Major Vessel Involvement Research Articles

Treatment of Metastatic Colon Cancer: “The Times They Are A-Changing”

In the 1950s, colon cancer was the poor stepchild for chemotherapists, with a median survival of 12 months for patients with metastatic disease. Now patients with metastatic disease, even hepatic metastases, can survive 5 years when surgical techniques for liver resection and new chemotherapy, with or without targeted agents, are used. In the article that accompanies this editorial, Ye et al prospectively randomly assigned patients with unresectable, liver-limited metastases (KRAS wild type) to systemic chemotherapy with or without cetuximab (Cetx). The primary end point was the number of patients converted to hepatic resection. The patients receiving chemotherapy plus Cetx had a significantly higher resection rate: 25% versus 7.4%. The patients were well matched for individual prognostic factors, but the two study groups differed slightly: high clinical risk score of 25% versus 35%; rectal primaries, 38% versus 48%; lesion larger than 5 cm, 44% versus 55%; and major vessel involvement, 37% versus 44%, for the chemotherapy plus Cetx group versus chemotherapy group, respectively. Overall, the chemotherapy plus Cetx group had 22% fewer patients with poor prognostic indicators. This may explain why patients who underwent resection and did not receive Cetx had a shorter survival than those who received chemotherapy plus Cetx (median survival, 22 months v 34.8 months, respectively). The 5-year survival rates obtained with liver resection, 30% to 50%, are superior to rates of survival obtained with systemic chemotherapy alone. Early studies showed a 30% 5-year survival for patients who had resection of one to three liver metastases. More recent studies have shown that resection is possible in patients with a greater volume of disease. Currently, the main consideration is not the total number of liver metastases but whether enough viable liver can be preserved to provide adequate liver function. What about patients with initially unresectable disease that becomes resectable after chemotherapy— what is their survival? French investigators have shown that patients withunresectablediseasewhosediseasebecomesresectableafterchemotherapy have a similar prognosis as those whose disease was initially resectable, with 5-year survivals of 33% for the converted group. To examine long-term outcomes: of 184 patients with unresectable disease whose disease became resectable and who were followed for 5 years or more, 33% had a 5-year survival and 27% had a 10-year survival. There was a greater chance of achieving long-term survival with fewer than three metastases. Others have reported a 23% actual 5-year survival in downstaged patients. In patients with resectable disease, trials should address whether neoadjuvant therapy is useful and, if so, what type of therapy should be used. A European Organisation for Research and Treatment of Cancer (EORTC) study that used both preoperative and postoperative therapy stated that preoperative chemotherapy was beneficial, given that there was an increase in 3-year disease-free survival (DFS) in the treated group versus the surgery alone group (36.2% v 27.8%, respectively, for eligible patients). There was no difference in 5-year survival (51.2% v 47.8%). The benefit of preoperative chemotherapy is not clear because patients received both preand postoperative therapy. Ninety-four percent of these patients had one to three liver metastases and other favorable characteristics. Do patients with good characteristics need preoperative chemotherapy? Are there poor-risk groups who would be helped by preoperative chemotherapy? In patients with unresectable hepatic metastases whose disease can be converted to resectable disease, what is the best preoperative chemotherapy regimen? The article by Ye et al attempts to answer this conversion question. For this type of trial, what is the definition of resectability? A multidisciplinary hepatobiliary team is needed to address this question. Are certain types of patients less likely to have disease that can be made resectable, such as patients with involvement of hepatic veins or inferior vena cava involvement? A Memorial SloanKettering Cancer Center trial outlined the reasons for unresectability for each patient and then reported which of these patients had disease that was made resectable, thus providing a framework to compare studies. Are there patients whose disease can be made resectable but who do not benefit from resection? Do some patients have a higher recurrence rate? Do techniques that enable more patients to undergo resection, such as portal vein embolization, two-stage resection, and radiofrequency ablation, produce a higher rate of recurrence? These are questions that need to be addressed in future trials. Is adjuvant chemotherapy after hepatic resection useful? The initial randomized trials of fluorouracil/leucovorin versus no treatment did not show a clear increase in progression-free survival, but a multivariable pooled analysis of two studies showed a significant benefit. Adding irinotecan to fluorouracil/leucovorin did not increase overall survival or DFS. Infusional fluorouracil, leucovorin, and oxaliplatin after resection has not been tested in a randomized study. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 31 NUMBER 16 JUNE 1 2013

