Background: For patients with symptomatic liver lesions, preoperative imaging characteristics and elevated tumor markers can sometimes obviate the need for preoperative biopsy in a patient that is otherwise resectable. We present a case where preoperative clinical evaluation was consistent with cholangiocarcinoma, but postoperative pathologic review revealed a rare, unconsidered tumor. Methods: We report a resection of a symptomatic 12 cm right-sided liver mass that on final pathology was found to be a small cell carcinoma of the liver, as well as the post operative treatment and 1 year post operative course. A literature review was conducted to categorize similar cases. Results: A 58 year old female presented initially to the hospital with complaints of right upper quadrant pain and was found on CT and subsequent MR imaging to have a 9.9 cm right hepatic mass that centrally was T2 hyperintense, T1 hypodense with a peripheral rim that demonstrated slight T2 hyperintense, T1 hypointense signaling. Synthetic liver function parameters, AFP and CA 19-9 were normal. Resection was offered without preoperative biopsy given its symptomatic nature and resectability. The patient underwent a R-0 open right hepatectomy. Pathology revealed a high-grade neuroendocrine carcinoma with high N/C ratio and positive immunohistochemical stains for neuroendocrine and epithelial markers, consistent with primary small cell carcinoma of the liver. Postoperatively, she recovered well and received etoposide and cisplatin for 6 months. Eleven months postoperatively she presented with a new metastatic pontine lesion that was treated with radiation therapy for improved symptoms. A literature review revealed that most patients previously described with small cell cancer of the liver were not candidates for operative resection due to poor underlying liver function or performance status. For those who underwent operative resection, intrahepatic recurrence was the most commonly described recurrence pattern. Conclusion: Small cell carcinoma of the liver is a rare malignancy, with few documented cases of the natural progression after R-0 resection. This appears to be the first description of a patient with R-0 resection and isolated intracranial recurrence.

the right and middle hepatic veins before freeing the mass inferiorly from the portal plate.The right hepatic vein was skeletonized laterally and the middle hepatic vein was skeletonized medially.After careful dissection off the major hepatic vessels, the entire identified HA was completely freed.Ultrasound of the residual liver showed proper inflow and outflow.The patient followed up with a MRI one month after operation which showed mild operative related inflammation and no other complications.Conclusion: Due to the location of the presenting mass, a central hepatectomy approach was selected to remove the entirety of the mass and preserve the maximum functional liver tissue.The approach resulted in removal of the tumor and preservation of more functional tissue then the traditional hepatic resections.The traditional resection approaches would result in significant loss of functional liver mass.The central hepatectomy approach taken in this case limited the removal of functional liver tissue to approximately 25%.Overall, the case illustrates the consideration of TAE and a central hepatectomy approach with careful dissection of vascular and biliary structures to expand the range of initially inoperable giant, central hepatic tumors.

Background: Complex HPB operations can lead to complicated outcomes and prolonged morbidity. Reliable pre-event predictors for these untoward events are desirable to allow for early intervention strategies. Methods: Clinicopathologic, therapeutic and early outcomes variables (n = 36), 12 clinical risk scores (CRSs, including NSQIP, POSSUM, Charlson, modified frailty index MFI) and 10 radiographic scan-based morphometric parameters (MM) were analyzed for consecutive HPB patients in a tertiary care cancer center setting. Associations with 4 prospectively charted parameters (A: any complication, B: serious complication, C: SSI/leak, D: death) were tested via univariate and logistic regression analyses. Results: Among 156 patients were 84 men and 72 women, with a median age of 66 (range: 17-89) and a mean BMI of 27.8. Procedures included 84 pancreatectomies (54%), 56 hepatectomies (36%), and 16 biliary resections or bypass procedures (10%); twelve percent of resections were multivisceral, and 2% emergent. Events of interest were encountered in 49% (A), 21% (B), 19% (C) or 3% (D). All non-lethal complications impacted length of stay (median: 8 d, range: 1–41; A: 9 vs 7 d, B: 13 vs 7 d, C: 12 vs 7 d, p < 0.0001). Predictive performance for CRSs for these events was poor; significant univariate associations (at p < 0.05) were only found for NSQIP (for B and D) and POSSUM scores (for D), but not for Charlson or MFI scores. In contrast, sarcopenia and/or visceral fat area MM correlated with A, B, C and D. Multivariate associations were found for age and IVF (A), COPD and abdominal depth (B), surgeon and visceral fat (C), and abdominal depth, WBC, steroid use and albumin (D). No significant multivariate associations were observed for any CRS or MM parameters when controlled for the covariates listed. Conclusion: Preoperative risk scores are unable to reliably predict morbidity events after HPB operations in this series, while few selected scores (NSQIP, POSSUM) may contribute to risk stratification. Targeted query of few simple clinical parameters would better inform potential early interventions strategies in patients at risk for postoperative morbidity.

