Hepatic Nodes Research Articles

A case of intraductal papillary neoplasm of the bile duct that developed 38\u2009years after choledochoduodenostomy with invasive adenocarcinoma and lymph node metastasis

BackgroundIntraductal papillary neoplasm of the bile duct (IPNB) is a bile duct neoplasm characterized as a precursor lesion of cholangiocarcinoma. An invasive component is present in approximately 40 to 80% of reported cases and lymph node metastasis is sometimes detected. We experienced a rare case of IPNB with invasive adenocarcinoma and lymph node metastasis that developed 38 years after choledochoduodenostomy.Case presentationA 72-year-old man presented to our hospital for liver dysfunction. The patient had a past medical history of choledochoduodenostomy for a bile duct stone 38 years previously and short bowel syndrome because of strangulation ileus 32 years previously.Ultrasonography and abdominal enhanced computed tomography (CT) revealed a left intrahepatic bile duct dilation and a papillary mass in the left hepatic duct. Positron emission tomography (PET) CT showed abnormal accumulation in the left hepatic duct and in the hepatic hilar lymph node. Endoscopic retrograde cholangiogram showed a filling defect in the left bile duct, and a cytological examination revealed the presence of atypical cells.We diagnosed cholangiocarcinoma (derived from IPNB) with lymph node metastasis and performed extended left hepatectomy, caudate lobectomy, and lymph node dissection without extrahepatic bile duct resection.Histopathological findings showed papillary adenoma and partially invasive poorly differentiated adenocarcinoma in the bile duct. Additionally, the hepatic hilar lymph node was positive.ConclusionsThe tumor was diagnosed as IPNB with invasive adenocarcinoma and lymph node metastasis. Biliary tract cancer that develops after choledochoduodenostomy is extremely rare, and only 17 cases (including IPNB) have been reported in the literature.

Extended Lymphadenectomy Versus Regional Lymphadenectomy in Resectable Hilar Cholangiocarcinoma

AimThe aim of this study is to compare the effects of extended lymphadenectomy (E-LD) and regional lymphadenectomy (R-LD) on outcome after radical resection of hilar cholangiocarcinoma (HCCA). MethodsData of 290 patients who underwent radical resection of HCCA were retrospectively analyzed. Demographic characteristics, surgical variables, and tumor and LN characteristics were evaluated for association with survival. ResultsA total of 63 patients underwent E-LD. Patients who underwent E-LD were more likely to have portal vein embolization (14.3% vs. 5.7%), radical hepatectomy (36.2% vs. 26.0%), higher proportion of M1 patients (22.2% vs. 5.3%), more lymph nodes (LNs) retrieved (17 vs. 7), and positive common hepatic artery lymph nodes (21.4% vs. 12.6%) when compared with R-LD (all P < 0.05). The Kaplan–Meier curve of overall survival for patients who underwent E-LD indicated improvement over patients who underwent R-LD in M0 (33.39 vs. 21.31 months; P = 0.032) and R0 resection (32.97 vs. 21.02 months; P = 0.044) disease, but not observed in M1 disease (P > 0.05). After propensity score matching, E-LD was not associated with a significant improvement in overall survival (OS) even in all subgroup analysis (all P > 0.05). On multivariable analysis, E-LD was associated with improved overall survival, but not after propensity score matching. ConclusionE-LD is more likely to be performed in higher stage tumors. E-LD significantly increases LN retrieval, thereby preventing under-staging and improving survival prediction. E-LD should not be adopted for HCCA patients with intraoperatively confirmed distant LN metastases. Future studies are required to further assess whether E-LD should be performed in negative celiac, superior mesenteric, and para-aortic lymph node in HCCA patients.