Preoperative Imaging for Resectable Periampullary Cancer: Clinicopathologic Implications of Reported Radiographic Findings

BackgroundHigh-resolution, multiphase, computed tomography (CT) is a standard preoperative test prior to pancreatectomy, yet the clinical significance of routinely reported findings remains unknown. MethodsWe identified patients who underwent a pancreaticoduodenectomy for a periampullary adenocarcinoma (PA) over the previous 5 years and had a pancreas protocol CT at our institution. Clinicopathologic implications of reported CT findings were evaluated. ResultsThere were 155 pancreatic ductal adenocarcinomas (PDA) and 47 non-pancreatic PAs. No mass was visualized on CT in 6 % of PDAs and 23 % of non-pancreatic PA. A size discrepancy of ≥1 cm between radiographic and pathologic tumor diameters was observed in 40 % of PAs, with CT underestimating the size in most instances (75 %). Radiographically enlarged lymph nodes were not associated with true lymph node metastases in PDAs (70 % lymph node positive cases were enlarged on CT vs 74 % lymph node negative, p = 0.5), but were associated with a preoperatively placed biliary endoprosthesis (63 % with endoprosthesis were enlarged vs 37 % no endoprosthesis, p = 0.013). Major visceral vessel involvement on CT was not associated with a vascular resection (3 % with CT vessel involvement vs 2 % without, p = 0.8) or a positive uncinate resection margin (24 vs 20 %, respectively, p = 0.6). DiscussionWhile dedicated pancreas protocol CT provides unprecedented detail, the test may lead to overinterpretation of the extent of disease in some instances. A radiographic suggestion of enlarged lymph nodes and vascular involvement does not necessarily preclude exploration with curative intent. CTs with local disease should be reported in an objective template and carefully reviewed by a multidisciplinary group of surgeons, radiologists, and oncologists to avoid missing an opportunity for neoadjuvant therapy or cure by resection.

Advances in understanding the pathogenesis of cerebrovascular vasculopathy in sickle cell anaemia

Cerebral vasculopathy is the most severe complication to affect children with sickle cell anaemia and its pathophysiology is complex. Traditionally, small-vessel occlusion by intravascular sickling and sludging was considered to underlie the strokes but, in the last 20 years, progressive major cerebral vessel involvement has become recognized as the principal responsible factor. Macrovasculopathy is well detected by abnormally high velocities on transcranial Doppler and with magnetic resonance angiography (MRA), and is responsible for the majority of overt strokes. Silent infarcts are ischaemic lesions detected by magnetic resonance imaging (MRI) in patients without history of stroke. They are associated with compromised cognitive functioning. The present review discusses the pathophysiologal mechanisms that could be involved in the development of cerebral vasculopathy, such as inflammation and hypoxia, anaemia, haemolysis and the resulting decreased nitric oxide bioavailability, genetic factors, impaired blood rheology and particular local haemodynamic profiles.

