Outcomes of Surgical Treatment of Skin Cancer at Surgical Oncology Unit of Donka, Conakry University Hospital

Aim: The main aim of this study was to evaluate outcomes after surgical treatment of skin cancer. Methods: This retrospective cohort study concerned 46 patients who presented 43 skin cancers lesions surgically treated at surgical oncology unit, Conakry University Hospital. There were 29 (61.7%) squamous cell carcinoma, 12 (25.5%) melanoma, 4 (8.5%) sarcomas and 1 (2.1%) porocarcinoma. Surgical indications and prognosis factors were analyzed. Results: Surgical treatment included simple excision in 2 cases (3.8%), wide excision in 38 cases (71.7%) and amputation/disarticulation in 13 cases (24.5%). Inguinal lymph node dissection was performed in 16 patients (34.3%). Postoperative complications were wound suppuration (5 cases), lower limb lymphedema (4 cases), seroma (2 cases) and skin flap necrosis (1 case). Surgical margins were free in 28 (60.9%) patients, infiltrated in 3 patients (6.5%) and unspecified in 15 patients (32.6%). The median follow-up after surgery was 29 months. During the follow-up, 13 patients (28.3%) had a relapse. The relapse was influenced by surgical margins (p = 0.012) and iterative resection (p = 0.04). Overall survival was 65.2%. Factors related to survival in univariate analysis were: iterative resection (p = 0.008), fungated tumor (p = 0.037), the status of surgical margins (p = 0.002) and the occurrence of relapse (p = 0.0000). In multivariate analysis, the status of surgical margins was the only independent prognostic factor. Conclusion: The prognosis after surgical treatment of cutaneous cancers depends on the resection margins.

Endoscopic and surgical resection of T1a/T1b esophageal neoplasms: A systematic review

AIM: To investigate potential therapeutic recommendations for endoscopic and surgical resection of T1a/ T1b esophageal neoplasms. METHODS: A thorough search of electronic databases MEDLINE, Embase, Pubmed and Cochrane Library, from 1997 up to January 2011 was performed. An analysis was carried out, pooling the effects of outcomes of 4241 patients enrolled in 80 retrospective studies. For comparisons across studies, each reporting on only one endoscopic method, we used a random effects meta-regression of the log-odds of the outcome of treatment in each study. "Neural networks" as a data mining technique was employed in order to establish a prediction model of lymph node status in superficial submucosal esophageal carcinoma. Another data mining technique, the "feature selection and root cause analysis", was used to identify the most impor-tant predictors of local recurrence and metachronous cancer development in endoscopically resected patients, and lymph node positivity in squamous carcinoma (SCC) and adenocarcinoma (ADC) separately in surgically resected patients. RESULTS: Endoscopically resected patients: Low grade dysplasia was observed in 4% of patients, high grade dysplasia in 14.6%, carcinoma in situ in 19%, mucosal cancer in 54%, and submucosal cancer in 16% of patients. There were no significant differences between endoscopic mucosal resection and endoscopic submucosal dissection (ESD) for the following parameters: complications, patients submitted to surgery, positive margins, lymph node positivity, local recurrence and metachronous cancer. With regard to piecemeal resection, ESD performed better since the number of cases was significantly less [coefficient: -7.709438, 95%CI: (-11.03803, -4.380844), P < 0.001]; hence local recurrence rates were significantly lower [coefficient: -4.033528, 95%CI: (-6.151498, -1.915559),P < 0.01]. A higher rate of esophageal stenosis was observed following ESD [coefficient: 7.322266, 95%CI: (3.810146, 10.83439), P < 0.001]. A significantly greater number of SCC patients were submitted to surgery (log-odds, ADC: -2.1206 ± 0.6249 vs SCC: 4.1356 ± 0.4038, P < 0.05). The odds for re-classification of tumor stage after endoscopic resection were 53% and 39% for ADC and SCC, respectively. Local tumor recurrence was best predicted by grade 3 differentiation and piecemeal resection, metachronous cancer development by the carcinoma in situ component, and lymph node positivity by lymphovascular invasion. With regard to surgically resected patients: Significant differences in patients with positive lymph nodes were observed between ADC and SCC [coefficient: 1.889569, 95%CI: (0.3945146, 3.384624), P<0.01). In contrast, lymphovascular and microvascular invasion and grade 3 patients between histologic types were comparable, the respective rank order of the predictors of lymph node positivity was: Grade 3, lymphovascular invasion (L+), microvascular invasion (V+), submucosal (Sm) 3 invasion, Sm2 invasion and Sm1 invasion. Histologic type (ADC/SCC) was not included in the model. The best predictors for SCC lymph node positivity were Sm3 invasion and (V+). For ADC, the most important predictor was (L+). CONCLUSION: Local tumor recurrence is predicted by grade 3, metachronous cancer by the carcinoma insitu component, and lymph node positivity by L+. T1b cancer should be treated with surgical resection.