Modern technologies of ultrasound diagnostics of cirrhosis in chronic liver diseases in children

By methods of ultrasound (US) diagnostics there were examined 177 children at the age offrom 2 months to 17 years, with liver cirrhosis (LC) in the outcome of chronic hepatitis (CH) of various etiologies. It was found that, irrespective of the etiological factor there is noted a large number of general ultrasound characters typical for stages of the formation of the LC: «streaking» of the hepatic image, cirrhotic nodes, splenomegaly and signs ofportal hypertension. The rate of the formation of LC was analyzed in dependence on the etiological factor. It was established that often, and in a short time LS develops in the outcome of CHD, autoimmune hepatitis and cryptogenic chronic hepatitis. In the examination of 135 children there were included invasive (biopsy) and non-invasive ultrasound methodologies for the quantitative assessment of the liver parenchyma structure: Acoustic Structure Quantification (ASQ) and Transient elastography (TEP). Based on a comparative analysis of US and morphological data SP values&gt; 2.77 and elasticity&gt; 13.90 were established to indicate LC (F4) according to METAVIR system. There were established additional diagnostic criteria for the assessment of the severity of the state of LC patients: density index (DI) increased significantly as far as the disease progresses. The use of non-invasive techniques dramatically expands the diagnostic capabilities of a traditional ultrasound examination of the liver.

Ultrasonic evaluation of the hepatic parenchyma in the end-stage cirrhosis in children with rare metabolic diseases

There were examined 209 children, agedfrom 3 months to 18years with metabolic liver diseases (MLD) of various etiology. The diagnosis of MLD was based on data of totality of clinical laboratory indices and data of molecular genetic studies. By means of ultrasonic (US) methods there was performed an evaluation both of the structure of the liver parenchyma and the grade of the pronouncement offibrosis with the use of traditional US method and non-invasive method for the quantitative assessment of the structure of liver parenchyma Acoustic Structure Quantification (ASQ) with the determination of density index (DI). At that US data were compared with morphological observations. According to data of the traditional US examination the signs of liver cirrhosis were of the «streaking» of the hepatic image, cirrhotic nodes and signs of portal hypertension. According to ASQ data in the end-stage cirrhosis DI was in the range of from 2.77 to 4.58 in dependence on etiologic factor: in glycogen storage disease in the average accounted of 2.88, in patients with Wilson disease -3.08, in hereditary tyrosinemia type 1 (HT-1) - 3.37, in cystic fibrosis patients - 3.89 and in congenitalfibrosis - 4.18. Comparative analysis of US and morphological data showed the expediency of complex non-invasive US observations in the assessment of the pronouncement of the stage of liver fibrosis in MLD children.

Th2-related cytokines are associated with Fasciola gigantica infection and evasion in the natural host, swamp buffalo

The infection of ruminants by Fasciola spp. always induces a non-protective Th2-type immune response. However, little is known about changes in the local and systemic immune environment during F. gigantica migration in buffalo. In this study, native swamp buffaloes were each infected with 500 viable F. gigantica metacercariae. Mesenteric lymph node (MLN), hepatic lymph node (HLN), spleen, and serum samples were collected from control and infected buffaloes at 3, 10, 28, 42, 70, and 98 days post-infection (DPI). The mRNA expression levels of the Th1- and Th2-related cytokines IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p40, IFN-γ, TNF-α, and CD4 were measured during different infection stages in the MLNs, spleens, and HLNs using quantitative real-time PCR (qRT-PCR). Levels of the specific anti-ESP isotype antibodies IgG, IgG1, and IgG2 were used to reflect changes in humoral immunity. The results of this study indicated that swamp buffaloes were susceptible to F. gigantica infection, and that susceptibility to this infection was closely related to the cytokine environment associated with the Th2-type immune response. The MLNs showed a mixed Th1- and Th2-type immune response during the acute infection stages, after which the production of these cytokines returned to normal. Cytokine expression in the HLNs also expressed a mixed Th1- and Th2-type immune response during the early infection stages. When the infection became chronic, the typical Th2 immune response was induced in the HLNs. At the acute infection stages, the spleen exhibited a Th2 immune response. Nevertheless, cytokines associated with the Th1 and Th2 immune responses were upregulated at 98 DPI. In addition, the total IgG and IgG1 of the parasite-specific antibodies increased. This suggested that the Th2-related cytokines and IgG1 induced by F. gigantica infection might mediate successful F. gigantica infection in the natural host, swamp buffalo.

Characterization of Antigen-Presenting Cell Subsets in Human Liver-Draining Lymph Nodes.

