Brazilian Landscape of Hepatocellular Carcinoma

The incidence of hepatocellular carcinoma (HCC) is expected to increase in the coming years, and strategies to mitigate the burden of this disease are needed in different regions. Geographic variations in epidemiology and risk factors, such as viral hepatitis and metabolic disease, pose challenges in adopting programs for early detection programs and management of patients with HCC. Brazil, like other countries, has high economic and social inequality, with heterogeneous access to health care. Viral hepatitis is the main risk factor but there is growing awareness of fatty liver disease. Risk factor monitoring and screening programs are unmet priorities because patients are often diagnosed at later stages. Advances in the management of patients with HCC have been made in recent years, including new tools for selecting patients for liver transplantation, sophisticated surgical techniques, and new systemic agents. High-volume academic centers often achieve favorable results through the adoption and application of established treatments, but this is not a reality in most regions of Brazil, because of disparities in wealth and resources. As HCC management requires a coordinated and multidisciplinary team, the role of local referral centers in decentralizing access to treatments and promoting health education in different regions should be encouraged and supported.

Histopathological factors versus margin size in single colorectal liver metastases: Does a 1-cm margin size matter?

Background and objective:

The ideal margin width for surgical resection of colorectal liver metastases has been extensively studied, but not sufficiently in accordance with other pathological factors. The aim of this study was to assess for the first time the prognostic impact of margin widths according to different prognostic pathological factors in colorectal liver metastasis.

Methods:

We evaluated 101 patients with a single resected metastasis. Slides stained by HE were assessed for the presence of poorly differentiated clusters, peritumoral inflammatory infiltrate, tumor pseudocapsule, and tumor borders pattern. Overall survival, disease-free survival, and hepatic recurrence were evaluated. The pathologic factors prognostic impact was evaluated according to a (< or ⩾) 10-mm margin size.

Results:

Factors independently associated with a shorter overall survival were absence of tumor pseudocapsule ( p < 0.001) and infiltrative tumor border pattern ( p = 0.019). The absence of tumor pseudocapsule was the only factor independently associated with shorter disease-free survival ( p < 0.001). Hepatic recurrence was associated with infiltrative tumor border and absence of pseudocapsule. Margin width ⩾10 mm did not impact overall survival independently of the studied histological prognostic factors.

Conclusions:

In colorectal liver metastasis resection, the absence of tumor pseudocapsule was significantly associated with shorter overall survival and disease-free survival and hepatic recurrence. However, margins larger than 10 mm did not offer survival benefit when other pathologic negative prognostic factors were concomitantly analyzed, reinforcing the idea that biology, rather than margin size, is crucial for prognosis.

How best to measure the levator hiatus: evidence for the non-Euclidean nature of the 'plane of minimal dimensions'

OBJECTIVE

To clarify whether the 'plane of minimal dimensions' of the levator hiatus on three-dimensional (3D) ultrasound accurately represents the minimal anatomical transverse hiatal dimension during a Valsalva maneuver.

METHODS

In this retrospective study of 3D transperineal ultrasound and magnetic resonance (MR) imaging, datasets from 19 female participants were used to measure the transverse diameter of the levator hiatus using the plane of minimal dimensions on maximum Valsalva maneuver. The term 'apparent minimal transverse diameter' (aMTD) was used to define the transverse diameter measured using axial ultrasound and comparable axial or coronal MR images. Coronal MR images, using the plane of the vagina as a reference, were also obtained on maximum Valsalva. The transverse diameter measured between the caudal margin of the pubococcygeus/puborectalis on the MR coronal image is denoted by the term 'true minimal transverse diameter' (tMTD). Statistical comparisons between the aMTD and tMTD were made using Student's t-test.

RESULTS

No significant difference was demonstrated between the aMTD as measured by ultrasonography and MRI. However, there were significant differences found between the aMTD measured by both ultrasound and MRI and the tMTD measured on coronal MR images (both P < 0.01), with mean ( ± SD) values of 4.36 ± 0.85, 4.13 ± 1.09 and 3.23 ± 0.49 cm, respectively.

CONCLUSION

This study highlights the complexity and 3D nature of the levator hiatus and pelvic floor muscles. Investigators have previously assumed that the plane of minimal dimensions of the hiatus can be measured in a flat plane, however, the 3D nature of the hiatus means that the true levator hiatus occupies a warped (non-Euclidean) plane. Hiatal measurements on Valsalva may be subject to systematic error if performed in a single section, i.e. using a flat (Euclidean) plane.

Pelvic floor function in elite nulliparous athletes

OBJECTIVE

There is preliminary evidence linking long-term participation in high-impact exercise with poor performance in labor and increased incidence of stress urinary incontinence, which may be due to altered pelvic floor function. Recent work has shown that HIFIT (high-impact, frequent intense training) athletes have an increased cross-sectional area of the levator ani muscle group as visualized using magnetic resonance imaging (MRI). The aim of this study was to further characterize pelvic floor muscle function and pelvic organ descent in a nulliparous athletic population and compare it with non-athletic controls matched for age and body mass index, using three-dimensional/four-dimensional (3D/4D) pelvic floor ultrasound imaging.

METHODS

In this prospective comparative study translabial ultrasound imaging was used to assess pelvic floor anatomy and function in 46 nulliparous female volunteers (aged 19-39 years), 24 HIFIT and 22 controls. Two-dimensional (2D) and 3D translabial ultrasonography was performed on all subjects, after voiding and in the supine position. Descent of the pelvic organs was assessed on maximum Valsalva maneuver, whilst volume datasets were acquired at rest, during pelvic floor muscle contraction and during a Valsalva maneuver. Participants performed each maneuver at least three times and the most effective was used for evaluation.

RESULTS

HIFIT athletes showed a higher mean diameter of the pubovisceral muscle (0.96 cm vs. 0.70 cm, P < 0.01), greater bladder neck descent (22.7 mm vs. 15.1 mm, P = 0.03) and a larger hiatal area on Valsalva maneuver (21.53 vs. 14.91 cm(2), P = 0.013) compared with the control group. There were no significant differences in hiatal area at rest or on maximal voluntary contraction between the two groups.

CONCLUSION

HIFIT athletes show significant differences in several of the measured parameters for both function and anatomy of the pelvic floor. Further research into the impact of this altered function on childbirth and continence mechanisms is needed.