Incidental renal cell carcinoma post bilateral nephrectomy in autosomal dominant polycystic kidney disease

BACKGROUND Renal cell carcinoma(RCC)is more common in patients with autosomal dominant polycystic kidney disease(ADPKD)than in the general population.Diagnosing RCC in ADPKD is challenging due to the presence of multiple renal cysts,often leading to delays and difficulties in distinguishing RCC from cyst infection or hemorrhage.A total of 38 kidneys were excised from 19 patients,with a mean age of 56.8 years and an average hemodialysis duration of 84.2 months.Eight patients underwent open nephrectomies,and 11 underwent hand-assisted laparoscopic nephrec-tomies.RCC was detected in 15.8%of kidneys,affecting 21.1%of patients.Two patients had multifocal RCC in both kidneys.All RCC cases were pT1 stage,with the largest lesion averaging 16.5 mm in diameter.The average operative duration was 120 minutes,with intraoperative blood loss averaging 184.2 mL.Five patients required blood transfusions.Postoperative complications occurred in five patients,with a mean hospital stay of 17.1 days.The mean follow-up period was 28.1 months.CONCLUSION The prevalence of RCC is higher in patients with ADPKD with ESRD than in those with ESRD alone.Thus,clinicians should be cautious and implement surveillance programs to monitor the development of RCC in patients with ADPKD,particularly those on dialysis.

Platelet-to-lymphocyte ratio in the setting of liver transplantation for hepatocellular cancer: A systematic review and meta-analysis

AIM To perform a systematic review and meta-analysis on platelet-to-lymphocyte ratio(PLR) as a risk factor for post-transplant hepatocellular cancer(HCC) recurrence. METHODS A systematic literature search was performed using PubM ed. Participants of any age and sex, who underwent liver transplantation for HCC were considered following these criteria:(1) studies comparing pre-transplant low vs high PLR values;(2) studies reporting post-transplant recurrence rates; and(3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measure was set for HCC recurrence after transplantation. RESULTS A total of 5 articles, published between 2014 and 2017, fulfilled the selection criteria. As for the quality of the reported studies, all the investigated articles presented an overall high quality. A total of 899 cases were investigated: 718 cases(80.0%) were males. Three studies coming from European countries and one from Japan presented HCV as the main cause of cirrhosis. On the opposite, one Chinese study presented a greater incidence of HBV-related cirrhotic cases. In all the studies apart one, the PLR cut-off value of 150 was reported. At meta-analysis, high PLR value was associated with a significant increase in recurrence after transplantation(OR = 3.33; 95%CI: 1.78-6.25; P < 0.001). A moderate heterogeneity was observed among the identified studies according to the Higgins I^2 statistic value.CONCLUSION Pre-transplant high PLR values are connected with an increased risk of post-operative recurrence of hepatocellular cancer. More studies are needed for better clarify the biological mechanisms of this results.

Comparison of laparoscopic vs open liver lobectomy(segmentectomy) for hepatocellular carcinoma

AIM:To investigate the effects of laparoscopic hepatectomy for the treatment of hepatocellular carcinoma(HCC) .METHODS:From 2006 to January 2011,laparoscopic hepatectomies were performed on 30 cases of HCC at Northern Jiangsu People's Hospital. During this sametime period,30 patients elected to undergo conventional open hepatectomy over laparoscopic hepatectomy at the time of informed consent. The degree of invasiveness and outcomes of laparoscopic hepatectomy compared to open hepatectomy for HCC were evaluated.RESULTS:Both groups presented with similar bloodloss amounts,operating times and complications. Patients in the laparoscopic hepatectomy group started walking and eating significantly earlier than those inthe open hepatectomy group,and these more rapid recoveries allowed for shorter hospitalizations. There were no significant differences between procedures insurvival rate.CONCLUSION:Laparoscopic hepatectomy is beneficial for patient quality of life if the indications are appropriately based on preoperative liver function and the location and size of the HCC.

Review of preoperative transarterial chemoembolization for resectable hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is one of the few cancers whose incidence has been continually increasing over recent years.Resection of HCC offers the only hope for cure.However,recurrences are common in patients who have undergone resection.In our opinion,the effectiveness with which transarterial chemoembolization(TACE) as a neoadjuvant therapy for resectable HCC prevents recurrence and prolongs survival has not been conclusively demonstrated.All published meta-analyses have consistently failed to demonstrate that preoperative TACE improves the prognosis of resectable HCC.We believe that these published articles have several limitations and have our own views about the results of meta-analyses.It is very important that the scientific community shed more light on the pathogenesis of HCC and relate this to choice of therapy.This review mainly concerns our understanding of preoperative TACE for resectable HCC and briefly addresses desirable directions for future studies.