Laparoscopic Whipple: An early experience

Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA Background: Laparoscopy has been applied to many intra-abdominal operations and resulted in improved patient-centered outcomes. However, its role in pancreas surgery has been limited. We describe a series of laparoscopic Whipple procedures to evaluate its feasibility and outcomes. Methods: We attempted a totally laparoscopic Whipple procedure in patients with no evidence of major vessel involvement presenting to two surgeons (MAM, BHE) over a two-year period (May 2010 May 2012). We collected data on operative time, estimated blood loss, pancreatic leak, bile leak, delayed gastric emptying, and length of stay. Results: We performed 34 laparoscopic Whipple procedures. Of these, 14 patients had a benign cyst, 17 patients had a malignant tumor, and 3 patients had a neuroendocrine tumor. The mean operative time was 6 hours, 51 min (411 minutes, range1⁄4270-600 minutes). The median estimated blood loss was 300cc (30-4000cc). A subsequent procedure was required in 2 patients (1 for a bleeding pseudoaneurysm and 1 for a bleeding gastric ulcer). Asymptomatic pancreatic leak rate occurred in 4 patients (11.8%) and asymptomatic bile leak occurred in 3 patients (8.8%). All were managed with external drainage alone. Delayed gastric emptying occurred in 3 patients (8.8%) and was self-limited. The median hospital length of stay was 8 days (range1⁄45-25 days). Conversion to open took place in 7 patients. Of these, 2 were due to extent of malignancy, 2 were due to visualization difficulty, 2 were due to bleeding, and 1 was due to a metabolic acidosis due to CO2 insufflation and COPD. The 30-day mortality was zero. Conclusions: In an early personal series performing a totally laparoscopic Whipple, we observed a high feasibility with a reasonable operative time and good patient-centered outcomes. With the optimal pancreas and laparoscopic surgery skills, laparoscopic Whipple can be performed safely.

Obesity increases macrophage, T-cell, and CD8+CD11blo cell infiltration in pancreata of mice

Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA Background: Laparoscopy has been applied to many intra-abdominal operations and resulted in improved patient-centered outcomes. However, its role in pancreas surgery has been limited. We describe a series of laparoscopic Whipple procedures to evaluate its feasibility and outcomes. Methods: We attempted a totally laparoscopic Whipple procedure in patients with no evidence of major vessel involvement presenting to two surgeons (MAM, BHE) over a two-year period (May 2010 May 2012). We collected data on operative time, estimated blood loss, pancreatic leak, bile leak, delayed gastric emptying, and length of stay. Results: We performed 34 laparoscopic Whipple procedures. Of these, 14 patients had a benign cyst, 17 patients had a malignant tumor, and 3 patients had a neuroendocrine tumor. The mean operative time was 6 hours, 51 min (411 minutes, range1⁄4270-600 minutes). The median estimated blood loss was 300cc (30-4000cc). A subsequent procedure was required in 2 patients (1 for a bleeding pseudoaneurysm and 1 for a bleeding gastric ulcer). Asymptomatic pancreatic leak rate occurred in 4 patients (11.8%) and asymptomatic bile leak occurred in 3 patients (8.8%). All were managed with external drainage alone. Delayed gastric emptying occurred in 3 patients (8.8%) and was self-limited. The median hospital length of stay was 8 days (range1⁄45-25 days). Conversion to open took place in 7 patients. Of these, 2 were due to extent of malignancy, 2 were due to visualization difficulty, 2 were due to bleeding, and 1 was due to a metabolic acidosis due to CO2 insufflation and COPD. The 30-day mortality was zero. Conclusions: In an early personal series performing a totally laparoscopic Whipple, we observed a high feasibility with a reasonable operative time and good patient-centered outcomes. With the optimal pancreas and laparoscopic surgery skills, laparoscopic Whipple can be performed safely.

A novel scoring system for arterial invasion of pancreatic body and tail cancer based on multidetector row computed tomography and biomarkers

