L’approche par minilaparotomie a été rapportée comme une alternative mini-invasive à la laparoscopie. Cependant, la qualité des données disponibles pour juger de l’efficience de la minilaparotomie pour traiter la lithiase (L) de la voie biliaire principale (VBP) est insuffisante.Deux cent vingt-huit patients ayant une lithiase de la VBP (LVBP) ont eu une exploration de la VBP par minilaparotomie entre 1995 et 2010. Tous les patients avaient une lithiase vésiculaire et une LVBP. Cent quatre-vingt-treize ont eu une tentative de clairance par endoscopie et 29 ne l’ont pas eu. Les six autres patients avaient une LVBP résiduelle ou récidivante pour lesquels la clairance endoscopique était un échec. Les évènements non désirables peropératoires et postopératoires ont été classés selon les classifications de Satava et de l’Accordion (classification de Clavien-Dindo-Strasberg), respectivement.Le taux de conversions a été de 3,9 %. La durée moyenne de l’intervention a été de 86 minutes. Des complications postopératoires sont survenues chez 6,1 %, y compris un taux de 2,2 % de complications majeures (Accordion grades 4–6). La mortalité a été de 0,9 %.La minilaparotomie est efficace dans le traitement de la LVBP. Elle devrait être considérée comme une alternative à l’approche laparoscopique pour l’exploration chirurgicale des patients porteurs de LVBP.Minilaparotomy has been reported to be an alternative minimally invasive option to laparoscopy. However, the quality of available data on the effectiveness of minilaparotomy to treat choledocholithiasis is poor.Two hundred and twenty-eight patients with choledocholithiasis underwent surgical exploration of the common bile duct via minilaparotomy from 1995 to 2010. Of these, 193 patients had choledocho/cholecystolithiasis with previous ineffective attempts at endoscopic clearance, and 29 patients had choledocho/cholecystolithiasis without previous attempts at endoscopic clearance. Six other patients had recurrent/residual choledocholithiasis despite ineffective attempts at endoscopic clearance. Perioperative adverse events were analyzed in accordance with the Satava classification for intraoperative events while postoperative complications were graded according to the Accordion classification.Conversion was needed in 3.9% of procedures. The mean operative time was 86 minutes. Postoperative complications occurred in 6.1%, 2.2% of which were major (Accordion grade 4–6). Mortality was 0.9%.Minilaparotomy is an effective minimally invasive approach for the surgical treatment of choledocholithiasis. This approach could be considered as an alternative to the laparoscopic approach for surgical exploration of the common bile duct in patients with choledocholithiasis.

BACKGROUND:The results of surgery for recurrent colorectal liver metastases (CLM) after radiofrequency ablation (RFA) have not been evaluated.METHODS:From 1993 to 2009, data on patients who underwent resection or RFA for recurrent CLM were collected prospectively. Inclusion criteria for this study were RFA as initial treatment for CLM and resection of recurrent CLM after RFA. Postoperative results and oncological outcomes were analysed.RESULTS:Twenty-eight patients (median number of tumours 1 (1-3), median size 2·8 (2·0-4·0) cm) met the inclusion criteria. Of these, 22 had recurrence at the site of RFA only, two developed new lesions, whereas four had both recurrent and de novo metastases. At the time of resection, patients had a median of 1 (1-13) CLM with a median maximum tumour diameter of 5·0 (1·8-11·0) cm, significantly larger than at the time of RFA (P = 0·021). Ninety-day postoperative morbidity and mortality rates were 46 per cent (13 of 28) and 7 per cent (2 of 28) respectively. After a median follow-up of 35 (0-70) months, 3-year overall and disease-free survival rates calculated by Kaplan-Meier analysis were 60 and 29 per cent respectively. Plasma carcinoembryonic antigen level over 5 ng/ml at the time of resection and a rectal primary tumour were associated with worse survival (P = 0·041 and P = 0·021 respectively).CONCLUSION:Resection for recurrence after RFA is associated with significant morbidity and modest long-term benefit.

