Robotic approach with neoadjuvant chemotherapy in adult Wilms’ tumor: A feasibility study report and a systematic review of the literature

Objective:The incidence of Wilms’tumor(WT)among adult individuals accounts for less than 1%of kidney cancer cases,with a prognosis usually less favorable when compared to younger individuals and an overall survival rate of 70%for the adult patients versus 90%for the pediatric cases.The diagnosis and treatment of WT are complex in the preoperative setting;neoadjuvant chemotherapy(NAC)or robotic surgery has rarely been described.This study aimed to review the literature of robotic surgery in WT and report the first adult WT management using both NAC and robotic strategy.Methods:We reported a case of WT managed in a multidisciplinary setting.Furthermore,according to Preferred Reporting Items for Systematic reviews and Meta-Analyses recommendations,a systematic review of the literature until August 2020 of WT treated with a robotic approach was carried out.Results:A 33-year-old female had a diagnosis of WT.She was scheduled to NAC,and according to the clinical and radiological response to a robotic radical nephrectomy with aortic lymph nodes dissection,she was managed with no intraoperative rupture,a favorable surgical outcome,and a follow-up of 25 months,which did not show any recurrence.The systematic review identified a total number of 230 cases of minimally invasive surgery reported in the literature for WT.Of these,approximately 15 patients were carried out using robotic surgery in adolescents while none in adults.Moreover,NAC has not been administered before minimally invasive surgery in adults up until now.Conclusion:WT is a rare condition in adults with only a few cases treated with either NAC or minimally invasive approach so far.The advantage of NAC followed by the robotic approach could lead to favorable outcomes in this complex scenario.Notwithstanding,additional cases of adult WT need to be identified and investigated to improve the oncological outcome.

Garg incontinence scores: New scoring system on the horizon to evaluate fecal incontinence. Will it make a difference?

The main aim of this opinion review is to comment on the recent article published by Garg et al in the World Journal of Gastroenterology 2023;29:4593–4603.The authors in the published article developed a new scoring system,Garg incon-tinence scores(GIS),for fecal incontinence(FI).FI is a chronic debilitating disease that has a severe negative impact on the quality of life of the patients.Rome IV criteria define FI as multiple episodes of solid or liquid stool passed into the clothes at least twice a month.The associated social stigmatization often leads to significant under-reporting of the condition,which further impairs management.An important point is that the complexity and vagueness of the disease make it difficult for the patients to properly define and report the magnitude of the problem to their physicians.Due to this,the management becomes even more difficult.This issue is resolved up to a considerable extent by a scoring ques-tionnaire.There were several scoring systems in use for the last three decades.The prominent of them were the Cleveland Clinic scoring system or the Wexner scoring system,St.Marks Hospital or Vaizey’s scores,and the FI severity index.However,there were several shortcomings in these scoring systems.In the opinion review,we tried to analyze the strength of GIS and compare it to the existing scoring systems.The main pitfalls in the existing scoring systems were that most of them gave equal weightage to different types of FI(solid,liquid,flatus,etc.),were not comprehensive,and took only the surgeon’s perception of FI into view.In GIS,almost all shortcomings of previous scoring systems had been addressed:different weights were assigned to different types of FI by a robust statistical methodology;the scoring system was made comprehensive by including all types of FI that were previously omitted(urge,stress and mucus FI)and gave priority to patients’rather than the physicians’perceptions while developing the scoring system.Due to this,GIS indeed looked like a paradigm shift in the evaluation of FI.However,it is too early to conclude this,as GIS needs to be validated for accuracy and simplicity in future studies.

Advances in computed tomography and magnetic resonance imaging of hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the most common primary liver cancer.Imaging is important for establishing a diagnosis of HCC and early diagnosis is imperative as several potentially curative treatments are available when HCC is small.Hepatocarcinogenesis occurs in a stepwise manner on a background of chronic liver disease or cirrhosis wherein multiple genes are altered resulting in a range of cirrhosisassociated nodules.This progression is related to increased cellularity,neovascularity and size of the nodule.An understanding of the stepwise progression may aid in early diagnosis.Dynamic and multiphase contrast-enhanced computed tomography and magnetic resonance imaging still form the cornerstone in the diagnosis of HCC.An overview of the current diagnostic standards of HCC in accordance to the more common practicing guidelines and their differences will be reviewed.Ancillary features contribute to diagnostic confidence and has been incorporated into the more recent Liver Imaging Reporting and Data System.The use of hepatocyte-specific contrast agents is increasing and gradually changing the standard of diagnosis of HCC;the most significant benefit being the lack of uptake in the hepatocyte phase in the earlier stages of HCC progression.An outline of supplementary techniques in the imaging of HCC will also be reviewed.