Malignant schwannoma of the pancreas involving transversal colon treated with en-bloc resection

Pancreatic schwannoma is a very uncommon tumor of the pancreas,with only 27 cases reported.Most pancreatic schwannomas are benign,with only four malignant tumors reported.We describe a case of giant malignant schwannoma of the pancreatic body and tail,which involved the transverse colon.The tumor was treated successfully with en bloc distal splenopancreatectomy and colon resection.This is believed to be the first reported radical operation for malignant schwannoma of the pancreatic body,with infiltration of the transverse colon,with excellent longterm results.The patient is alive and well 28 mo after the operation.The authors conclude that pancreatic schwannomas should be considered in the differential diagnosis of cystic neoplasms of the pancreas,although the diagnosis can only be confirmed by microscopic examination.In the case of the benign tumors,local excision is adequate,but in the case of malignant schwannoma,oncological standards must be fulfilled.

Artificial intelligence in the diagnosis and management of colorectal cancer liver metastases

Colorectal cancer(CRC)is the third most common malignancy worldwide,with approximately 50%of patients developing colorectal cancer liver metastasis(CRLM)during the follow-up period.Management of CRLM is best achieved via a multidisciplinary approach and the diagnostic and therapeutic decision-making process is complex.In order to optimize patients’survival and quality of life,there are several unsolved challenges which must be overcome.These primarily include a timely diagnosis and the identification of reliable prognostic factors.Furthermore,to allow optimal treatment options,a precision-medicine,personalized approach is required.The widespread digitalization of healthcare generates a vast amount of data and together with accessible high-performance computing,artificial intelligence(AI)technologies can be applied.By increasing diagnostic accuracy,reducing timings and costs,the application of AI could help mitigate the current shortcomings in CRLM management.In this review we explore the available evidence of the possible role of AI in all phases of the CRLM natural history.Radiomics analysis and convolutional neural networks(CNN)which combine computed tomography(CT)images with clinical data have been developed to predict CRLM development in CRC patients.AI models have also proven themselves to perform similarly or better than expert radiologists in detecting CRLM on CT and magnetic resonance scans or identifying them from the noninvasive analysis of patients’exhaled air.The application of AI and machine learning(ML)in diagnosing CRLM has also been extended to histopathological examination in order to rapidly and accurately identify CRLM tissue and its different histopathological growth patterns.ML and CNN have shown good accuracy in predicting response to chemotherapy,early local tumor progression after ablation treatment,and patient survival after surgical treatment or chemotherapy.Despite the initial enthusiasm and the accumulating evidence,AI technologies’role in healthcare and CRLM management is not yet fully established.Its limitations mainly concern safety and the lack of regulation and ethical considerations.AI is unlikely to fully replace any human role but could be actively integrated to facilitate physicians in their everyday practice.Moving towards a personalized and evidence-based patient approach and management,further larger,prospective and rigorous studies evaluating AI technologies in patients at risk or affected by CRLM are needed.

Liquid biopsy in cholangiocarcinoma:Current status and future perspectives

Cholangiocarcinoma(CCA)are a heterogeneous group of tumors in terms of aetiology,natural history,morphological subtypes,molecular alterations and management,but all sharing complex diagnosis,management,and poor prognosis.Several mutated genes and epigenetic changes have been detected in CCA,with the potential to identify diagnostic and prognostic biomarkers and therapeutic targets.Accessing tumoral components and genetic material is therefore crucial for the diagnosis,management and selection of targeted therapies;but sampling tumor tissue,when possible,is often risky and difficult to be repeated at different time points.Liquid biopsy(LB)represents a way to overcome these issues and comprises a diverse group of methodologies centering around detection of tumor biomarkers from fluid samples.Compared to the traditional tissue sampling methods LB is less invasive and can be serially repeated,allowing a real-time monitoring of the tumor genetic profile or the response to therapy.In this review,we analysis the current evidence on the possible roles of LB(circulating DNA,circulating RNA,exosomes,cytokines)in the diagnosis and management of patients affected by CCA.