Background: Progress in the treatment of hepatic colorectal metastases (HCRM) demands pathologic indicators of therapy response. We observed that a majority of residual tumor cells are seen at the tumor-normal interface (TNI) in resected HCRM specimens and hypothesized that tumor thickness at the TNI correlates with radiologic and pathologic response and recurrence-free survival (RFS).Design: This study included 103 patients with HCRM resected after preoperative chemotherapy with or without bevacizumab. Imaging response was assessed by response evaluation criteria in solid tumors (RECIST) and recently described CT morphology criteria by Chun et al. The pathologic response was categorized as complete (no tumor cells), major (< 50% residual tumor cells), or minor (>= 50% residual tumor cells). The maximum thickness of uninterrupted layers of tumor cells was measured perpendicular to the TNI by 2 pathologists independently, followed by consensus review for discrepant cases. For specimens containing > 1 tumor, the average tumor thickness at the TNI was used.Results: Sixty-five patients received oxaliplatin-based chemotherapy, 38 received irinotecan-based chemotherapy, and 75 received concurrent bevacizumab. A complete pathologic response was seen in 9 patients, a major response in 44, and a minor response in 50. Median tumor thickness at the TNI was 2.8 mm (interquartile range, 0.5 to 6 mm). Tumor thickness correlated better with radiologic response as determined by Chun et al (P < 0.0001) than by RECIST criteria (Spearman r = 0.35, P < 0.001). Tumor thickness correlated with pathologic response (Spearman r = 0.80, P < 0.0001). Greater thickness predicted shorter recurrence-free survival, and this correlation remained in multivariate analysis (P = 0.015). Tumor thickness was smaller in patients treated with bevacizumab than in patients not given bevacizumab (P = 0.03).Conclusions: Tumor thickness measured at the TNI is potentially a new prognostic factor for therapy response and survival outcome in patients with resected HCRM.

BACKGROUND:Preoperative chemoradiation can potentially improve outcomes in patients with pancreatic cancer. This study addresses its effect on staging pancreatic cancer with multidetector computed tomography (MDCT).METHODS:Fifty-five patients underwent a dual-phase MDCT pancreas protocol for proved pancreatic cancer. Of these, 16 patients underwent preoperative chemoradiation. Three radiologists independently reviewed images to assess for locally advanced disease, liver and peritoneal metastases on baseline studies of all 55 patients, and on follow-up preoperative studies for the 16 patients receiving preoperative therapy. Overall score for resectability was graded on a scale from 1 to 5 (1, definitely resectable; 5. definitely unresectable). Receiver operating characteristic curves and weighted (kappa statistics were determined.RESULTS:The areas under the receiver operating characteristic curves for readers 1, 2, and 3 were 0.98, 0.96, and 0.90, respectively. Weighted kappa values for reader 1 versus reader 2, reader 1 versus reader 3, and reader 2 versus reader 3 were 0.90, 0.57, and 0.54, respectively. Interpreting scores of 1 to 3 for resectability as resectable disease, the mean values for sensitivity, specificity, negative predictive value, positive predictive value, and accuracy were 0.92, 0.91, 0.74, 0.98, and 0.92 respectively.CONCLUSION:The negative predictive value for MDCT for identifying unresectable pancreatic cancer in the setting of preoperative therapy is comparable to that reported in the absence of neoadjuvant therapy.