Background/objectivesThe absence of major-vessel involvement is a crucial factor in the resectability and prognosis of pancreatic cancer. However, arterial invasion cannot be evaluated adequately using imaging findings alone. We therefore developed a scoring system to assess arterial invasion by pancreatic adenocarcinoma using multidetector row computed tomography (MDCT) and serum tumor markers. MethodsTwenty patients who underwent distal pancreatectomy and splenectomy for pancreatic adenocarcinoma were examined retrospectively using 4-, 16- or 64-row MDCT and serum tumor markers. Splenic arterial invasion was evaluated in terms of length of tumor contact, circumferential involvement (<180° or ≥180°) and deformity of vascular diameter. Preoperative expression of carbohydrate antigen 19-9 (CA19-9), DUPAN-2 and S-Pancreas-1 antigen (SPan-1) were also evaluated. The presence or absence of arterial invasion was confirmed histopathologically in all 20 cases. ResultsIn 11 of 20 cases invasion into splenic arteries was observed histopathologically, mostly involving the external elastic lamina and periarterial nerves. Sensitivity, specificity and accuracy were 100%, 88.9% and 95%, respectively, for length of tumor contact (<16 mm or ≥16 mm), 90.9%, 77.8% and 85% for circumferential involvement (<180° or ≥180°), and 100%, 66.7% and 85% for deformity of vascular diameter. Furthermore, the sensitivity, specificity and accuracy were all increased to 100% when tumor markers were included in the score. ConclusionsMDCT is a useful technique for diagnosing arterial invasion of pancreatic body and tail cancer, even in comparison with pathological examination; however, this new scoring system can be further complemented and made more reliable by measurements of serous tumor markers.

Serum apolipoprotein C-II is prognostic for survival after pancreatic resection for adenocarcinoma

Background:Pancreaticoduodenectomy remains a major undertaking. A preoperative blood test, which could confidently predict the benefits of surgery would improve the selection of pancreatic cancer patients for surgery. This study aimed to identify protein biomarkers prognostic for long-term survival and to validate them with clinico-pathological information.Methods:Serum from 40 preoperative patients was used to train for predictive biomarkers using surface-enhanced laser desorption/ionisation time-of-flight mass spectrometry (SELDI), and the results were verified on 21 independent samples. Two predictive proteins were identified by tryptic peptide mass fingerprinting and sequencing, and validated on serum from another 57 patients by enzyme-linked immunosorbent assay (ELISA). The influence of these proteins on growth and invasion of two cancer cell lines was tested in-vitro.Results:The SELDI panel of m/z 3700, 8222 and 11 522 peaks predicted <12 months’ survival (ROC AUC: 0.79, 0.64–0.90; P<0.039). When CA19-9 was added, the ROC AUC increased to 0.95 (0.84–0.99; P<0.0001). The six subjects in the verification group who died within 12 months were correctly classified. The m/z 8222 and 11 522 proteins were identified as Serum ApoC-II and SAA-1, respectively. In the validation samples, ELISA results confirmed that ApoC-II was predictive of survival (Kaplan–Meier P<0.009), but not SAA-I. ApoC-II, CA19-9 and major-vessel involvement independently predicted survival. ApoC-II and SAA-1 increased cell growth and invasion of both cancer cell lines.Conclusion:Serum ApoC-II, CA19-9 and major-vessel invasion independently predict survival and improves selection of patients for pancreaticoduodenectomy.

Luteinizing hormone, sex steroids and extracorporeal circulation – A promising link to treat retroperitoneal sarcomas. A reconsideration of cancer treatment

Retroperitoneal sarcomas are rare and aggressive tumors with a negative prognosis as there is currently no satisfactory treatment for them. The only proven factor that can significantly increase the otherwise poor survival of sarcoma patients is the radically of resection. However, the completeness of resection is hindered by the hypervascularized nature of sarcomas and the frequent involvement of major blood vessels. In this context, we propose to operate on retroperitoneal sarcomas only with the use of extracorporeal circulation, applying vascular clamps above and below the tumor, even with short periods of hypothermic circulatory arrest in complex cases. This technique would allow the surgeon to achieve complete tumor resections, approach large blood vessels easier and perform sofisticated vascular reconstructions with no fear of hemorrhage which is fundamental to achieve a bloodless surgical field.Also, we speculate on the etiology of retroperitoneal sarcomas that appear mostly during the period of menopause/andropause. Although both estrogens and androgens have been incriminated in inducing various cancer types, including sarcomas, an endogenous estradiol cathabolyte has been shown to have anti-tumor effects. Considering that during menopause/andropause sex steroid levels actually decrease, our second working hypothesis is that the increasing follicle-stimulating hormone (FSH) and especially luteinizing hormone (LH) levels, together with the relative estrogen/androgen imbalance, may be the triggering cause. Also, a certain level of estrogens (Methoxyestradiol) may be essential in limiting tumor development and dedifferentiation. Given that extragonadal sarcomas appear to behave as endocrine tumors, a targeted hormonal therapy, together with controlled radical resections in complex cases of tumor vascular involvement, would certainly provide a strong link to both prevention and treatment of retroperitoneal sarcomas and even of cancer in general.