Perfusion magnetic resonance imaging of the liver

Perfusion magnetic resonance imaging (MRI) studies quantify the microcirculatory status of liver parenchyma and liver lesions, and can be used for the detection of liver metastases, assessing the effectiveness of antiangiogenic therapy, evaluating tumor viability after anticancer therapy or ablation, and diagnosis of liver cirrhosis and its severity. In this review, we discuss the basic concepts of perfusion MRI using tracer kinetic modeling, the common kinetic models applied for analyses, the MR scanning techniques, methods of data processing, and evidence that supports its use from published clinical and research studies. Technical standardization and further studies will help to establish and validate perfusion MRI as a clinical imaging modality.

Ductal adenocarcinoma of the pancreatic head:A focus on current diagnostic and surgical concepts

Complete surgical resection still remains the only possibility of curing pancreatic cancer,however,only 10% of patients undergo curative surgery.Pancreatic resection currently remains the only method of curing patients,and has a 5-year overall survival rate between 7%-34% compared to a median survival of 3-11 mo for unresected cancer.Pancreatic surgery is a technically demanding procedure requiring highly standardized surgical techniques.Nevertheless,even in experienced hands,perioperative morbidity rates(delayed gastric emptying,pancreatic fistula etc.) are as high as 50%.Different strategies to reduce postoperative morbidity,such as different techniques of gastroenteric reconstruction(pancreatico-jejunostomy vs pancreatico-gastrostomy),intraoperative placement of a pancreatic main duct stent or temporary sealing of the main pancreatic duct with fibrin glue have not led to a significant improvement in clinical outcome.The perioperative application of somatostatin or its analogues may decrease the incidence of pancreatic fistulas in cases with soft pancreatic tissue and a small main pancreatic duct(< 3 mm).The positive effects of external pancreatic main duct drainage and antecolic gastrointestinal reconstruction have been observed to decrease the rate of pancreatic fistulas and delayed gastric emptying,respectively.Currently,the concept of extended radical lymphadenectomy has been found to be associated with higher perioperative morbidity,but without any positive impact on overall survival.However,there is growing evidence that portal vein resections can be performed with acceptable low perioperative morbidity and mortality but does not achieve a cure.

Hydrochloric acid-enhanced radiofrequency ablation for treating a large hepatocellular carcinoma with spontaneous rapture:a case report

Background:A ruptured hepatocellular carcinoma(HCC)is often fatal.In addition to surgery and transarterial embo?lization,radiofrequency ablation(RFA)might be another option for treating a ruptured HCC.Unfortunately,conven?tional RFA has a limited ablation zone;as such,it is rarely used to treat ruptured tumors.Case presentation:This case was a 60?year?old man who had a large,ruptured HCC in which hydrochloric acid(HCl)?enhanced RFA successfully controlled the bleeding and made the tumor completely necrotic.Conclusion:Considering the effectiveness of HCl?enhanced RFA in achieving hemostasis and tumor ablation,it might be a new option for treating large,ruptured HCCs.

Rectal arterio-portal fistula: An unusual cause of persistent bleeding per rectum following a proximal spleno-renal shunt

Gastrointestinal arterio-venous malformations are a known cause of gastrointestinal bleeding. We present a rare case of persistent rectal bleeding due to a rectal arterio-portal venous fistula in the setting of portal hypertension secondary to portal vein thrombosis. The portal hypertension was initially surgically treated with splenectomy and a proximal splenorenal shunt. However, rectal bleeding persisted even after surgery, presenting us with a diagnostic dilemma. The patient was re-evaluated with a computed tomography mesenteric angiogram which revealed a rectal arterio-portal fistula. Arterio-portal fistulas are a known but rare cause of portal hypertension, and possibly the underlying cause of continued rectal bleeding in this case. This was successfully treated using angiographic localizationand super-selective embolization of the rectal arterioportal venous fistula via the right internal iliac artery. The patient subsequently went on to have a full term pregnancy. Through this case report, we hope to high-light awareness of this unusual condition, discuss the diagnostic workup and our management approach.

Prospect of Functional Salivary Gland Enhancement with Biomedical Strategies for Head and Neck Cancers

Xerostomia is the main complication inflicting head and neck cancer patients treated with radiotherapy.Conventional treatment is not very effective in alleviating this morbidity.Biomedical strategies such as gene transfer and tissue engineering have made substantial progress that will potentially lead to successful new treatment options for this condition.This report reviews the process of radiation damage to the salivary glands and the advances in functional salivary gland enhancement with these two brand-new technologies.