A rare case of periampullary carcinoma with ectopic ending of Vater's ampulla

A 71-year-old woman was referred to our department complaining of painless progressive jaundice for the last 3 too. Magnetic resonance imaging and magnetic resonance cholangiopancreatography （MRCP） showed the ectopic hepatopancreatic ampulla draining into the fourth part of the duodenum adjacent to the duodenojejunal flexure; the irregular morphology of the duodenojejunal flexure likely due to a soft tissue mass. Laparotomy confirmed the presence of the abnormal ampulla of Vater located at the fourth part of the duodenum and a soft tissue tumor about 6 cm × 5 cm×5 cm with a peduncle adjoining the ampulla. Resection of the tumor, including some peripheral tissue, and a Roux-Y loop anastomosis choledochojejunostomy were performed. Pathological examination indicated an intestinal villous adenoma accompanied by severe dysplasia and focal canceration. Periampullary carcinoma with ectopic ending of the Vater＇s ampulla into the fourth part of the duodenum is rather rare. The embryonic genetic background of this anomaly has not yet been fully explained. It is worth mentioning that MRCP is useful for demonstrating anomalies and anatomic variants of the biliary tract system and pancreatic duct.

Delayed internal pancreatic fistula with pancreatic pleural effusion postsplenectomy

The occurrence of pancreatic pleural effusion,secondary to an internal pancreatic fistula,is a rare clinical syndrome and diagnosis is often missed.The key to the diagnosis is a dramatically elevated pleural fluid amylase.This pancreatic pleural effusion is also called a pancreatic pleural fistula.It is characterized by profuse pleural fluid and has a tendency to recur.Here we report a case of delayed internal pancreatic fistula with pancreatic pleural effusion emerging after splenectomy.From the treatment of this case,we conclude that the symptoms and signs of a subphrenic effusion are often obscure;abdominal computed tomography may be required to look for occult,intra-abdominal infection;and active conservative treatment should be carried out in the early period of this complication to reduce the need for endoscopy or surgery.

Chronic pancreatitis as presentation of Crohn's disease in a child

It is reported that a pancreatic disease may precede the diagnosis of inflammatory bowel disease(IBD) both in children and in adults.Idiopathic chronic pancreatitis,however,occasionally co-exists with the IBD,mainly at pediatric age.We report a case of a patient who progressively developed the features of a chronic pancreatitis,before the diagnosis of Crohn's Disease(CD).Ten months after the onset of the first episode of pancreatitis the patient developed bloody diarrhea,mucus stools and biochemical findings of inflammation.The colonoscopy revealed a diffuse colitis without involvement of the last loop and the gastroscopy showed inflammation of the iuxta-papillary area.The histological findings confirmed the diagnosis of CD that involved the colon and the duodenum.In conclusion,in children the idiopathic chronic pancreatitis may be an unusual presentation of CD.Thus,if other known cause of chronic pancreatitis are not found,a not invasive work up to exclude the IBD should be warranted.An early coincidental diagnosis of the IBD may delay the progression of the pancreatic disease.

Fluorescent cholangiography: An up-to-date overview twelve years after the first clinical application

Laparoscopic cholecystectomy(LC)is one of the most frequently performed gastrointestinal surgeries worldwide.Bile duct injury(BDI)represents the most serious complication of LC,with an incidence of 0.3%-0.7%,resulting in significant perioperative morbidity and mortality,impaired quality of life,and high rates of subsequent medico-legal litigation.In most cases,the primary cause of BDI is the misinterpretation of biliary anatomy,leading to unexpected biliary lesions.Near-infrared fluorescent cholangiography is widely spreading in clinical practice to delineate biliary anatomy during LC in elective and emergency settings.The primary aim of this article was to perform an up-to-date overview of the evolution of this method 12 years after the first clinical application in 2009 and to highlight all advantages and current limitations according to the available scientific evidence.

Ambispective comparative study of two surgical strategies for liver hydatidosis

AIM:To investigate the morbidity,mortality,recurrence and technical aspects of two distinct surgical strategies that were implemented in successive periods.METHODS:Ninty-two patients with 113 cysts underwent surgical procedures.The study was divided into 2 periods.Data from first period(P1) were compiled retrospectively.The surgical strategy was conservative surgery.The second period(P2) included a prospective study conducted according to a protocol following the criterion that radical procedures should be performed whenever it is technically feasible.RESULTS:Patients of both periods showed no statistically significant differences in age,gender,cyst location or mortality.Among the P2 group,patients exhibited more preoperative jaundice,and cyst size was smaller(P < 0.05).Changes in surgical strategy increased the rate of radical surgery,decreases morbidity and in-hospital stay(P < 0.001).A negative result in P2 was the death of two old patients(4.8%) who had undergone conser-vative treatments.The rate of radical surgery in P2 was around 75%.CONCLUSION:Radical surgery should be the technique of choice whenever it is feasible,because it diminishes morbidity and in-hospital stay.Conservative surgery must be employed only in selected cases.