T-cell immunity in the liver is tightly regulated to prevent chronic liver inflammation in response to antigens and toxins derived from food and intestinal bacterial flora. Since the main sites of T cell activation in response to foreign components entering solid tissues are the draining lymph nodes (LN), we aimed to study whether Antigen-Presenting Cell (APC) subsets in human liver lymph-draining LN show features that may contribute to the immunologically tolerant liver environment. Healthy liver LN, iliac LN, spleen and liver perfusates were obtained from multi-organ donors, while diseased liver LN were collected from explanted patient livers. Inguinal LN were obtained from kidney transplant recipients. Mononuclear cells were isolated from fresh tissues, and immunophenotypic and functional characteristics of APC subsets were studied using flowcytometry and in ex vivo cultures. Healthy liver-draining LN contained significantly lower relative numbers of CD1c+ conventional dendritic cells (cDC2), plasmacytoid DC (PDC), and CD14+CD163+DC-SIGN+ macrophages (MF) compared to inguinal LN. Compared to spleen, both types of LN contained low relative numbers of CD141hi cDC1. Both cDC subsets in liver LN showed a more activated/mature immunophenotype than those in inguinal LN, iliacal LN, spleen and liver tissue. Despite their more mature status, cDC2 isolated from hepatic LN displayed similar cytokine production capacity (IL-10, IL-12, and IL-6) and allogeneic T cell stimulatory capacity as their counterparts from spleen. Liver LN from patients with inflammatory liver diseases showed a further reduction of cDC1, but had increased relative numbers of PDC and MF. In steady state conditions human liver LN contain relatively low numbers of cDC2, PDC, and macrophages, and relative numbers of cDC1 in liver LN decline during liver inflammation. The paucity of cDC in liver LN may contribute to immune tolerance in the liver environment.

Robotic portal lymphadenectomy with segment 4b and 5 resection for gallbladder cancer

Background: Our video describes the use of the da Vinci Surgical System Xi® (Intuitive Surgical, Sunnyvale, CA) to perform a portal lymphadenectomy with resection of segment 4B and 5 of the liver for gallbladder cancer. The patient is a 76 y.o. female who was found to have an incidental pT2pNx gallbladder adenocarcinoma following a laparoscopic cholecystectomy. CT of the chest, abdomen and pelvis were negative for metastasic disease. The procedure was begun with diagnostic laparoscopy which was negative for peritoneal metastasis. Results: The round ligament was taken down using the monopolar scissors and left attached to the under surface of the liver. This was later used as a vascularized pedicle flap to cover the resection bed of the liver at the end of the procedure. Firefly™ fluorescence imaging was used to confirm the junction of the cystic duct stump and the common bile duct. The cystic duct stump was then clipped and divided close to the common bile duct. Intra operative ultrasound was used to identify critical vascular structures and their relationship to the common bile duct and portal lymph nodes. The lymphadenectomy was begun at the lateral aspect of the porta hepatis by incising the peritoneum overlying the porta hepatis and common bile duct. The lateral portal and posterior duodenal lymph nodes were dissected off the common bile duct and portal vein using the mono polar scissors. The lesser omentum was then opened and the hepatic artery lymph nodes were dissected off the hepatic artery. The posterior medial lymph nodes and celiac nodes were also dissected and the specimen was removed en bloc. The EndoWrist® One™ vessel sealer was used to take a wedge of segments 4B and 5 of the liver with a 2 cm margin around the gallbladder fossa. The previously fashioned round ligament flap was then placed into the defect as a vascularized pedicle flap. Final pathology revealed six negative lymph nodes, with a negative cystic duct stump and liver parenchymal margin. The patient’s post-operative course was uneventful and as expected for the procedure.