Inflammatory colonic carcinogenesis: A review on pathogenesis and immunosurveillance mechanisms in ulcerative colitis

Ulcerative colitis(UC)is characterized by repeated flare-ups of inflammation that can lead to oncogenic insults to the colonic epithelial.UC-associated carcinogenesis presents a different sequence of tumorigenic events compared to those that contribute to the development of sporadic colorectal cancer.In fact,in UC,the early events are represented by oxidative DNA damage and DNA methylation that can produce an inhibition of oncosuppressor genes,mutation of p53,aneuploidy,and microsatellite instability.Hypermethylation of tumor suppressor and DNA mismatch repair gene promoter regions is an epigenetic mechanism of gene silencing that contribute to tumorigenesis and may represent the first step in inflammatory carcinogenesis.Moreover,p53 is frequently mutated in the early stages of UC-associated cancer.Aneuploidy is an independentrisk factor for forthcoming carcinogenesis in UC.Epithelial cell-T-cell cross-talk mediated by CD80 is a key factor in controlling the progression from low to high grade dysplasia in UC-associated carcinogenesis.

Updates on abdominal desmoid tumors

Desmoid tumor is a monoclonal, f ibroblastic proliferation arising in musculoaponeurotic structures. This connective tissue hyperplasia inf iltrates locally, recurs frequently after resection but does not metastasize. Abdominal desmoid occurs sporadically, in association with some familial syndromes and often represents a clinical dilemma for surgeons. The enigmatic biology and anatomical location of abdominal desmoids make treatment recommendations diff icult. This distinct pathological entity is reviewed with a specif ic focus on aetiology and management.

Neo-adjuvant chemo(radio)therapy in gastric cancer: Current status and future perspectives

In the last 20 years, several clinical trials on neoadjuvant chemotherapy and chemo-radiotherapy as a therapeutic approach for locally advanced gastric cancer have been performed. Even if more data are necessary to define the roles of these approaches, the results of preoperative treatments in the combined treatment of gastric adenocarcinoma are encouraging because this approach has led to a higher rate of curative surgical resection. Owing to the results of most recent randomized phase III studies, neoadjuvant chemotherapy for locally advanced resectable gastric cancer has satisfied the determination of level I evidence. Remaining concerns pertain to the choice of the optimal therapy regimen, strict patient selection by accurate pre-operative staging, standardization of surgical procedures, and valid criteria for response evaluation. New well-designed trials will be necessary to find the best therapeutic approach in pre-operative settings and the best way to combine old-generation chemotherapeutic drugs with new-generation molecules.