Primary hepatic myelolipoma: A case report and review of the literature

BACKGROUND Primary hepatic myelolipoma is a rare hepatic mesenchymal tumor mixed by adipose tissue and bone marrow,and there is a lack of general guidelines related to its epidemiology and clinical management.CASE SUMMARY A 26-year-old woman was admitted to our department complaining of a newly found tumor on her left lobe of the liver.The tumor was painless and not associated with any systemic or localized compressive symptoms.Serological tests disclosed a slight increase of gamma-glutamyl transpeptidase(70.0 U/L)and total bilirubin(19.2 pmol/L).Ultrasonography showed a mass about 5.0 cm x 5.0 cm in size that was located in the left lobe of the liver and displayed hyperechoic and well-encapsulated characteristics.Surgical resection was applied,and the following histopathological examination observed a variable proportion of myeloid tissues scattering throughout mature fibrotic adipose tissues,in which myeloid,erythroid,and megakaryocytic cells can be found in magnified view.The follow-up did not show any changes 6 mo after surgery.CONCLUSION This case highlights an extremely rare hepatic mesenchymal tumor,the primary hepatic myelolipoma,and discloses the common characteristics behind this disease and gives clinical recommendations.

Early pancreatic cancer in Ig G4-related pancreatic mass:A case report

BACKGROUND IgG4-related disease can manifest diversely,including autoimmune pancreatitis and IgG4-related cholangiopathy.We are reporting a very unusual cause of pancreatic cancer triggered in a previously unknown IgG4-related disease.CASE SUMMARY A 75-year-old man was diagnosed with a 43 mm×33 mm pancreatic head tumor after consulting for abdominal pain and jaundice.A pancreaticoduodenectomy was carried out uneventfully,and the histopathology report showed an early stage of acinar-cell pancreatic cancer.The patient reconsulted on the 30th postoperative day with fever,jaundice and asthenia.Magnetic resonance cholangiopancreatography evidenced an extense bile duct stricture.A percutaneous biliary drainage proved to be ineffective,even after exchanging it with larger bore drainage.Reviewing the surgical specimen,features compatible with IgG4-related disease were observed.Consequently,empiric treatment with steroids was initiated achieving excellent results.CONCLUSION IgG4-related disease may cause chronic inflammation of the pancreas and can condition pancreatic malignancies.

Comparison of imaging-based and pathological dimensions in pancreatic neuroendocrine tumors

AIM To establish the ability of magnetic resonance(MR) and computer tomography(CT) to predict pathologic dimensions of pancreatic neuroendocrine tumors(Pan NET) in a caseload of a tertiary referral center.METHODS Patients submitted to surgery for Pan NET at the Surgical Unit of the Pancreas Institute with at least 1 preoperative imaging examination(MR or CT scan) from January 2005 to December 2015 were included and data retrospectively collected. Exclusion criteria were: multifocal lesions, genetic syndromes, microadenomas or mixed tumors, metastatic disease and neoadjuvant therapy. Bland-Altman(BA) and Mountain-Plot(MP) statistics were used to compare size measured by each modality with the pathology size. Passing-Bablok(PB) regression analysis was used to check the agreement between MR and CT.RESULTS Our study population consisted of 292 patients. Seventy-nine(27.1%) were functioning Pan NET. The mean biases were 0.17 ± 7.99 mm, 1 ± 8.51 mm and 0.23 ± 9 mm, 1.2 ± 9.8 mm for MR and CT, considering the overall population and the subgroup of non-functioning-Pan NET, respectively. Limits of agreement(LOA) included the vast majority of observations, indicating a good agreement between imaging and pathology. The MP further confirmed this finding and showed that the two methods are unbiased with respect to each other. Considering ≤ 2 cm non-functioning-Pan NET, no statistical significance was found in the size estimation rate of MR and CT(P = 0.433). PBR analysis did not reveal significant differences between MR, CT and pathology.CONCLUSION MR and CT scan are accurate and interchangeable imaging techniques in predicting pathologic dimensions of Pan NET.