Hepatocellular carcinoma masquerading as a bleeding gastric ulcer: A case report and a review of the surgical management

Hepatocellular Carcinoma (HCC) is a common malignancyworldwide. While bleeding from the gastrointestinal tract(BGIT) has a well known association with HCC, suchcases are mainly due to gastric and esophageal varices.BGIT as a result of invasion of the gastrointestinal tractby HCC is extremely rare and is reportedly associatedwith very poor prognosis. We describe a 67-year-oldmale who presented with BGIT. Endoscopy showed thesite of bleeding to be from a gastric ulcer, but endoscopictherapy failed to control the bleeding and emergencysurgery was required. At surgery, the ulcer was found tohave arisen from direct invasion of the gastrointestinaltract by HCC of the left lobe. Control of the bleedingwas achieved by surgical resection of the HCC en-bloc with the lesser curve of the stomach. The patientremains alive 33 mo after surgery. Direct invasion of thegastrointestinal tract by HCC giving rise to BGIT is veryuncommon. Surgical resection may offer significantlybetter survival over non-surgical therapy, especially if thepatient is a good surgical candidate and has adequatefunctional liver reserves. Prognosis is not uniformly grave.

Relationship between Expression of CEA,E-cadherin and Liver Metastasis in Colorectal Cancer

OBJECTIVE To investigate the expression of E-cadherin andCEA in serum in colorectal carcinoma and their relationship withliver metastasis.METHODS CEA level was measured post-operativelyby radioimmunoassay of 60 patients with colorectal cancer.Immunohistochemical analysis was used to evaluate theexpression of E-cadherin.RESULTS In liver metastasis group,24 patients (24/26,92.3%)were high level of CEA,but only 9 patients in non-liver metastasisgroup.The difference is significant (P=0.004).Expression ofE-cadherin significantly correlated with differentiation,but wasnot associated with Tstage or N stage.Liver metastatic rate innegative expression was higher than that in positive expression.And the survival analysis showed that time of liver metastasis wassignificant different in two groups (P<0.05).CONCLUSION The expression of CEA in serum can be usedto predict liver mestatasis of colorectal cancer after operation.E-cadherin,associated with tumor differentiation,is also a hopefulindicator for the prediction of liver metastasis in patients withcolorectal cancer.

Review of incomplete macroscopic resections(R2)in rectal cancer:Treatment,prognosis and future perspectives

Colorectal cancer is one of the most prevalent tumours,but with improved treatment and early detection,its prognosis has greatly improved in recent years.However,when the tumour is locally advanced at diagnosis or if there is local recurrence,it is more difficult to perform a complete tumour resection,and there may be a residual macroscopic tumour.In this paper,we review the literature on residual macroscopic tumour resections,concerning both locally advanced primary tumours and recurrences,evaluating the main problems encountered,the treatments applied,the prognosis and future perspectives in this field.

Lipoma of the pancreas,a case report and a review of the literature

Lipomas of the pancreas are very rare.There are fewer than 25 reported cases of lipoma originating from the pancreas.We present a case of pancreatic lipoma in a 61-year-old woman with magnetic resonance imaging findings and confirmatory histological findings.We discuss and highlight the radiological features distinguishing a pancreatic lipoma from other fatty lesions of the pancreas and pancreatic liposarcoma and provide a brief review of the literature.

Comparison of open and closed hyperthermic intraperitoneal chemotherapy: Results from the United States hyperthermic intraperitoneal chemotherapy collaborative

BACKGROUND Cytoreductive surgery(CRS)with hyperthermic intraperitoneal chemotherapy(HIPEC)for peritoneal carcinomatosis can be performed in two ways:Open or closed abdominal technique.AIM To evaluate the impact of HIPEC method on post-operative and long-term survival outcomes.METHODS Patients undergoing CRS with HIPEC from 2000-2017 were identified in the United States HIPEC collaborative database.Post-operative,recurrence,and overall survival outcomes were compared between those who received open vs closed HIPEC.RESULTS Of the 1812 patients undergoing curative-intent CRS and HIPEC,372(21%)patients underwent open HIPEC and 1440(79%)underwent closed HIPEC.There was no difference in re-operation or severe complications between the two groups.Closed HIPEC had higher rates of 90-d readmission while open HIPEC had a higher rate of 90-d mortalities.On multi-variable analysis,closed HIPEC technique was not a significant predictor for overall survival(hazards ratio:0.75,95%confidence interval:0.51-1.10,P=0.14)or recurrence-free survival(hazards ratio:1.39,95%confidence interval:1.00-1.93,P=0.05)in the entire cohort.These findings remained consistent in the appendiceal and the colorectal subgroups.CONCLUSION In this multi-institutional analysis,the HIPEC method was not independently associated with relevant post-operative or long-term outcomes.HIPEC technique may be left to the discretion of the operating surgeon.

