and obstructed the ampulla of Vater, resulting in dilation of the common bile duct (white arrowhead), pancreatic duct (black arrow), and gallbladder. The mass was resected surgically, and microscopic evaluation (Figure D) revealed a low-grade spindle-cell neoplasm expressing CD117 (KIT), which is consistent with a gastrointestinal stromal tumor (GIST). The patient recovered well from surgery. Her serum bilirubin and lipase levels normalized, and postoperative imaging showed resolution of the pancreatobiliary ductal dilation. Because this GIST carried a low (<5%) risk for recurrence on the basis of its size (5–10 cm), location (stomach), and low mitotic rate ( 5 mitoses/50 high-power field), we did not recommend any adjuvant therapy. Comprising fewer than 1% of all gastrointestinal tumors, GISTs are intramucosal spindle-cell neoplasms that can arise throughout the gastrointestinal tract but are most commonly found in the stomach. Although they are frequently discovered incidentally, GISTs may cause early satiety, bloating, bleeding, pain, or frank bowel obstruction. Our patient presented with pancreatitis and biliary obstruction (manifested by elevated serum lipase and bilirubin levels and a radiographic “double-duct” sign) because of a prolapsed GIST obstructing the ampulla of Vater. Although gastric GISTs or polyps may infrequently prolapse through the pylorus into the duodenum, to our knowledge there are only 2 published case reports of gastric GIST causing pancreatitis and no published reports of gastric GIST causing both pancreatitis and biliary obstruction. After resection of a GIST, the consulting oncologist can assess recurrence risk on the basis of tumor size, mitotic rate, and anatomic location and, in turn, determine whether to recommend imatinib, which has been shown to improve recurrence-free survival in patients with resected intermediate or highrisk GIST.