Randomized controlled trial of 8 weeks' vs 12 weeks' interval between neoadjuvant chemoradiotherapy and surgery for locally advanced rectal cancer

AIM

The aim was to compare the pathological complete response (pCR) rate at 8 compared to 12 weeks' interval between completion of neoadjuvant chemoradiotherapy (CRT) and surgery in patients with locally advanced rectal cancer.

METHOD

This was a randomized trial which included a total of 330 patients from two institutions. Patients with locally advanced (T3-4N0M0, TxN+M0) rectal cancer were randomized into 8- and 12-week interval groups. All the patients received long-course CRT (45 Gy in 1.8 Gy fractions and concomitant oral capecitabine or 5-fluorouracil infusion). Surgery was performed at either 8 or 12 weeks after CRT. The primary end-point was pCR. Secondary end-points were sphincter preservation, postoperative morbidity and mortality.

RESULTS

Two-hundred and fifty-two patients (n = 125 in the 8-week group, n = 127 in the 12-week group) were included. Demographic and clinical characteristics were similar between groups. The overall pCR rate was 17.9% (n = 45): 12% (n = 15) in the 8-week group and 23.6% (n = 30) in the 12-week group (P = 0.021). Sphincter-preserving surgery was performed in 107 (85.6%) patients which was significantly higher than the 94 (74%) patients in the 12-week group (P = 0.016). Postoperative mortality was seen in three (1.2%) patients overall and was not different between groups (1.6% in 8 weeks vs 0.8% in 12 weeks, P = 0.494). Groups were similar in anastomotic leak (10.8% in 8 weeks vs 4.5% in 12 weeks, P = 0.088) and morbidity (30.4% in 8 weeks and 20.1% in 12 weeks, P = 0.083).

CONCLUSION

Extending the interval between CRT and surgery from 8 to 12 weeks resulted in a 2-fold increase in pCR rate without any difference in mortality and morbidity.

The Analysis of Posthepatectomy Liver Failure Incidence and Risk Factors Among Right Liver Living Donors According to International Study Group of Liver Surgery Definition

AIM

There is a well-known risk of the emergence of hepatic failure in living donor transplant cases on whom are performed a right donor hepatectomy (RDH). There are different prevalence ratios in literature on this phenomenon. In our study, we aim to depict the prevalence of hepatic failure and risk factors in our cases regarding the most recent description criteria related to hepatic failure.

PATIENTS AND METHODS

We included right liver donor hepatectomy cases who fit the donor evaluation algorithm at the Dokuz Eylul University Liver Transplantation Unit between the period of June 2000 and September 2017. The patients were evaluated regarding preoperative data. Liver failure was defined according to the International Study Group of Liver Surgery (ISGLS) criteria. We also included statistical analysis of risk factors that are potentially related to liver failure.

RESULTS

We included a total of 276 patients. In 27 (9.7%) patients, we observed posthepatectomy liver failure (PHLF). In 26 (9.4%) patients, we observed Grade A liver failure; in 1 (0.3%) patient, we observed Grade B liver failure. We did not observe any Grade C hepatic failure. In patients with hepatic failure, we observed a significantly longer period of hospitalization (P = .007). Old age (odds ratio = 1.065, 95% confidence interval, 1.135-29.108, P = .035) and preoperatory red blood cell (RBC) transfusion (odds ratio = 5.749, 95% confidence interval, 1.019-1.113, P = .005) were shown as independent risk factors for PHLF.

CONCLUSION

Posthepatectomy liver failure is a vital complication of RDH. The risk can be decreased by careful selection of donor candidates. Elderly donor candidates and intraoperative RBC are independent risk factors for PHLF.

Synchronous appearance of male breast cancer and pancreatic cancer 15 years after the diagnosis of testicular cancer--report of a case

The frequency of new neoplastic diseases among patients cured of testicular cancer is higher than in normal population. For these patients, synchronous occurrence of multiple neoplasms is not common. Also, less than 1% of all cases of breast cancer occur in males. We present herein a case having both breast and concurrent pancreatic cancer after being effectively treated for testicular cancer. To the best of our knowledge, this is the first case of synchronous breast and pancreatic cancer in a male patient following testicular cancer. Second cancer is the most severe long-term complication of chemotherapy or radiotherapy for patients with testicular cancer and the possibility of multiple cancers has to be taken into consideration when multiple lesions are present.