Corticosteroid-free immunosuppression in liver transplantation: An evidence-based review

Thirty-six randomized controlled trials and two metaanalyses were reviewed. With respect to adult patients undergoing first orthotopic liver transplantation(OLT), steroid replacement resulted in fewer cases of overall acute rejection in the corticosteroid free-immunosuppression arm. Initial steroid administration for two weeks and early tacrolimus monotherapy is a feasible immunosuppression regimen without steroid replacement, although further investigations are needed in view of chronic rejections. No significant differences were noted between the treatment groups in terms of patient and graft survival independently of steroid replacement. Renal insufficiency, de novo hypertension, neurological disorders and infectious complications did not differ significantly among steroid and steroidfree groups. Diabetes mellitus, cholesterol levels and cytomegalovirus infection are more frequent in patients within the steroid group. With respect to diabetes mellitus and hypercholesterolemia, the difference was independent of steroid replacement. In relation to transplanted hepatitis C virus patients, mycophenolate mofetil does not appear to have a significant antiviral effect despite early reports. Male gender of donors and recipients, living donors, cold ischemia times, acute rejection, and early histological recurrence were related to the development of advanced hepatitis. There is sufficient scientific clinical evidence advocating avoidance of the ab initio use of steroids in OLT.

Sentinel lymph node metastasis after neoadjuvant treatment in breast cancer:Any size matters?

One of the advantages of neoadjuvant chemotherapy(NAC) treatments is its ability to convert patients who need a mastectomy in breast conservative surgery. NAC has also increased the conversion of node positive patients into node negative in around 40% allowing the use of sentinel node biopsy(SLN) in this setting. Timing of SLN biopsy after NAC has been a subject of debate. In patients with clinically node negative before NAC,rates of success and false negative rates of SLN after NAC are similar to those in the adjuvant setting,so SLN after NAC in previous negative axilla has been incorporated in the staging of the axilla. More controversial is its use in patients with positive axillary nodes before NAC who convert to node negative after NAC. Several randomized studies have reported the identification rates and the false negative rates of the SLN after NAC,concordant in the importance of surgical technique. As there is an agreement in the abandon of the immunohistochemistry(IHC) for SLN in the adjuvant setting as SLN IHC detected metastasis appear to have no impact on overall survival,in patients with SLN after NAC the inclusion of isolated tumor cell(ITC) as positive nodes lowers the false negative rates of the technique,suggesting the importance of assessing the SLN by IHC after NAC and considering it as residual disease. Longer follow up is needed to determine the prognostic implications of ITC in the SLN after NAC.

Relationship between pouch microbiota and pouchitis following restorative proctocolectomy for ulcerative colitis

Restorative proctocolectomy with ileal pouch-anal anastomosis(IPAA)has become the surgical treatment of choice for many patients with medically refractory ulcerative colitis(UC)and familial adenomatous polyposis(FAP).UC patients with IPAA(UC-IPAA)are,nevertheless,susceptible to inflammatory and noninflammatory sequelae such as pouchitis,which is only rarely noted in FAP patients with IPAA.Pouchitis is the most frequent long-term complication of UC-IPAA patients,with a cumulative prevalence of up to 50%.Although the aetiology of pouchitis remains unclear,accumulating evidence suggests that a dysbiosis of the pouch microbiota and an abnormal mucosal immune response are implicated in its pathogenesis.Studies using culture and molecular techniques have detected a dysbiosis of the pouch microbiota in patients with pouchitis.Risk factors,genetic associations,and serological markers suggest that interactions between the host immune response and the pouch microbiota underlie the aetiology of this idiopathic inflammatory condition.This systematic review focuses on the dysbiosis of the microbiota that inhabit the pouch in UC and FAP patients and its interaction with the mucosal immune system.A metaanalysis was not attempted due to the highly heterogeneous microbiota composition and the different detection methods used by the various studies.Although no specific bacterial species,genus,or family has as yet been identified as pathogenic,there is evidence that a dysbiosis characterized by decreased gut microbiota diversity in UC-IPAA patients may,in genetically predisposed subjects,lead to aberrant mucosal immune regulation triggering an inflammatory process.