BACKGROUND Hepatic resection (HR) and radiofrequency ablation (RFA) have been proposed as equivalent treatments for colorectal liver metastasis. HYPOTHESIS Recurrence patterns after HR and RFA for solitary liver metastasis are similar. DESIGN Analysis of a prospective database at a tertiary care center with systematic review of follow-up imaging in all of the patients. PATIENTS AND METHODS Patients with solitary liver metastasis as the first site of metastasis treated for cure by HR or RFA were studied (patients received no prior liver-directed therapy). Prognostic factors, recurrence patterns, and survival rates were analyzed. RESULTS Of the 180 patients who were studied, 150 underwent HR and 30 underwent RFA. Radiofrequency ablation was used when resection would leave an inadequate liver remnant (20 patients) or comorbidity precluded safe HR (10 patients). Tumor size and treatment determined recurrence and survival. The local recurrence (LR) rate was markedly lower after HR (5%) than after RFA (37%) (P<.001). Treatment by HR was associated with longer 5-year survival rates than RFA, including LR-free (92% vs 60%, respectively; P<.001), disease-free (50% vs 0%, respectively; P = .001), and overall (71% vs 27%, respectively; P<.001) survival rates. In the subset with tumors 3 cm or larger (n = 79), LR occurred more frequently following RFA (31%) than after HR (3%) (P = .001), with a 5-year LR-free survival rate of 66% after RFA vs 97% after HR (P<.001). Patients with small tumors experienced longer 5-year overall survival rates after HR (72%) as compared with RFA (18%) (P = .006). CONCLUSIONS The survival rate following HR of solitary colorectal liver metastasis exceeds 70% at 5 years. Radiofrequency ablation for solitary metastasis is associated with a markedly higher LR rate and shorter recurrence-free and overall survival rates compared with HR, even when small lesions (< or = 3 cm) are considered. Every method should be considered to achieve resection of solitary colorectal liver metastasis, including referral to a specialty center, extended hepatectomy, and chemotherapy.

Objective: To evaluate the influence of surgical margin status on survival and site of recurrence in patients treated with hepatic resection for colorectal metastases.Methods: Using a multicenter database, 557 patients who underwent hepatic resection for colorectal metastases were identified. Demographics, operative data, pathologic margin status, site of recurrence (margin, other intrahepatic site, extrahepatic), and long-term survival data were collected and analyzed.Results: On final pathologic analysis, margin status was positive in 45 patients, and negative by 1 to 4 mm in 129, 5 to 9 mm in 85, and >= 1 cm in 298. At a median follow-up of 29 months, the 1-, 3-, and 5-year actuarial survival rates were 97%, 74%, and 58%; median survival was 74 months. Tumor size >= 5 cm, > 3 tumor nodules, and carcinoembryonic antigen level > 200 ng/mL predicted poor survival (all P < 0.05). Median survival was 49 months in patients with positive margins and not yet reached in patients with negative margins (P = 0.01). After hepatic resection, 225 (40.4%) patients had recurrence: 21 at the surgical margin, 56 at another intrahepatic site, 82 at an extrahepatic site, and 66 at both intrahepatic and extrahepatic sites. Patients with negative margins of 1 to 4 mm, 5 to 9 mm, and >= 1 cm had similar overall recurrence rates (P > 0.05). Patients with positive margins were more likely to have surgical margin recurrence (P = 0.003). Adverse preoperative biologic factors including tumor number greater than 3 (P = 0.01) and a preoperative CEA level greater than 200 ng/mL (P = 0.04) were associated with an increased risk of positive surgical margin.Conclusions: A positive margin after resection of hepatic colorectal metastases is associated with adverse biologic factors and increased risk of surgical-margin recurrence. The width of a negative surgical margin does not affect survival, recurrence risk, or site of recurrence. A predicted margin of < 1 cm after resection of hepatic colorectal metastases should not be used as an exclusion criterion for resection.