Laparoscopic liver resection for intrahepatic cholangiocarcinoma

Background: Cholangiocarcinoma is the most common biliary tract malignancy, and the second most common type of primary liver cancer. It is more common in Asia but its incidence in North America is increasing. CCA can be categorized as intrahepatic (iCCA) or extrahepatic (perihilar – pCCA/distal – dCCA). There are three main staging systems: American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC); Liver Cancer Study Group of Japan (LCSGJ); and National Cancer Center of Japan (NCCN). Its clinical presentation is unspecific, and it varies depending on tumor location and stage disease. Combined interpretation with different diagnostic modalities is necessary. Methods: A 73-year-old female presented with mild abdominal discomfort and back pain to her primary care physician. Laboratorial exams were requested, and elevated liver enzymes were noted. Abdominal ultrasound was performed that showed left-sided bile duct dilation. Patient underwent an abdominal MRI that identified tortuous and markedly dilated left intrahepatic bile ducts with lobular enhancing intraductal mass with restricted diffusion in the left main hepatic duct measuring approximately 2.3 x 0.9 x 0.8 cm. ERCP with biopsy was made, and a polypoid lesion in the left bile duct was seen. The papillary epithelium was consistent with high-grade dysplasia with possible intraductal papillary neoplasm or cholangiocarcinoma. Laparoscopic surgery was indicated. Patient underwent a cholecystectomy, hepatoduodenal lymphadenectomy, left hepatectomy, and en bloc caudate resection. Results: The Patient was in supine position. General anesthesia was induced. A supraumbilical incision was made. The abdomen was entered without difficulty. Hasson trocar was placed, pneumoperitoneum established. The laparoscope was induced, and the abdomen was explored. The patient had no signs of metastatic or peritoneal disease. The left lobe appeared atrophied, and the right lobe appeared quite hypertrophied. No signs of underlying liver disease. Therefore, 2 additional right-sided 12-mm trocars, an epigastric 5 and a left side 5 trocars were placed. An enlarged hepatic artery lymph node was identified, resected and sent for frozen, it was negative for neoplasia. Cholecystectomy and hepatoduodenal lymphadenectomy were performed. The intrahepatic lesion was resectable, and the caudate lobe appeared potentially involved. It was decided to perform a left hepatectomy with en bloc caudate lobe resection. Specimen was analyzed by Pathology, that confirmed grossly and microscopically widely negative margins. The surface of the liver was cut, and packed with gauze and Surgicel. This was completely dry. There was adequate arterial and portal inflow with biliary drainage to the right lobe of the liver, and no sign of bile leak. Surgicel SNoW and Surgicel gauze were placed against the cut surface of the liver, and closed the specimen extraction site with multiple figure-of-eight 0 Vicryl sutures, and desufflated the abdomen through the trocars, removed the trocars, and closed the 12-mm trocar with a single interrupted 0 Vicryl, and closed the skin with running 4-0 subcuticular stitch and covered with Dermabond. Counts were reported as correct. No complications. No drains. Estimated blood loss was 300 mL. Patient tolerated the surgery well, and was discharged on postoperative day 3. Conclusion: Surgery is the only potentially curative therapeutic option for Cholangiocarcinoma. Minimally invasive approach is challenging, and not widely performed by surgeons. It requires expertise in liver and laparoscopic technique. Despite this, it is feasible, and safe for intrahepatic Cholangiocarcinoma. There are no differences in oncologic outcomes. Blood loss seems to be higher when open surgery is performed, and lymphadenectomy higher in minimally invasive approaches. There are no significant differences between length of hospital stay and complication rates. Laparoscopic liver resection is a treatment modality that should be considered for selected patients with intrahepatic cholangiocarcinoma.

Identification of reference genes for real-time PCR cytokine gene expression studies in sheep experimentally infected with Fasciola hepatica

The aim of this study was to validate reference genes for gene normalisation using qRT-PCR in hepatic lymph nodes (HLN) and livers from sheep infected with Fasciola hepatica during early and late stages of infection. To this end, a comprehensive statistical approach (RefFinder) encompassing four different methods of analysis (geNorm, BestKeeper, ΔCt method and NormFinder) was used to validate ten candidate reference genes. Stability analysis of gene expression followed by pairwise variation (Vn/Vn + 1) analysis revealed that PGK1, HSP90AA1 and GYPC were the most stable reference genes and suitable for qRT-PCR normalisation in both HLN and liver tissues. These three genes were validated against FoxP3, IL-10, TGF-β, TNF-α and IL-1β genes in the HLN tissue of sheep vaccinated with Cathepsin L1 from F. hepatica and unvaccinated infected and uninfected controls during early stages of infection. In the liver, the three reference genes were validated against TNF-α and IL-1β during chronic stages of infection with F. hepatica and in uninfected controls. Our study is the first to evaluate and validate sheep reference genes in order to provide tools for monitoring cytokines in Fasciola hepatica infected sheep target organs. Our results present an approach to elucidate the role of different cytokines in F. hepatica vaccinated and infected sheep.

Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma?

Background: The aim of this study was to describe the predictive value of hepatic artery lymph node(HALN) metastasis compared to peripancreatic lymph node (PPLN) in overall survival (OS) and disease-free survival(DFS) of those patients who underwent pancreaticoduodenectomy(PD) for pancreatic adenocarcinoma(PA). Methods: A single-center retrospective study which analyze prospectively those patients who underwent PD for PA between 2003 and 2014.Patients were included if during PD the HALN was submitted for pathologic evaluation and with at least one year of follow-up.Patients were excluded if margins were macroscopically positive.The median follow-up was 21 months. Results: Of the 125 who underwent PD for PA,HALN status was analyzed for 64 patients.HALN was positive in 12 patients(19%),HALN and PPLN were negative in 12 patients(19%) and 40 patients (62%) were HALN-/PPLN+.The OS at 1, 3 and 5 years was:HALN+ group 72%, 9% and 9%; HALN-/PPLN- group 91%, 70%, 47% and HALN-/PPLN+ group 68%,29%,17% respectively (p = 0.015). The DFS at 1,3 and 5 years was:HALN+ group 45%,9% and 0%; HALN-/PPLN- group 81%,38%,38% and HALN-/PPLN+ group 43%,17%,10% respectively(p = 0.05). In multivariable model, the main risk factor for OS and DFS was the PPLN involvement(HR 2.7;CI 1.05-6.93) and the adjuvant chemotherapy the main protective factor(HR 0,13;IC 0,05-0,31). Conclusion: Despite OS as DFS are significantly reduced in patients with positive HALN,multivariate model showed the PPLN status as the main factor of poor prognosis in our series.

Colorectal liver metastases and concomitant extrahepatic disease: is resection justified? Single center survival analysis on 84 patients

Background: Limited extrahepatic disease (EHD) in patients with colorectal liver metastases (CRLM) is no longer considered an absolute contraindication to resection. However the impact of the different sites of EHD on survival remains to be defined. Methods: Between 2000 and 2015, 702 patients underwent liver resection for CRLM at our Unit. Of these, 84 patients (11.8%) underwent resection of concomitant EHD and they are the object of our study. Results: Site of EHD was: lung in 27 patients (32.1%), hepatic pedicle lymph nodes (LN) in 38 (44.1%), peritoneum in 18 (19.0%), distant LN (inguinal and aortocaval sites) in 4 (4.8%). Sixty patients (71.4%) underwent preoperative chemotherapy (CT): 5-year overall survival (OS) after resection of CRLM and concomitant EHD was significantly higher in patients with response to CT than that in patients resected with progression (32.4% vs. 14.6%, respectively, p=0.01). Five-year OS of patients resected for liver-only CRLM was not significantly different from that of patients resected for CRLM and concomitant lung metastases (55.3% vs. 39.5%, respectively, p=ns). Resection of concomitant hepatic pedicle LN metastases was associated with a significantly lower 5-year OS (15.0%, p<0.001). Conclusion: In selected patients resection of concomitant lung metastases can be associated with similar OS to that of patients resected for liver-only disease. Presence of hepatic pedicle LN metastases is a poor prognostic factor and resection should be considered in patients showing response to CT.

Colorectal liver metastases and concomitant extrahepatic disease: is resection justified? Single center survival analysis on 84 patients