PMO-111 Should all patients with locally advanced pancreatic cancer be offered intraoperative assessment?

IntroductionSurgery is the only potentially curative option in patients with pancreatic cancer. Hence it is extremely important that the diagnostic tests used to ascertain resectability is very reliable before this...

Fungating Thyroid Cancer: A Complex Clinical Scenario

Most research reporting the management of advanced thyroid cancer focuses on major aerodigestive system or vessel involvement. In the present study, we investigated patients with locally advanced thyroid cancers who presented with malignant skin infiltration. The term fungating thyroid cancer (fTC) has been used to describe such a condition. The study was based on prospective collection of clinical, laboratory, imaging, and pathological data of all patients admitted to the head and neck and endocrine surgery unit, Main University Hospital, Alexandria School of Medicine, during the period April 2005-March 2011. Eleven patients were referred with fTC, eight of whom had undergone subtotal thyroidectomy for an undiagnosed well-differentiated thyroid cancer (DTC) in another institution. The final pathological diagnosis showed (DTC, n = 3), poorly differentiated thyroid cancer (n = 5), anaplastic cancer (n = 2), and medullary thyroid cancer (n = 1). Extensive resections and reconstruction using flaps (pectoralis major, n = 6; deltopectoral, n = 1; sternocleidomastoid, n = 1) were undertaken. Complete tumor clearance (R0) was achieved in one patient and the others had microscopic (R1, n = 6) or macroscopic (R2, n = 1) residual disease. The three patients who did not undergo operation died within one month of presentation. The latest review of the eight patients who did undergo operation ranged from 3 to 6 months, but their survival remains unknown as access for follow-up was limited.

Pancreatic Endocrine Tumors With Major Vascular Abutment, Involvement, or Encasement and Indication for Resection

Surgery for pancreatic endocrine tumors (PETs) with blood vessel involvement is controversial. Resection of PETs with major blood vessel involvement can be beneficial. The combined databases of the National Institutes of Health and Stanford University hospitals were queried. Operation, pathologic condition, complications, and disease-free and overall survival. Of 273 patients with PETs, 46 (17%) had preoperative computed tomography evidence of major vascular involvement. The mean size for the primary PET was 5.0 cm. The involved major vessel was as follows: portal vein (n = 20), superior mesenteric vein or superior mesenteric artery (n = 16), inferior vena cava (n = 4), splenic vein (n = 4), and heart (n = 2). Forty-two of 46 patients had a PET removed: 12 (27%) primary only, 30 (68%) with lymph nodes, and 18 (41%) with liver metastases. PETs were removed by either enucleation (n = 7) or resection (n = 35). Resections included distal or subtotal pancreatectomy in 23, Whipple in 10, and total in 2. Eighteen patients had concomitant liver resection: 10 wedge resection and 8 anatomic resections. Nine patients had vascular reconstruction: each had reconstruction of the superior mesenteric vein and portal vein, and 1 had concomitant reconstruction of the superior mesenteric artery. There were no deaths, but 12 patients had complications. Eighteen patients (41%) were immediately disease free, and 5 recurred with follow-up, leaving 13 (30%) disease-free long term. The 10-year overall survival was 60%. Functional tumors were associated with a better overall survival (P < .001), and liver metastases decreased overall survival (P < .001). These findings suggest that surgical resection of PETs with vascular abutment/invasion and nodal or distant metastases is indicated.