MDCT findings in neuroendocrine carcinoma of the gallbladder: case report

Neuroendocrine tumors are commonly seen in the gastrointestinal tract, but they are extremely rare in the gallbladder. In this study, sonographic and multidetector-row computed tomographic findings of a patient with neuroendocrine tumors of the gallbladder are presented.

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation

BACKGROUND

Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial.

METHODS

Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21.

RESULTS

Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13).

CONCLUSIONS

In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Cystic ovarian teratoma with intracystic floating globules

Ovarian cystic teratomas are cystic fatty tumors that are often found in patients of reproductive age, and the diagnosis can be easily made radiologically. We present a case of postmenopausal ovarian cystic teratoma with an unusual radiologic appearance of intracystic floating globules.

Interruption of the inferior vena cava with azygos/hemiazygos continuation accompanied by distinct renal vein anomalies: MRA and CT assessment

We report a case of interruption of the inferior vena cava with azygos/hemiazygos continuation and additional variations of the renal veins, an uncommon developmental anomaly. Magnetic resonance angiography and computed tomography, in association with clinical awareness, can be used to diagnose this entity.

Malignant islet cell tumor of the pancreas associated with portal venous thrombus

In this report, CT and MR findings of a malignant islet cell tumor of the pancreas associated with tumor thrombus in the portal vein is presented. Imaging findings revealed diffuse involvement of the body and tail of the pancreas by the tumor. The most unusual finding was that this invasive tumor was an insulinoma.

Pancreatic adenocarcinoma: detection and staging with dynamic MR imaging

OBJECTIVE

To compare the efficacy of dynamic contrast-enhanced MR imaging and spin-echo T1-weighted with and without fat-saturated MR imaging in the detection and staging of pancreatic adenocarcinoma.

METHODS AND MATERIAL

Spin-echo T1-weighted, fat-saturated T1-weighted and dynamic breath-hold 2D-FLASH MR imaging were performed in 25 patients with pancreatic adenocarcinoma. MR images were analysed by calculating the CNR between tumor and normal portion of the pancreas. The CNRs calculated at each sequences were compared. A total of 16 out of 25 patients underwent surgery. Preoperative staging according to TNM classification was also done in patients undergoing surgery.

RESULTS

The CNR was significantly different (P<0.05) in the arterial phase of dynamic MR images. The accuracy of 'T' staging was 75% for SE T1-W, fat-saturated T1-W and arterial phase of dynamic MR images.

CONCLUSION

The CNRs between pancreatic carcinoma and normal pancreas is significantly higher in dynamic MR sequences than the SE T1-W, fat-saturated T1-W sequences. However, the accuracy of tumor staging according to TNM is equivocal to SE T1-W and fat-saturated T1-W images.

Phe 84 deletion of the PMP22 gene associated with hereditary motor and sensory neuropathy HMSN III with multiple cranial neuropathy: clinical, neurophysiological and magnetic resonance imaging findings

Hereditary motor and sensory neuropathy (HMSN) is a heterogeneous group of peripheral neuropathies which are diagnosed on the basis of clinical, electrophysiological and neuropathological findings. Among the hypertrophic demyelinating neuropathies, HMSN III is the most severe. It is often associated with de novo mutations in the genes encoding for peripheral myelin proteins. While peripheral nerve hypertrophy is an expected finding in HMSN III, cranial nerve hypertrophy is exceptional. Here we describe a mutation in the PMP22 gene in a 19-year-old man with infantile onset of sensory motor polyneuropathy without family history and multiple cranial nerve hypertrophy shown by cranial magnetic resonance imaging.

Various radiological appearances of angiomyolipomas in the same kidney

A 21-year-old woman with tuberous sclerosis presented with abdominal distension and flank pain. Imaging studies, including CT and MR imaging, revealed bilateral renal mass lesions, containing fat and suggesting the diagnosis of tuberous sclerosis. However the imaging characteristics of one of these lesions differed from the others with no radiologically detectable fat tissue in this solid lesion suggesting renal cell carcinoma. Histopathological examination of this lesion in the left kidney revealed an angiomyolipoma within minimal fat tissue. The radiological diagnosis of angiomyolipomas with minimal fat tissue remains difficult and the differential diagnosis is discussed.