Survival and Prognostic Factors in Patients with Carcinoma of Cervical Stump

Purpose: To evaluate patients with carcinoma of cervical stump (CCS) and analyse different clinico-pathologic factors affect prognosis. Patients and Methods: This study was carried out through review of clinical records of patients. Recorded data included information on age, tumor stage, presenting symptoms, size of tumor, histopathology, grade, type, cause of subtotal hysterectomy (STH), treatment and follow-up results. Staging according to International Federation of Gynecology and Obstetrics (FIGO) staging system was done through: PHYSICAL examination, pelvic examination under anaesthesia, chest X-ray, magnetic resonance imaging (MRI) of the abdomen and pelvis, cystoscopy, rectosigmoidoscopy and intravenous pyelography. Prognostic factors as age, size of tumor, stage, lymph node (LN) involvement, pathological type, grade and type of CCS either true or coincidental were analysed through multivariate analysis. Results: 62% of patients are above 50 years with stage II in 48.7%. Squamous cell carcinoma was more common but 54% are of GIII. 89% were true CCS. Positive lymph nodes were reported in 27%. The predominant reason for STH was abnormal bleeding (73%). In about 95% of cases, women seeked medical attention because of symptoms and the most common presenting symptom was bleeding (54%). According to the stage and performance status of patients, treatment consisted of radiotherapy either external or interstitial, chemotherapy and chemoradiotherapy. Through multivariate analysis, the following was found to have adverse impact on survival: Coincidental type (P = 0.04), high grade (P = 0.03), advanced stage (P = 0.01), larger tumor size (P = 0.02), lymph node involvement (P = 0.029) and older age (P = 0.035). While pathological type was not (P = 0.52). After median follow-up of 52 months;5-year overall survival was 65%. Conclusion: CCS has a low morbidity. Adverse survival outcomes can be anticipated in those patients with: high grade lesions, advanced stages, large tumor size, coincidental type, older age and positive lymph node involvement.

Accuracy of Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients;Single Center Experience

Purpose: Most important factor affecting prognosis of breast cancer is axillary nodal involvement. Several studies evaluated the accuracy of Sentinel lymph node biopsy in breast cancer patients post neoadjuvant chemotherapy. In this study, we will examine accuracy and feasibility of using Sentinel lymph node biopsy in predicting axillary lymph node status in breast cancer patients after neoadjuvant chemotherapy. Methods: 45 female patients with resectable, nonmetastatic breast carcinoma cases who received neoadjuvant chemotherapy were enrolled in this study according to the routine Mansoura Oncology Center—guidelines of management of breast cancer. Methylene blue dye used for detection of Sentinel lymph node. Results: Successful Sentinel lymph node detection was 82.2%. Skin involvement (T4 disease) were linked to a low identification (P = 0.005). False negative rate equals 11/27 = (40.7%).With advancement of the stage of the tumor, the incidence of false negative results increases significantly (p = 0.012) with 95% confidence interval;1.2 - 5.4. Conclusion: Sentinel lymph node should be adopted to be the standard method for axillary staging with T1-3 tumors after receiving neoadjuvant chemotherapy, in T4 patients, it is associated with low detection rate & high false negative rate making it doubtful technique for axillary staging.

Impact of jejunostomy during esophagectomy for cancer on health related quality of life

Background： The aim of this study was to evaluate the impact of jejunostomy during esophagectomy for cancer on postoperative health-related quality of life（HRQL）.Methods： We evaluate all consecutive patients who underwent esophagectomy for cancer at the surgical oncology unit of the Veneto Institute of Oncology（IOV-IRCCS） between January 2008 and March 2014. The primary outcome was HRQL, which was assessed using nine scales of EORTC C30 and OES18 questionnaires. General linear models were estimated to evaluate mean score difference（MD） of each selected scale in patients with and without jejunostomy, adjusting for clinically relevant confounders. The secondary outcomes were morbidity, hospital stay, postoperative weight loss and postoperative albumin impairment. Results： Jejunostomy was performed in 40 on 109 patients（41.3%） who participated in quality of life investigation. A clinically and statistically significantly worse eating at admission（P=0.009） became not clinically significant at 3 months after surgery（MD =9.1）. Jejunostomy was associated to clinically and statistically significantly poorer emotional function（EF） at 3 months after surgery（MD =-15.6; P=0.04）. Hospital stay was longer in jejunostomy group（median, 20 vs. 17 days, P=0.02）.Conclusions： In our series patients who had a jejunostomy during esophagectomy had been selected for their risk for postoperative complication. However, their postoperative outcome was actually similar compared to those without jejunostomy. Nevertheless, jejunostomy was associated to clinically and statistically significantly poorer EF at 3 months after surgery. Therefore, patient candidate to esophagectomy and feeding jejunostomy should receive additional psychological support.