Background: Limited extrahepatic disease (EHD) in patients with colorectal liver metastases (CRLM) is no longer considered an absolute contraindication to resection. However the impact of the different sites of EHD on survival remains to be defined. Methods: Between 2000 and 2015, 702 patients underwent liver resection for CRLM at our Unit. Of these, 84 patients (11.8%) underwent resection of concomitant EHD and they are the object of our study. Results: Site of EHD was: lung in 27 patients (32.1%), hepatic pedicle lymph nodes (LN) in 38 (44.1%), peritoneum in 18 (19.0%), distant LN (inguinal and aortocaval sites) in 4 (4.8%). Sixty patients (71.4%) underwent preoperative chemotherapy (CT): 5-year overall survival (OS) after resection of CRLM and concomitant EHD was significantly higher in patients with response to CT than that in patients resected with progression (32.4% vs. 14.6%, respectively, p=0.01). Five-year OS of patients resected for liver-only CRLM was not significantly different from that of patients resected for CRLM and concomitant lung metastases (55.3% vs. 39.5%, respectively, p=ns). Resection of concomitant hepatic pedicle LN metastases was associated with a significantly lower 5-year OS (15.0%, p<0.001). Conclusion: In selected patients resection of concomitant lung metastases can be associated with similar OS to that of patients resected for liver-only disease. Presence of hepatic pedicle LN metastases is a poor prognostic factor and resection should be considered in patients showing response to CT.

Undifferentiated Carcinoma of the Gallbladder: Report of Three Cases

Introduction: Undifferentiated carcinoma (UC) is a rare malignant neoplasm in gallbladder (GB). We report here four cases of UC arising in the GB together with a review of the literature. Method: Between 1994 to 2015, patients with GB cancer who received curative resection were reviewed and we found three UC cases. Result: The first 68-year-old man presented with body weight loss, febril and chilly sensation. Imaging studies revealed an 4.2x2.4-cm fungating mass in the fundus of the GB. Multiple hepatic and para-arotic lymph node metastasis was detected at postoperative 2 months and the patient died at 4 months after surgery. In the second case, a 72-year-old man presented with abdominal pain and febrile sensation. On gross examination, a 15x10-cm tumor was originated from the gallbladder and directly invaded into liver, transverse colon, and omentum. Histological section revealed an UC and hepatic resection margin was involved by the tumor cell. Regional node metastasis was confirmed. Unfortunately, the patient diet at 50 day after surgery due to postoperative sepsis. The third case was a 65-year-old woman who presented with right upper quadrant abdomian pain. The patients was detected multiple hepatic and para-aortic lymph node metastasis at postoperative 2 months after surgery and was treated with systemic chemotherapy, but disease rapidly was progressed and the patient died at 6 months after surgery. Conclusion: Undifferentiated carcinoma of the gallbladder was a rare highly malignant neoplasms. It showed a large tumor pattern with involvement of adjacent organ and the prognosis was very poor.

Spectrum of lymphnodal involvement following extended cholecystectomy and its correlation with pT stage in carcinoma gall bladder patients

Introduction: The spectrum of lymph nodal involvement following extended cholecystectomy and its correlation with pT Stage in carcinoma gall bladder patients is an area with less reported inspite of its pivotal role in staging and prognosis. Method: A prospective observational study including 57 patients with Carcinoma gall bladder who had undergone extended cholecystectomy with systematic lymphadenectomy between January 2014 to December 2015 in PGIMER, Chandigarh. All the resectable patients underwent standard extended Cholecystectomy with n aim to achieve R0 resections and lymphnodal dissection of cystic, pericholedochal, peripancreactic, periportal, coeliac artery, Common Hepatic Artery, LHA, RHA, Hepato-duodenal lymph nodes were sent separately with main specimen for evaluation. Result: Out of 57 patients, 8 were excluded (5 were xanthogranulomatous cholecystitis, 2 were chronic cholecystitis, 1 was IgG4 related disease). A total of 555 lymph nodes were examined in 49 patients with range of 0 to 26 and median of 11.79.Lymph nodal involvement found in 19 patients(38.7% ) out of 49. Lymph nodal involvement in order of frequency was peripancreatic (n=9/49;18.4%),common hepatic artery(n=7/49;14.3%), periportal(n=7/49;14.3%), hepato-duodenal(n=5/49;10.2%), pericholedochal (n=4/49;8.2%), cystic (n=3/49;6.1%) ,coeliac (n=2/49;4.1%), LHA nodes(1/49;2%) and RHA lymph nodes (1/49;2%). Lymph nodal involvement in our study with respect to tumor staging was, pT1 stage (n=5/49;10.2%) - periportal lymph nodes involved(n=1/5;20%), pT2 stage (n=12/49;24.5%) - pericholedochal (n=3/12;25%), cystic (n=2/12;16.6%) ,peripancreatic (n=2/12;16.6%) ,Common Hepatic Artery nodes (n=1/12;8.3%),periportal(n=1/12;8.3)hepato-duodenal nodes(n=1/12;8.3), pT3 stage tumors(n=32/49;65.3%) - peri-pancreatic(n=7/32;21.9%),Common Hepatic Artery (n=6/32;18.7%), periportal (n=5/32;15.6%),hepato-duodenal(n=4/32;12.5%) ,celiac (n= 2/32 ;6.25%) ,pericholdecochal (n=1/32;3.1%), LHA nodes (n=1/32;3.1%),RHA nodes(n=1/32;3.1%),cystic lymph nodes (n=1/32;3.1%) with p>0.05. Conclusion: Peripancreatic lymph nodes were the most commonly involved irrespective of ‘pT’stage. Our study mandates the role of systemic lymphadenctomy for better tumor clearance and staging even in early carcinoma Gallbladder however its translation in to better survival is yet to be studied.

Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma?

Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma?

Ulcerated duodenal gastrointestinal stromal tumor – Demonstration of an interesting radiological sign (the Torricelli-Bernoulli sign)

The Torricelli-Bernoulli sign is a useful computed tomographic sign seen in ulcerated/necrotic gastrointestinal stromal tumor (GIST) or leiomyosarcoma characterized by the collection of air in the nondependent aspect of larger gastrointestinal cavitating tumors. This sign is based on the physical principle of the law of Torricelli's and Bernoulli's principle. Herein, we describe this interesting imaging sign in an adult male with malignant duodenal GIST with extensive hepatic, peritoneal, omental, and lymph nodes (though rare in GIST) metastasis. The patient succumbed few days after admission.

EDGE non-invasive radiosurgery for gastric neuroendocrine hepatic portal lymph node metastases: a case report

Abstract Treating metastatic gastric neuroendocrine neoplasms (gNENs) is challenging, especially for those with progressive disease during somatostatin analog processing. In this report, we present a case of a well-differentiated grade 2, type 3 gNEN with metastatic hepatic portal lymph nodes. EDGE non-invasive radiosurgery (800 cGy × 5 F) was performed to radiate the metastatic hepatic portal lymph nodes. Three months after the hyperfractionated radiotherapy, no signs of metastatic hepatic portal lymph nodes were observed using 8Ga-dotatate positron emission tomography-computed tomography or magnetic resonance imaging. Therefore, EDGE non-invasive radiosurgery could be a potential option for treating local metastatic nodes.

Dissection of the hepatic artery lymph node for the preparation of a safe laparoscopic portal-mesenteric venous tunnel

Dissection of the hepatic artery lymph node for the preparation of a safe laparoscopic portal-mesenteric venous tunnel

Abstract 3627: Organ-specific differential responses to immune checkpoint inhibitors in patients with advanced hepatocellular carcinoma