Background: Increasingly, patients with multiple co-morbidities undergo surgery for rectal cancer. We aimed to evaluate if decreased psoas muscle area and volume, as measures for sarcopenia, were associated with postoperative morbidity. Methods: Retrospective review of patients undergoing rectal cancer resection at a tertiary medical center (2007-2015). Variables included demographics, co-morbidities, preoperative psoas muscle area and volume, and postoperative complications. Results: Among 180 patients (58% male, mean age 62.7 years), 44% experienced complications (n = 79), of which 38% (n = 30) were major complications. Malnourished patients had smaller height-adjusted total psoas area than non-malnourished patients (6.4 vs. 9.5 cm(2)/m(2), p = 0.004). Among patients with imaging obtained within 90 days of surgery, major morbidity was associated with smaller total psoas area (6.7 vs. 10.5 cm(2)/m(2), p = 0.04) and total psoas volume (26.7 vs. 42.2 cm(3)/m(2), p = 0.04) compared to those with minor complications. Conclusion: Preoperative cross-sectional imaging may help surgeons anticipate postoperative complications following rectal cancer surgery. (C) 2017 Elsevier Inc. All rights reserved.

The molecular mechanism underlying gastric cancer (GC) invasion and metastasis is still poorly understood. In this study, we tried to investigate the roles of CXCR4 and CXCR2 signalings in gastric cancer metastasis. A highly invasive gastric cancer cell model was established. Chemokines receptors were profiled to search for the accountable ones. Then the underlying molecular mechanism was investigated using both in vitro and in vivo techniques, and the clinical relevance of CXCR4 and CXCR2 expression was studied in gastric cancer samples. CXCR4 and CXCR2 were highly expressed in a high invasive gastric cancer cell model and in gastric cancer tissues. Overexpression of CXCR4 and CXCR2 was associated with more advanced tumor stage and poorer survival for GC patients. CXCR4 and CXCR2 expression strongly correlated with each other in the way that CXCR2 expression changed accordingly with the activity of CXCR4 signaling and CXCR4 expression also changed in agreement with CXCR2 activity. Further studies demonstrated CXCR4 and CXCR2 can both activated NF-κB and STAT3 signaling, while NF-κBp65 can then transcriptionally activate CXCR4 and STAT3 can activate CXCR2 expression. This crosstalk between CXCR4 and CXCR2 contributed to EMT, migration and invasion of gastric cancer. Finally, Co-inhibition of CXCR4 and CXCR2 is more effective in reducing gastric cancer metastasis. Our results demonstrated that CXCR4 and CXCR2 cross-activate each other to promote the metastasis of gastric cancer.

BACKGROUND:The impact of immediate breast reconstruction on the time to first adjuvant therapy is controversial. METHODS:Retrospective study design comparing time to first treatment in women undergoing mastectomy with and without immediate reconstruction in a community cancer center. RESULTS:Seventy-six cases fit inclusion criteria of which 44 (58%) underwent mastectomy with immediate reconstruction. Women undergoing immediate reconstruction were younger, had more bilateral mastectomies and had fewer prior breast procedures. The median time to first adjuvant therapy was longer in the immediate reconstruction group [80.5days (36-343) versus 53.5 days (18-96), p = 0.003]. Fifteen of 44 patients had the start of adjuvant treatment over 90 days after resection, 14 of whom (93%) had immediate reconstruction versus 1 (7%) who did not (p = 0.01). CONCLUSION:In this study immediate breast reconstruction was associated with a longer time to first adjuvant treatment, with adjuvant therapies being more likely delayed over 90 days.