Growth-inhibitory effects of MOB2 on human hepatic carcinoma cell line SMMC-7721

AIM:To investigate the growth-inhibiting and apoptosis-inducing effects of the gene MOB2 on human hepatic carcinoma cell line SMMC-7721.METHODS:The full-length cDNA of the MOB2 gene was amplified from human umbilical vein endothelial cells.The correct full-length MOB2 cDNA was subcloned into the eukaryotic expression vector pEGFP-C1.After lipofection of the MOB2 gene into cancer cells,the levels of MOB2 protein in the cancer cells were detected by immunoblotting.To transfect the recombined plasmid vector pEGFP-CI-MOB2 into SMMC-7721 cells,the cells were cultured in Dulbecco's Modified Eagle'sMedium with 10% fetal calf serum and glutamine,and then mixed with liposomes,Lipofectamine 2000 and the plasmid vector pEGFP-CI-MOB2.RESULTS:We observed the growth and proliferation of SMMC-7721 cells containing pEGFP-CI-MOB2 and analyzed their apoptosis and growth cycle phases by flow cytometry.We successfully transfected the recombined plasmid vector pEGFP-CI-MOB2 into SMMC-7721 cells and screened for a single clone cell containing MOB2.After transfection,MOB2 enhanced growth suppression,induced apoptosis,increased the ratio of G0/G1,significantly inhibited the advance of cell cycle phase,and arrested cells in G0/G1 phase.CONCLUSION:MOB2 overexpression induces apoptosis and inhibits the growth of human hepatic cancer cells,which may be useful in gene therapy for hepatic carcinoma.

Combined endovascular-surgical treatment for complex congenital intrahepatic arterioportal fistula: A case report and review of the literature

BACKGROUND Congenital intrahepatic arterioportal fistula(IAPF) is a rare vascular malformation in infants that causes severe portal hypertension(PH) with poor prognosis if untreated. Currently, radiological embolisation is considered the first-line therapy for simple IAPF; however, it might be not resolutive for complex hepatic vascular lesions. When endovascular embolization is not sufficient to completely obliterate the IAPF, surgical intervention is needed, but it has been associated with severe morbidity and mortality in small children.Furthermore, indications are not defined.CASE SUMMARY We present the first case of a 6-month-old girl with trisomy 21 affected by a complex congenital IAFP, which caused severe PH, successfully treated with an endovascular-surgical hybrid procedure. The novel technique comprised a multistep endovascular embolisation, including a superselective transarterial embolisation of the afferent vessels and a direct transhepatic embolisation of the dilated portal vein segment, combined with selective surgical ligation of the arterial branches that supply the fistula, which were too small to be embolised.The complex IAPF was also associated with severe cholestasis and intra/extrahepatic biliary tree dilatation, which was successfully treated by a temporary biliary drainage. At 24-mo follow-up, the hybrid endovascularsurgical procedure achieved complete occlusion of the complex IAPF and resolution of the PH. A comprehensive review of the literature on congenital IAPF management, focussed on alternative treatment strategies, is also reported.CONCLUSION The combined radiological-surgical approach is a safe and effective treatment option for complex IAPF and avoids major invasive surgery.

Donor-to-recipient gender match in liver transplantation: A systematic review and meta-analysis

AIM To perform a systematic review and meta-analysis on donor-to-recipient gender mismatch as a risk factor for post-transplant graft loss. METHODS A systematic literature search was performed using PubM ed, Cochrane Library database and EMBASE. The primary outcome was graft loss after liver transplantation. Odds ratios and 95% confidence intervals were calculated to compare the pooled data between groups with different donor-to-recipient gender matches. Three analyses were done considering(1) gender mismatches(F-M and M-F) vs matches(M-M and F-F);(2) Femaleto-Male mismatch vs other matches; and(3) Male-toFemale mismatch vs other matches.RESULTS A total of 7 articles were analysed. Gender mismatch(M-F and F-M) was associated with a significant increase of graft loss respect to match(M-M and F-F)(OR: 1.30; 95%CI: 1.13-1.50; P < 0.001). When F-M mismatch was specifically investigated, it confirmed its detrimental role in terms of graft survival(OR: 1.83; 95%CI: 1.20-2.80; P = 0.005). M-F mismatch failed to present a significant role(OR: 1.09; 95%CI: 0.73-1.62; P = 0.68).CONCLUSION Gender mismatch is a risk factor for poor graft survival after liver transplantation. Female-to-male mismatch represents the worst combination. More studies are needed with the intent to better clarify the reasons for these results.

New insights in the management of the middle hepatic vein dilemma

When the first series of adult-to-adult living donor liver transplantation(A2A-LDLT)were performed in Hong Kong[1],it was immediately clear that great technical challenges existed,mainly concerning the middle hepatic vein(MHV)tributaries management.

Survivals after liver transplantation for hepatocellular carcinoma:Granular data for a better allocation process?

To the Editor:A large international study has been recently published focusing on the combination of morphological aspects and alpha-fetoprotein(AFP)as predictors of survival in patients with hepatocellular cancer(HCC)treated with liver transplantation(LT)[1].As a matter of fact,morphology and biology represent the two sides of the same