Abstract Background: Immune checkpoints inhibitors (ICIs) such as anti-PD-1/PD-L1 monoclonal antibodies exhibit significant clinical activity in patients with advanced hepatocellular carcinoma (HCC). Immune microenvironments of different organs are often different and may affect the efficacy of immunotherapy. The study explores whether tumor response to ICIs of HCC may vary among different organs. Patients and Methods: We reviewed patients with advanced HCC who had received anti-PD-1, anti-PD-L1, or anti-CTLA-4 therapy, alone or in combination, in 3 medical centers in Taiwan. Patients with measurable diseases were enrolled. An organ-specific response criteria, modified from RECIST 1.1, allowing a maximum of 5 measurable lesions per organ system, was used to evaluate the responses to ICIs for tumors of individual organ system. The organ-specific complete responses (CR), partial responses (PR), stable diseases (SD), or progressive diseases (PD) were determined for individual organ system. Results: A total of 76 patients (Male: Female= 62: 14, median age of 59.1 years) with advanced HCC were enrolled. Among them, 51 (67.1%) and 12 (15.8%) patients had chronic hepatitis B virus or chronic hepatitis C infection. The ICI treatments included anti-PD-1 or anti-PD-L1 alone, anti-CTLA4 alone, and anti-PD-1/PD-L1 plus anti-CTLA4 combination in 59, 1, and 16 patients; 20 and 56 patients had received ICIs as first-line or ≥ 2nd-line therapy. The overall response rate (RR) by RECIST 1.1 was 28.9%. Fifty-nine, 34, 18, and 18 patients who had measurable hepatic tumors, lung, lymph node, and intra-abdomen metastases were subject to organ-specific response evaluation. Organ-specific RRs of hepatic tumors, lung, lymph node, and intra-abdomen metastases, were 23.7, 41.2, 27.8, and 38.9%, respectively. Among 39 patients who had both hepatic and extrahepatic tumors, 16 had significant differential responses between hepatic and extrahepatic tumors: 12 of them had disease control (CR/PR/SD) in extrahepatic tumors and PD in hepatic tumors, and 4 exhibited disease control in hepatic tumors and PD in extrahepatic tumors (p=0.046). Moreover, in 16 patients with only evaluable hepatic tumors and lung metastases, 8 had disease control in lung metastases and PD in hepatic tumors, and none experienced disease control in liver tumors and PD in lung metastases (p=0.005). Conclusions: The hepatic tumors of HCC are less responsive to ICIs than the extrahepatic lesions. Lung metastases show best response to ICIs. The underlying mechanism warrants further investigation. (This work is supported by grants from the Ministry of Science and Technology, Taiwan, MOST 106-2314-B-002-210). Citation Format: Li-Chun Lu, Chiun Hsu, Yu-Yun Shao, Yee Chao, Chia-Jui Yen, I-Lun Shih, Yi-Ping Hung, Chun-Jung Chang, Ying-Chun Shen, Jhe-Cyuan Guo, Tsung-hao Liu, Chih-Hung Hsu, Ann-Lii Cheng. Organ-specific differential responses to immune checkpoint inhibitors in patients with advanced hepatocellular carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3627.

Impact of affected lymph nodes on long-term outcome after surgical therapy of alveolar echinococcosis.

Alveolar echinococcosis (AE) is a life-threatening helminthic disease. In humans, AE mostly affects the liver; the regional hepatic lymph nodes may be involved, indicating dissemination of AE from the liver. To achieve complete removal of the disease, enlarged hepatic lymph nodes may be resected during surgical treatment. We evaluated the frequency of affected lymph nodes by conventional microscopic and immunohistochemical analyses including detection of small particles of Echinococcus multilocularis (spem). Furthermore, we analyzed the association of resection of enlarged and affected lymph nodes with long-term outcome after surgical therapy of patients who underwent surgery with curative intent. We identified 43 patients who underwent hepatic surgery with curative intent with lymph node resection for AE. We analyzed the cohort for the manifestation of the parasite in the resected lymph nodes by conventional histology and by immunohistochemistry and compared these data with the further course of AE. Microscopically infected lymph nodes (laminar layer visible) were found in 7 out of these 43 patients (16%). In more than three quarters (25/32) of all specimens investigated, lymph nodes showed spems when stained with antibody against Em2G11, a monoclonal antibody specific for the Em2 antigen of the Echinococcus multilocularis metacestode. Most frequently, lymph nodes were resected due to enlargement. The median size of microscopically affected lymph nodes was 2cm (range, 1.2 to 2.5cm), the median size of immunohistochemically and non-affected lymph nodes was 1.3cm each (range, "small" to 2.3 or 2.5cm, respectively). Median follow-up was 8years for all patients, 5years for patients with lymph node resection, and 4years for patients with infested lymph nodes. Overall, recurrent disease was seen in ten patients (10/109; 9%) after a median period of 1.5years (range, 4months to 4years). None of the seven patients with conventionally microscopically affected lymph nodes suffered from recurrent disease. One patient with negative resected nodes and one patient with spems showed recurrent disease after 4 and 35months, respectively. Lymph node involvement in AE is frequent, particularly when evaluated by immunohistochemical examination of lymph nodes with the monoclonal antibody Em2G11. Affected lymph nodes tend to be larger in size. Lymph node involvement is not associated with recurrent disease and therefore warrants further analysis of the biological significance of lymph node involvement.