Impact and Analysis of Prognostic Factors in Patients with Non-Metastatic Esophageal Squamous Cell Carcinoma: A Retrospective Single Institution Study

Objective: To investigate the impact of local tumor factors on the prognosis of non-metastatic esophageal squamous cell carcinoma patients. Methods: We performed a retrospective analysis of data from 278 consecutive esophageal squamous cell carcinoma patients between January 2009 and December 2016. The prognosis factors such as the GTV volume, GTV maximum diameter, and GTV length were analyzed. Results: The results of ROC curve analysis showed that prognosis critical values of the GTV volume, GTV maximum diameter, and GTV length were 27.98 cm3, 1.80 and 5.85 cm, respectively. The result of the univariate analysis showed that the GTV volume (P = 0.0184), GTV maximum diameter (P = 0.0246), and GTV length (P = 0.0035) were the prognostic factors for overall survival;the barium meal length (P = 0.0149) was the prognostic factor for local control. The multivariate analysis showed that the barium meal length (P = 0.0013), GTV maximum diameter (P = 0.0047), and GTV length (P = 0.0032) as the independent prognostic factors associated with overall survival;the barium meal length (P = 0.0037) was the only independent prognostic factors for local control. Conclusion: The esophageal lesion length was the main prognosis factor for patients with non-metastatic esophageal squamous cell carcinoma. Therefore, we suggest that the physician must give enough attention to these patients in clinical practice, and give active treatment.

Dual loop(Roux en Y) reconstruction with isolated gastric limb reduces delayed gastric emptying after pancreatico-duodenectomy

BACKGROUND Single loop reconstruction(SLR) was routine in our institution for patients undergoing pancreatico-duodenectomy(PD). Roux-en Y reconstruction with an isolated gastric limb(RIGL) recently became the reconstruction of choice.AIM To evaluate the impact of RIGL on incidence and severity of delayed gastric emptying(DGE).METHODS This is a single institution, retrospective analysis of patients undergoing PD. All patients undergoing PD from July 2010 through December 2016 were included in the study. Outcome of RIGL were compared to SLR. Primary measure of outcome included incidence and severity of DGE. Secondary measures of outcome were overall complications and postoperative mortality.RESULTS One hundred and seventy-nine patients were included in the study. Fifty-two had RIGL, 127 had SLR. Overall complication rate was 40.2%, patients in the RIGL group experienced lower rates of DGE(15.4% vs 59.1%, P = 0.001). Other patient related outcomes were also significantly reduced: day of nasogastric tube removal(3 vs 5, P < 0.001), regain of normal diet(8 vs 9, P < 0.001). On multivariate analysis RIGL was associated independently with reduced rates of DGE(P < 0.001, OR 0.14)CONCLUSION The current study shows that RIGL reduces the rate of DGE after PD. Further prospective randomized controlled trials are required to affirm the current data.

Role of human nucleoside transporters in pancreatic cancer and chemoresistance

The prognosis of pancreatic cancer is poor with the overall 5-year survival rate of less than 5%changing minimally over the past decades and future projections predicting it developing into the second leading cause of cancer related mortality within the next decade.Investigations into the mechanisms of pancreatic cancer development,progression and acquired chemoresistance have been constant for the past few decades,thus resulting in the identification of human nucleoside transporters and factors affecting cytotoxic uptake via said transporters.This review summaries the aberrant expression and role of human nucleoside transports in pancreatic cancer,more specifically human equilibrative nucleoside transporter 1/2(hENT1,hENT2),and human concentrative nucleoside transporter 1/3(hCNT1,hCNT3),while briefly discussing the connection and importance between these nucleoside transporters and mucins that have also been identified as being aberrantly expressed in pancreatic cancer.The review also discusses the incidence,current diagnostic techniques as well as the current therapeutic treatments for pancreatic cancer.Furthermore,we address the importance of chemoresistance in nucleoside analogue drugs,in particular,gemcitabine and we discuss prospective therapeutic treatments and strategies for overcoming acquired chemoresistance in pancreatic cancer by the enhancement of human nucleoside transporters as well as the potential targeting of mucins using a combination of mucolytic compounds with cytotoxic agents.