OBJECTIVE. The purpose of this study was to evaluate the sensitivity and specificity of helical CT in the detection of adenocarcinomas of the pancreas measuring 2 cm or smaller at pathologic examination.MATERIALS AND METHODS. Thin-section triple phase (20, 40, and 70 sec after the start of injection) contrast-enhanced helical CT scans of the abdomen in 18 patients with a pancreatic carcinoma that was 2 cm or smaller and 18 patients with a normal pancreas were retrospectively reviewed by two senior radiologists who specialized in oncologic abdominal imaging. Discrepancies were resolved by consensus. The observers were unaware of the clinical information. CT scans were evaluated for the presence of a pancreatic mass, bile, and pancreatic duct stricture. The location and size of tumors as determined on CT were compared with pathologic findings. The CT results were also compared with the prospective CT interpretations derived from the radiology reports and with the endoscopic sonographic reports when available.RESULTS. The sensitivity of thin-section triple-phase helical CT in the detection of small pancreatic masses was 77%, and the specificity was 100% for the two experienced observers. The sensitivity and specificity were 72% and 100%, respectively, for the prospective interpretations done by 10 observers. There was no correlation between the tumor size at pathology and the CT measurements.CONCLUSION. Thin-section contrast-enhanced helical CT is sensitive and highly specific for the detection of pancreatic tumors measuring 2 cm or smaller. Improvement in the detection rate of this technique compared with previous techniques lies in the optimization of parenchymal enhancement during the pancreatic phase and the decrease in slice thickness.

Purpose: The purpose of this study was to evaluate the clinical activity and toxicity of recombinant human Interleukin (IL)-12 in patients with relapsed and refractory non-Hodgkin’s lymphoma (NHL) or Hodgkin’s disease (HD). Experimental Design: Forty-two previously treated patients (32 patients with NHL and 10 patients with HD) were enrolled on the study. Patients were treated with either intravenous (n = 11) or subcutaneous (n = 31) administration of IL-12. The patients had received a median of three prior treatment regimens, and 16 patients had undergone prior autologous stem cell transplantation. Results: All patients were assessable for toxicity, and 39 of 42 (93%) patients were assessable for response. Six of 29 (21%) patients with NHL had a partial or complete response, whereas none of the 10 patients with HD responded. Furthermore, 15 patients had stable disease that lasted for up to 54 months. Progression-free survival in patients with indolent NHL, aggressive NHL, and HD was 6, 2, and 2.5 months, respectively. Treatment was well tolerated, and the most common toxicity was flu-like symptoms. Reversible grade 3 hepatic toxicity was observed in three patients requiring dose reduction. IL-12 therapy increased the median number of peripheral blood CD8 T lymphocytes from 423/μl to 576/μl (P = 0.0019). Furthermore, IL-12 therapy decreased serum vascular endothelial growth factor and basic fibroblast growth factor concentrations in 37% of the patients. Conclusions: The ability of recombinant human IL-12 therapy to increase the number of circulating CD8+ cells and induce clinical remissions in patients with relapsed NHL warrants further investigation of the drug.

In this paper, a machine learning approach was used for brain tumour localization on FLAIR scans of magnetic resonance images (MRI). The multi-modal brain images dataset (BraTs 2012) was used, that is a skull stripped and co-registered. In order to remove the noise, bilateral filtering is applied and then texton-map images are created by using the Gabor filter bank. From the texton-map, the image is segmented out into superpixel and then the low-level features are extracted: the first order intensity statistical features and also calculates the histogram level of texton-map at each superpixel level. There is a significant contribution here that the low features are not too much significant for the localization of brain tumour from MR images, but we have to make them meaningful by integrating features with the texton-map images at the region level approach. Then these features which are provided later to classifier for the prediction of three classes: background, tumour and non-tumour region, and used the labels for computation of two different areas (i.e. complete tumour and non-tumour). A Leave-one-out (LOOCV) cross validation technique is applied and achieves the dice overlap score of 88% for the whole tumour area localization, which is similar to the declared score in MICCAI BraTS challenge. This brain tumour localization approach using the textonmap image based on superpixel features illustrates the equivalent performance with other contemporary techniques. Recently, medical hypothesis generation by using autonomous computer based systems in disease diagnosis have given the great contribution in medical diagnosis.