Clinical results of limb salvage operation with major vascular reconstruction for sarcomas of extremities

Objective To determine the feasibility of limb salvage with major vascular reconstruction for sarcomas of extremities, focusing on the early complications, oncological and functional outcomes.Methods Between August 2004 and June 2009, 13 patients （mean age 38 years, range 14-63 years） underwent wide resection of upper and lower extremity sarcomas to include the involved arterial and venous segments. 4 patients had bone sarcomas and 9 soft tissue sarcomas, 6 patients only had underwent artery replacement and the other 7 had underwent both artery and vein. 8 resected vessels were reconstructed with vascular graft and 5 with ipsilateral or contralateral saphenous vein. Results No patient suffered from reperfusion injury and infection. The patient with osteosarcoma in proximal humerus had suffered acute arterial graft thrombosis at first day postoperatively; however, the limb was salvaged after successful thrombectomy. 5 of 8 patients with synthetic graft developed minor delayed wound healing and hematoma, but the other 5 patients with autologous saphenous vein replacement did not. The mean follow-up was 19.4 months （7-45months）. One patient died of pulmonary metastasis; the patient with osteosarcoma in proximal humerus had developed local recurrence, but refused amputation and was alive with metastasis. No arterial occlusion was observed at final follow-up or at the time of death, but the patency of artery and vein was 100% and 28.6%respectively. One patient who has pulmonary metastases before operation died of metastases 7.5 months after operation. Four patients developed pulmonary metastases, therefore, Kaplan-Meier survival analysis showed that 2-year overall and metastasis-free survival rate was 90.9% and 63.6% respectively. Functional status were judged as good or excellent （mean MSTS score 72%） in 12 of 13 patients. Conclusion The study indicate that malignant involvement of major vessels is not a contraindication for limb-salvage. Vascular reconstruction is a feasible option in limb salvage surgery. Wide resection with vascular reconstruction provide acceptable oncological and functional outcome of limb salvage. Key words: Sarcoma; Angioplasty; Blood vessel prosthesis; Graft occlusion, vascular

What we learned from difficult hepatectomies in patients with advanced hepatic malignancy.

Backgrounds/AimsBy reviewing difficult resections for advanced hepatic malignancies, we discuss the effectiveness and extended indications for hepatectomy in such patients.MethodsWe reviewed 7 patients who underwent extensive surgery between July 2008 and March 2011 for advanced hepatic malignancies. They had stage IV disease, except for in one case that was a stage IIIC (T4N0M0) hepatocellular carcinoma (HCC).ResultsPatient 1 with intrahepatic cholangiocarcinoma (IHCC) underwent right hemihepatectomy and resection of the bile duct and left portal vein. At 39 months after surgery, she had no recurrence or metastasis. Patient 2 with HCC underwent palliative right trisectionectomy. At 38 months after surgery, he is alive despite residual pulmonary metastases. Patient 3 with HCC invading the hepatic vein and diaphragm underwent right trisectionectomy and caval venoplasty. At 12 months after surgery, he had no recurrence or metastasis. Patient 4, who had 2 large HCCs and pulmonary thromboembolism, underwent a right trisectionectomy. At 7 months after surgery, he had no evidence of recurred HCC. Patient 5, who had IHCC invading her inferior vena cava and main portal vein, underwent preoperative radiotherapy, left hemihepatectomy, and caval resection. At 20 months after surgery, she is well despite a caval thrombus. Patient 6 and 7 underwent repeated surgery due to a recurred IHCC and metastatic colon cancer, respectively. In addition, they are alive during each 20 and 17 months after surgery.ConclusionsDespite macroscopic extrahepatic metastases or major vessel involvement, extensive surgery for advanced hepatic malignancy may result in relatively favorable outcomes and be important modality for improving of survival in such patients.