Differentiation of recurrent rectal cancer and scarring with dynamic MR imaging

The accuracy of dynamic contrast enhanced magnetic resonance (MR) imaging in the differentiation of malignant and benign pelvic lesions during follow-up of patients with treated colorectal tumours was evaluated prospectively. 19 patients (11 men, 8 women; age range 35-70 years; mean 57 years) with suspected local recurrence of colorectal malignancy were evaluated with MR imaging. Dynamic MR imaging with axial Turbo-FLASH gradient echo imaging and bolus injection of contrast medium was performed. Dynamic images, each consisting of one slice in the same location, were acquired at 5, 10, 15, 20 and 30 s, and at 1, 2, 3, 4, 5 and 10 min. The maximum change in signal intensity (Emax), the acceleration rate of the time-intensity curve (TIC) and the ratio of the signal intensity of the lesions to the signal intensity of the iliac artery (SIL/SIA) were used as the enhancement parameters. The TIC and SIL/SIA ratio at 60 s were found to be valuable in the differential diagnosis; Emax had no significance in differentiating benign and malignant lesions. Sensitivity was 83% for each calculated parameter. SIL/SIA has the highest specificity and accuracy among the parameters.

Is magnetic resonance imaging necessary in the staging of prostate cancer?

OBJECTIVE

To evaluate the necessity of using magnetic resonance imaging (MRI) in the staging of patients with clinically localized prostate cancer.

METHODS

Sixty-one patients with prostate cancer were evaluated with MRI for preoperative staging with a conventional body-coil (Siemens Magnetom, 1.0 Tesla superconducting system). Twenty-nine patients underwent radical prostatectomy for presumed clinically localized disease. Of those, 17 were staged both with MRI and computerized tomography (CT). The remaining patients were staged with CT alone. MRI and CT findings, and the final pathologic staging of patients are reviewed.

RESULTS

On pathological examination of the surgical specimens, the tumor was found to extend beyond the prostate in 7 patients (41%). Among the 17 patients who were operated, extraprostatic extension (EPE) was detected accurately in 3 patients with MRI (sensitivity 20%, specificity 92%, accuracy 70. 5%). No metastatic lymph nodes were detected on the basis of MRI (sensitivity 0%, specificity 93%, accuracy 88.2%). In 1 patient EPE was correctly identified by CT (sensitivity 14%, specificity 100%, accuracy 64.7%).

CONCLUSION

Neither MRI with conventional body-coild nor CT are sufficient to indicate local extension of disease in clinically localized prostate cancer.

Herpes encephalitis in children. MRI assessment

The magnetic resonance imaging (MRI) findings in 14 patients with biopsy or polymerase chain reaction proven herpes simplex encephalitis were retrospectively reviewed to evaluate the diagnostic value of MRI in the early diagnosis of herpes simplex encephalitis in children. In addition to the early findings, follow-up MRI scans were obtained in four patients. Typical limbic system involvement was seen in 78 percent of the cases. Contrast-enhanced MRI was found to be superior to routine MRI sequences and computerized tomography (CT) in the early detection of inflammation. Follow-up MR images in four patients demonstrated the volume loss and late petechial hemorrhage in the involved regions. Magnetic resonance imaging is the method of choice in the diagnosis and follow-up of herpes simplex encephalitis.

Aneurysmal bone cyst secondary to infantile cartilaginous hamartoma of rib

We report the first case, in a 4-month-old girl, of an aneurysmal bone cyst secondary to infantile cartilaginous hamartoma of the rib. Infantile cartilaginous hamartoma of the rib (benign mesenchymoma) is a large, expansile tumour that is characterised by cartilaginous, vascular and primitive-appearing stromal and mesenchymal elements. Most cases are diagnosed at less than 1 year of age and may even be congenital. Aneurysmal bone cyst may be a secondary lesion to pre-existing tumours such as giant cell tumours, osteoblastomas, angiomas and chondroblastomas. This unique case is presented with radiological and pathological findings.