Volumetric Modifications of Metastatic Liver Volumes after Dramatic Responses under Chemotherapy

Objective: To analyze the volumetric modifications of the non tumourous part of the liver when liver metastases (LM) decrease under chemotherapy. Methods: Patients were highly selected based on the following criteria: multiple bilateral large colorectal LM, response of LM attaining at least 85% under chemotherapy. The volumes and ratios of the whole liver, of the LM, and mainly of the non tumourous (normal) part of the liver, were measured on CT scan before and after chemotherapy. Results: Only ten (5%) among 198 treated patients were eligible. Nine of them had received intra-arterial chemotherapy. Metastatic involvement was initially 34% before chemotherapy (range: 13% - 75%), and was 5% (range: 1% - 25%) after chemotherapy. The whole liver volume decreased by 41% (range: 23% - 68%) after chemotherapy. The non metastatic liver (volume and ratio) decreased after chemotherapy in 6 patients and increased in 4 patients. The volume and ratio increased in the 4 patients whose disease initially exhibited the highest metastatic involvement (p = 0.01). Conclusion: The volume of the non metastatic part of the liver varied slightly under standard chemotherapy. Intra-arterial chemotherapy induces dramatic responses, but also liver injury which impairs liver regeneration. However increasing volumes were observed when initial tumour involvement was major.

Treatment-Plan Comparison of Three Advanced Radiation Treatment Modalities for Fractionated Stereotactic Radiotherapy to the Head and Neck

Purpose: Fractionated stereotactic radiosurgery (FSRS) can be given with at least three modalities: Gamma Knife, with the noninvasive frameless extend system (GKE);linear accelerator-based volumetric modulated arc therapy (VMAT);and intensity-modulated proton therapy (IMPT). We extracted treatment plans for patients who had received FSRS with GKE for recurrent skull base or intracranial tumors, created corresponding plans for VMAT and IMPT, and compared the quality of the three sets of plans. Methods and materials: Plans were extracted for 9 patients with recurrent malignant skull-base tumors (n = 6) or large intracranial tumors (n = 3) who had received FSRS with GKE (median dose 24 Gy in 3 fractions) in 2013 through 2015. Plans for VMAT were generated with a TrueBeam STx LINAC machine using 6-MV photons, and plans for IMPT were generated with multi-field optimization. The optimized VMAT and IMPT plans were normalized to achieve the best possible target coverage while meeting the same dose-volume constraints on organs at risk (OARs) as the GKE plans. Plans were evaluated on the basis of target coverage, conformity index, homogeneity index, gradient index, and treatment efficiency. Results: The median target volume was 10.2 cm3 (range 1.9 - 33.8 cm3). The VMAT and IMPT plans met all OAR constraints, and target coverage and conformity were comparable among all plans. VMAT and IMPT plans showed significantly better target uniformity and treatment delivery efficiency (P P Conclusion: FSRS for skull base and large intracranial lesions delivered by VMAT and IMPT can achieve comparable target coverage, conformity, and sparing of critical structure as the GKE while providing superior target uniformity and treatment delivery efficiency. The GKE had superior high-dose gradients outside the target and thus better protected surrounding normal structures.

Oncofertility in adolescent and young adult hereditary cancer: Considerations for genetics professionals

Adolescents and young adults(AYA)with a cancer diagnosis or those at risk for cancer due to hereditary cancer syndromes may benefit from genetic counseling and testing not only to manage personal risk but also to address reproductive concerns,especially fertility.The opportunity for genetic counselors to provide important risk information is relevant to both the newly diagnosed as well as to unaffected carriers and survivors.However,genetic counselors may need additional training in reproductive options related to AYA cancer to provide this valuable counsel.This commentary uses hereditary breast and ovarian cancer syndrome as a model to highlight important considerations when discussing preimplanatation genetic diagnosis and prenatal diagnosis,particularly in the context of expanded testing for hereditary cancer risk including multigene panels or whole exome or whole genome sequencing.Other hereditary cancers are also addressed;however,less is known about the psychosocial and fertility concerns in these AYA populations.Additionally,we provide an overview of the concept of"oncofertility"-the linkage between cancer care and reproductive medicine that aims to expand the reproductive opportunities of cancer patients-and offer support for the expansion of guidelines to include genetic counselors in AYA cancer patients’treatment planning related to reproductive health and fertility.