Major vessel involvement in Behçet's disease: an update

Large vessel vasculitis occurs in a subgroup of patients with Behçet's disease who are at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and aggressive treatment are essential for optimal care of these patients. We review the expanding knowledge on large vessel problems in Behçet's disease, highlighting recent contributions. Vasculo-Behçet patients are at risk for multiple vessel-related complications including thromboses, stenoses, occlusions, and aneurysms. The primary reason for clot seems to be an inflammatory process in the vessel wall. Less invasive endovascular procedures are increasingly used to treat aneurysms in Behçet patients. Because of earlier recognition, aggressive medical treatment, and novel surgical procedures, the morbidity and mortality of large vessel vasculitis in Behçet's disease are improving.

Preoperative 3-phase contrast-enhanced multidetector-row computed tomography image in evaluating resectibility of pancreatic carcinoma: a comparison with postoperative pathological results

Objective To evaluate the role of 3-phase contrast-enhanced multidetector-row computed tomography ( MDCT) in observing blood vessel invasion around the pancreas before operation and its value in assessing the resectibility of pancreatic carcinoma. Methods The 3-phase contrast-enhanced MDCT scanning images of 25 patients with pancreatic carcinoma were retrospectively analyzed. The intensity difference in 3 -phase contrast-enhanced MDCT scanning images between pancreatic carcinoma and normal pancreas and the involvement of major blood vessel were analyzed; the results were compared with those of operative finding. Results Seventeen patients had pancreatic carcinomas at the head of pancreas,six at the body of pancreas,and two at the tail of pancreas. The diameters of pancreatic carcinomas were ≤2 cm in two patients,and the others with diameter 2 cm. All the 25 patients were surgically treated,12 receiving pancreaticoduodenectomy and 13 receiving palliative surgery. Four ( 9 blood vessels) patients were misdiagnosed as unresectable and 3 ( 8 blood vessels) as resectable. The arterial phase of MDCT was helpful for observation of the blood vessel involvement and for performing computed tomographic arteriography ( CTA) ,which can better assess the tumor invasion of arteries around the pancreas. The largest intensity difference between normal pancreas and pancreatic carcinomas was found during the pancreatic phase,making it easier to discover pancreatic carcinoma. The largest intensity difference between liver and metastatic tumor was found in the liver phase,making it easier for qualitative diagnosis. Conclusion Three phase contrast-enhanced scanning with MDCT has great value for diagnosis of pancreatic carcinoma and for assessment of major blood vessel involvement. MDCT,together with other criteria,can help to assess the resectibility of tumor before operation.

Photodynamic therapy with acridine orange in musculoskeletal sarcomas

Limb salvage involving wide resection and reconstruction is now well established for managing musculoskeletal sarcomas. However, involvement of major nerves and vessels with a large volume of muscle and skin may result in a useless limb, contributing to depression and a low quality of life. We have been studying alternative treatments for musculoskeletal sarcoma since 1990, and have recently established a regime using photodynamic surgery with cells labelled with acridine orange, photodynamic therapy with cells treated similarly and radiodynamic treatment using the effect of X-rays on such cells. These techniques have been used after marginal or intralesional resection of tumours since 1999 and have enabled maintenance of excellent limb function in patients with sarcomas.