Multidetector row computed tomography (CT) can acquire abdominal images of unprecedented thinness in a single breath-hold. This study investigated whether acquiring source axial images at 1.25 mm as opposed to 2.5 mm would result in a perceptible difference in image quality for coronal oblique reformations. Similarly, the hypothesis that a slice pitch of 3:1 would be superior to 6:1 was evaluated. Twenty-nine CT studies were retrospectively evaluated. The images were divided into four groups: 1.25-mm axial images, pitch 3: 1; 2.5-mm axial images, pitch 3: 1; 1.25-mm axial images, pitch 6: 1; and 2.5-mm axial images, pitch 6:1. Three radiologists evaluated by consensus the coronal oblique reformations for overall image quality and image quality of structures in the hepatoduodenal ligament and of nodal groups. Use of 1.25-mm rather than of 2.5-mm source axial images resulted in statistically significant better scores for overall image quality and visualization of the hepatic artery, portal vein, pancreatic duct, and nodal groups. However, a pitch of 3:1 rather than of 6:1 did not result in significant differences in ratings of image quality. Use of 1.25-mm rather than of 2.5-mm source axial images improves image quality when creating coronal oblique reformations for abdominal anatomy.

Mullen, John T. MD*; Walsh, Garrett L. MD, FACS†; Abdalla, Eddie K. MD*; Loyer, Evelyne M. MD‡; Curley, Steven A. MD, FACS*; Vauthey, Jean-Nicolas MD, FACS*,* Author Information

Computed tomography (CT) is used increasingly to measure liver volume in patients undergoing evaluation for transplantation or resection. This study is designed to determine a formula predicting total liver volume (TLV) based on body surface area (BSA) or body weight in Western adults. TLV was measured in 292 patients from four Western centers. Liver volumes were calculated from helical computed tomographic scans obtained for conditions unrelated to the hepatobiliary system. BSA was calculated based on height and weight. Each center used a different established method of three-dimensional volume reconstruction. Using regression analysis, measurements were compared, and formulas correlating BSA or body weight to TLV were established. A linear regression formula to estimate TLV based on BSA was obtained: TLV = -794.41 + 1,267.28 x BSA (square meters; r(2) = 0.46; P < .0001). A formula based on patient weight also was derived: TLV = 191.80 + 18.51 x weight (kilograms; r(2) = 0.49; P < .0001). The newly derived TLV formula based on BSA was compared with previously reported formulas. The application of a formula obtained from healthy Japanese individuals underestimated TLV. Two formulas derived from autopsy data for Western populations were similar to the newly derived BSA formula, with a slight overestimation of TLV. In conclusion, hepatic three-dimensional volume reconstruction based on helical CT predicts TLV based on BSA or body weight. The new formulas derived from this correlation should contribute to the estimation of TLV before liver transplantation,or major hepatic resection.

An alternative to surgical resection of liver tumors, radio-frequency ablation induces in situ thermal coagulation necrosis through the delivery of high-frequency alternating current to the tissues. Imaging helps to detect treatable lesions, guide the placement of the probe, and assess the effect of therapy. Computed tomography (CT) is used most frequently to determine whether the ablation is complete and to screen for early recurrences that may benefit from reablation. Complete ablation creates an area of necrosis that, at CT, is of low attenuation compared with the surrounding liver tissue, is often homogeneous, and has smooth margins. The most important features are the size of the necrotic defect, which, immediately after treatment, should be larger than that of the pretreatment tumor, and the sharpness of the margins, which indicates an abrupt change in attenuation between the necrotic tissue and surrounding liver tissue. Enhancement, when present, is due to perfusion abnormality or granulation tissue and forms a regular rim or a homogeneous zone at the margin of the defect. It is seen immediately after ablation but may be prolonged. Enhancement is affected by the scanning technique. Over time, the size of the defect remains stable or decreases. Any variation from this general pattern is suggestive of incomplete ablation or recurrence.

Cystic Lymphangioma of the PancreasTitus R. Koenig1, Evelyn M. Loyer2, Gary J. Whitman2, A. Kevin Raymond3 and Chusilp Charnsangavej2Audio Available | Share