Dynamic Contrast-Enhanced MRI of Mouse Liver: A Feasibility Study Using a Dual-Input Two-Compartment Tracer Kinetic Model

Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) has been widely applied to evaluate microcirculatory parameters in clinical settings. However, pre-clinical studies involving DCE-MRI of small animals remain challenging with the requirement for high spatial and temporal resolution for quantitative tracer kinetic analysis. This study illustrates the feasibility of applying a high temporal resolution (2 s) protocol for liver imaging in mice by analyzing the DCE-MRI datasets of mice liver with a dual-input two-compartment tracer kinetic model. Phantom studies were performed to validate the T1 estimates derived by the proposed protocol before applying it in mice studies. The DCE-MRI datasets of mice liver were amendable to tracer kinetic analysis using a dual-input two-compartment model. Estimated micro-circulatory parameters were consistent with liver physiology, indicating viability of applying the technique for pre-clinical drug developments.

Atypical manifestation of herpes esophagitis in an immunocompetent patient: Case report and literature review

Herpes simplex virus(HSV) is known to cause esophagitis in immunosuppressed patients; however, it is rarely seen in immunocompetent patients. We present a unique case of HSV esophagitis in a healthy male, without any immunocompromising conditions or significant comorbidities. The patient presented with a two-week history of dysphagia, odynophagia and epigastric pain. Physical exam revealed oral hyperemia without any visible ulcers or vesicles. He underwent esophagogastroduodenoscopy which noted severe esophagitis with ulceration. Esophageal biopsies were positive for HSV. Serology was positive for HSV as well. After initiating treatment with Famciclovir 250 mg 3 times/d, high dose proton pump inhibitor and sucralfate, patient had complete resolution of symptoms at his 2.5 wk follow up appointment. Subsequent workup did not reveal any underlying immune disorders. While HSV is a known causative of esophagitis in the immunocompromised, its presentation in healthy patients without any significant comorbidity is uncommon. Presentation with a systemic viral prodrome further makes this case unique.

HER2-positive adenocarcinoma arising from heterotopic pancreas tissue in the duodenum:A case report

BACKGROUND Adenocarcinoma originating from heterotopic pancreas tissue is a rare disease.Furthermore,to our knowledge,no HER2-positive cases in the duodenum have been reported in the scientific literature nor has the efficacy of trastuzumab treatment for the disease been reported.CASE SUMMARY A 65-year-old woman whose clinical diagnosis was unresectable advanced duodenal cancer with HER2 overexpression responded well to trastuzumab chemotherapy.The main tumor in the duodenum reduced drastically.The patient underwent pancreaticoduodenectomy and lymph node dissection.A small number of cancer cells remained in the submucosal layer of the duodenum and pancreas head.After histological and immunohistochemical examination,the patient was diagnosed with duodenal adenocarcinoma originating from heterotopic pancreas tissue.CONCLUSION Trastuzumab treatment is effective in HER2-positive adenocarcinoma originating from heterotopic pancreas tissue in the duodenum.

宫颈上皮内瘤变的保守治疗——局部切除术

Objective: The purpose of this study was to evaluate a conservative cold-knife section technique for treatment of cervical intraepithelial neoplasia (CIN). This procedure can be adapted to patient age, preservation of childbearing potential and extent of dysplasia. Design: Prospective study. Setting: Gynecological Oncology Department in French Public Hospital. Population: A total of 460 women treated for CIN between 1985 and 1999 were included. Methods: A conservative cold-knife cervical section followed by blanket suture reconstruction was used in all cases. Main outcome measures: Immediate operative results, recurrence and reproductive function were assessed. Results: The mean length of the cervical specimen was 11.4 mm (range, 4-22 mm). Mean specimen thickness was strongly correlated with age: 10.6 ± 4.1 mm in women < 40 years versus 12.1 in women >40 years; p < 0.001. Complete excision was achieved in 395 cases (85.8% ). Post-operative bleeding was observed in 5 cases (1.1% ). The mean duration of follow-up was 62 months (range, 12.3-156.5 months). Recurrences developed in 26 patients (6.6% ) including CIN 1 in 9 cases, CIN 2 in 9 and CIN 3 in 8. No patient developed carcinoma. The actuarial risk of recurrence was 2.4% (± S.D., 0.9) at 24 months and 7.8% (± S.D., 1.9) at 60 months. A total of 52 pregnancies were observed in 39 patients. No case of de novo infertility was reported post-operatively. Amenorrhea was noted in 1 patient (0.1% ) and dysmenorrhea in 1 patient (0.1% ). Conclusions: This conservative cold-knife section technique is effective for treatment of CIN with low morbidity and little adverse effect on childbearing potential. Exposure of the squamo columnar junction (SCJ) greatly facilitates follow-up.