Major Blood Vessel Reconstruction During Sarcoma Surgery

To evaluate the outcomes of major vessel reconstruction as part of surgery to remove sarcomas. Retrospective review. Tertiary academic medical center. Fourteen patients (10 female) with retroperitoneal or extremity sarcomas and major blood vessel involvement who underwent surgery to remove the tumor and had blood vessel reconstruction between 2003 and 2008. Each patient underwent computed tomography angiography. Early (<30 days) and late (>30 days) operative morbidity and mortality, freedom from disease, and graft patency. Seven patients had retroperitoneal sarcomas and 7, extremity sarcomas. Thirteen tumors were malignant (7 high grade and 6 low grade) and 1, benign (leiomyoma). Seven patients had replacement of artery and vein; 5, artery only; and 2, vein only. In all, 16 arteries were reconstructed (2 common femoral; 5 iliac; 2 superficial femoral; 1 brachial; 1 popliteal; and 2 aorta, one with implantation of both iliac arteries and the other with implantation of the left renal, superior mesenteric, and hepatic arteries). Eight patients (57%) had 9 veins reconstructed (3 external iliac, 3 superficial femoral, 2 vena cava, and 1 popliteal). Primary arterial patency was 58% and primary-assisted patency was 83%. Venous patency was 78%. Local recurrence occurred in 3 patients (21%). Five-year disease-free and overall survival were 52% and 68%, respectively. Limb salvage was achieved in 93%. Involvement of vascular structures is not a contraindication for resection of sarcomas, but appropriate planning is necessary to optimize outcome.

Ulnar artery aneurysm in a patient with Behçet’s disease

Behçet's disease is a systemic disease characterized by oral aphthosis, genital ulcers, ocular lesions, gastrointestinal, musculoskeletal, neurological and major vessel involvement. Arterial involvement, aneurysms and arterial thrombosis have been reported in 1.5-3% of patients. In this case report, we present a patient with ulnar arterial aneurysm associated with Behçet's disease.

Faraway from the Silk Route: demographic and clinical features of Behçet’s disease in 106 Brazilian patients

To describe clinical and epidemiological data of Behçet's disease (BD) in Brazil, we retrospectively reviewed records of all patients seen between 2006 and 2007 at the BD outpatient clinic of University of Sao Paulo. One hundred and six patients fulfilled the International Study Group for Behçet's Disease diagnostic criteria and they were included in this study. There was a female/male ratio of 2.2:1 and mean age at diagnosis was 31.9 +/- 9.2 years. In order of frequency, oral (100%) and genital ulcerations (92.5%), pseudofolliculitis (59.4%), erythema nodosum (49.1%), ocular lesions (47.2%), and musculoskeletal complaints (35.8%) were the most common manifestations. Blindness and major vessel involvement (18.2% vs. 5.5%, p = 0.038 and 27.3% vs. 9.6%, p = 0.019) were more frequent among male than female patients. We concluded that in Brazil, a South American country faraway from the Silk Route, BD follows the same pattern exhibited on its usual endemic area.

Limb conservation in extremity soft tissue sarcomas with vascular involvement

Background:The major neurovascular involvement and large primary tumors are indication of amputation. The present study is an attempt to explore the feasibility of a limb salvage surgery in extremity sarcoma cases with major vessel involvement. Oncological outcomes and surgery-related morbidities are compared with those reported in literature.Materials and Methods:A retrospective review of all limb salvage surgeries done in our department between 2005 and 2008 was done and four cases of extremity sarcoma of lower limb involving femoral vessels analyzed. Interpretation of data from these cases, along with review of literature, is done.Results:In all these cases a wide monobloc excision was done adhering to oncological principles. This required resection of superficial femoral artery alone in two cases, resection of superficial femoral artery along with common femoral vein and femoral nerve in another, and of common femoral vein alone in yet another. Reconstruction was done in all these cases with reversed long saphenous vein graft. Histopathology of resected margins was free of tumor in all the four patients. One patient developed local recurrence and one developed distant metastsis. Two were disease free for one year with good functional limb, one has been disease-free for three years and another was disease-free at two years, after which he defaulted further follow-up. One patient developed arterial blowout which required ligation of common femoral artery which resulted in gangrene of the limb. He underwent amputation.Conclusion:Major neurovascular involvement in extremity sarcoma is not considered a contraindication for limb salvage surgery. Review of literature also supports our view. Post-operative wound related complications are more in this group of patients. However, long term functional outcome is good. Literature suggests a good long term local control after vascular resection and reconstruction.