Objectives: To determine the incidence of preoperative malnutrition among patients scheduled to undergo pancreatoduodenectomy and to evaluate the effect of preoperative nutritional status on early postoperative outcome.Material and methods:This study was conducted between July 2011 and December 2012 at the Surgical Gastroenterology department at a tertiary centre.Patients posted for Whipple pancreatoduodenectomy for various etiologies were included.Nutritional assessment (Subjective Global Assessment (SGA), body mass index (BMI; normal >18 kg/m 2 or less than 25),Mid Arm Muscle Circumference (MAMC; normal > 27 mm), Triceps skin fold thickness (TSFT; normal >9 mm)), serum albumin (normal >3.0 g/dl) and Prognostic Nutritional Index (normal >40)was done for 83 patients scheduled for pancreatoduodenectomy on the day prior to surgery.Resectionwas done in 73 patients and these patients were analyzed for post operative outcome.Results -Median age of study group was 56 years.Fifty one were male and 32 female.Median value of BMI was 23.2 Kg/ m 2 (range 13.54-32.90).Median value of PNI was 47 (range 27.5-65.5).Malnutrition was identified in 59 (SGA grade B-48, SGA grade C-11) out of 83 patients.With other modalities rate of detection of malnutrition was less (BMI -21/83, PNI-11/83, MAMC-7/83 andTSFT-11/83).Five out of 11 SGA grade C patients were found to have unresectable/metastatic disease at exploration whereas PNI < 40 only picked up 3 advanced disease.Univariate analysis failed to show significant correlation between SGA predicted under nutrition and post operative complications like pancreatic fistula (p= 0.639), post pancreatectomy hemorrhage (p= 0.120), abdominal collections (P=0.399).Poor SGA grade had statistically significant correlation with post operative delayed gastric emptying (p= 0.001).For over all complication rate correlation was not significant, but trend towards Poor SGA score resulted in higher frequency of complications (p = 0.094).BMI >25 was significantly associated with pancreatic fistula (0.009),abdominal collections (p=0.005) as well as readmission rates (p=0.039).Multivariate analysis had also shown high BMI as independent predictive factor for pancreatic fistula (p= 0.04).However, correlation was not significant between BMI and over all complication rate (p=0.161).Conclusions: Multiple risk factors associated in pancreatic surgery that results in pancreatic fistula, malnutrition is a modifiable risk factor, and it should be addressed.Subjective Global Assessment appears to be superiorin identifying patients with a nutritional risk at early stage as compare to other assessment tools.Early enteral feeding may account for the fact that patients with malnutrition did not have a higher frequency of overall post operative complications in this study.

BACKGROUND: Esophagectomy is associated with high morbidity and mortality, leading to calls for restricted performance at high-volume centers.METHODS: Patients with esophageal cancer were evaluated prospectively in a multidisciplinary tumor board from January 2012 - December 2012. A 2-surgeon team was utilized and detailed outcomes were assessed prospectively.RESULTS: Thirty-one patients underwent esophagectomy, 20 patients underwent laparoscopic trans-hiatal (65%) approach, and 11 patients underwent laparoscopically assisted Ivor-Lewis (35%) approach. Eighty-one percent of the patients were male, with a median age of 64 years (range: 35 to 83 years) and 73% of the patients had adenocarcinoma. Neoadjuvant chemoradiation was performed in 79% of the patients. R0 resection was achieved in 29 (94%) patients, median nodes identified were 15. Major complications (grade III to V) occurred in 13 (42%) patients and did not correlate with surgical techniques, anastomotic leak occurred in 5 (16%) patients, and significant pulmonary complications occurred in 11 (35%) patients. The length of stay at the hospital was 10 days, readmission rate 23%, and 30-day mortality rate 6%.CONCLUSIONS: High-quality esophagectomy can be performed safely at a mid-volume cancer center. Our outcomes question the reliance on volume alone as an indicator of cancer surgical quality. (C) 2014 Elsevier Inc. All rights reserved.

BACKGROUND: Pediatric melanoma rates are increasing nationally. Our purpose was to determine the incidence of melanoma in New Mexico's (NM's) American Indian, Hispanic, and non-Hispanic white children.METHODS: A retrospective review (1981 to 2009) of the NM Tumor Registry was conducted. Melanomas diagnosed in children <= 19 years of age were identified. Average annual age-adjusted incidence rates per million were calculated.RESULTS: Sixty-four cases were identified. Rates per million were 7.4 for non-Hispanic whites, 2.1 for Hispanics, and 3.3 for American Indians. Fifty-nine percent were women. Fifty-five (86%) cases were localized, 6 (9%) were regional, and 1 (3%) case was metastatic. Majority of cases (49/64; 77%) occurred in children >14 years of age. American Indians presented with thicker melanomas as compared to whites and Hispanics.CONCLUSIONS: Incidence rates for pediatric melanoma in NM are highest for non-Hispanic whites. Distant metastasis is uncommon. Melanoma in children is rare, but practitioners must be aware of its occurrence for prompt diagnosis and treatment. (C) 2014 Elsevier Inc. All rights reserved.

Pancreatic neuroendocrine tumors (PNETs) are rare but are well understood to cover a broad spectrum of clinical presentation, tumor biology and prognosis. More than 60% of PNETs are diagnosed at advanced disease stage and are ineligible for surgical resection. Prior to 2011, streptozocin was the only approved agent for unresectable advanced PNETs. In recent years, breakthroughs in signal pathway research have led to the identification of new therapeutic targets and agents directed at the molecular level. In 2011, two new targeted therapeutic agents, sunitinib and everolimus, were approved by the Food and Drug Administration (FDA). Sunitinib is an inhibitor of multiple tyrosine kinases, and everolimus is an inhibitor of the mammalian target of rapamycin (mTOR) pathway. This review discusses the major signaling pathways that are frequently mutated or deregulated in PNETs, and the implications of molecular alterations for PNET therapy. Biologic therapy through targeting relevant pathways represents a promising approach in the therapy of advanced and unresectable PNETs.