Prognosis of Breast Cancer Patients Underwent Surgery in a Developing Country

Background: We aim to review different factors associated with the relapse and the mortality in breast cancer patients in restricted-resource settings over a five-year period. Method: A retrospective cohort study including 133 women underwent breast cancer surgery was performed at the Surgical Oncology Unit of the Conakry University Hospital in Guinea. Socio-demographical characteristics, clinical information, treatment and data on relapse and survival were retrieved from medical files. Predictor factors of relapse were analyzed by using univariate and multivariate logistic regression. Factors associated with mortality were analyzed by Kaplan Meier survival and Cox models. Results: Breast cancer surgery was conservative in 13 cases (9.8%) and radical in 120 cases (90.2%). Five-year relapse was 33.8% ± 8.0% and the predictor factors of this relapse were age and stage III (p = 0.005). The overall 5-year mortality was 42.1% and the risk factors independently associated with death were body mass index (p = 0.01), origin of patients (p = 0.02), radiotherapy (p = 0.01) and cancer relapse (p = 0.001). Conclusion: The proportions of relapse and death were higher in breast cancer patients. The age and the stage of cancer at the time of surgery were the predictor factors of relapse. Body mass index, origin of patients, radiotherapy and cancer relapse were associated with death.

Frozen Section in Postmenopausal Women Presented with Suspicious Ovarian Masses, Does It Have a Role?

Background: Frozen section (FS) has a valuable role in the diagnosis of ovarian tumors. It is considered a pivotal point in guiding the surgical therapy, particularly in premenopausal women. In postmenopausal women, it may be required as well to avoid unnecessary surgical staging in benign ovarian tumors. Aim: This study aims to evaluate the accuracy of intraoperative frozen section in ovarian neoplasms in postmenopausal women. Materials and Methods: A retrospective analysis was done for intraoperative FS for suspected ovarian neoplasms. The study was conducted in Oncology Center, Mansoura University from March 2008 to December 2014. The frozen and paraffin section reports were compared, and overall accuracy, sensitivity, specificity, positive and negative predictive values were determined. Results: The study included 105 patients and the overall accuracy of FS in determining malignancy was 81.7%. The sensitivity for malignant tumors was 75.32% with specificity of 100%. For benign tumors, the sensitivity and specificity were 100% and 93%, respectively. Borderline tumors had the lowest sensitivity of 100% with specificity of 95.19%. Conclusion: The present study concurs that frozen section is an accurate test for diagnosis of benign and malignant tumors in postmenopausal women thus determining the extent of surgery done for them. On the other hand, accuracy rates for borderline tumors are low.

Concomitant Boost Radiotherapy after Conservative Breast Surgery in Early Breast Cancer

Background: Radiation therapy after breast conserving surgery is a standard part of treatment for invasive breast cancer. Based on radiobiological models, it was found that shorter radiation schedules offered the promise of equivalent local control to standard radiation therapy by giving larger doses per fraction in shorter period of time. Methods: This study included 36 female patients with operable invasive stage I-II breast cancer. These patients underwent microscopic wide local excision of the primary tumor and lymph node dissection. They received adjuvant radiotherapy. The radiation dose was 40 Gy total dose in 15 fractions for whole breast and additional dose of 9 Gy in three consecutive fractions was delivered to tumour cavity simultaneously. Results: Mean age was 52 years (range: 30 - 67);most patients were of stage II disease and Grade II was the most common one. Invasive ductal carcinoma was reported in 94.4% and 72.2% of patients were hormone receptor positive. After median follow-up of 52 months, all patients were alive and ipsilateral local recurrence was reported in 1 case only. Grade IV radiation toxicity was not observed;moist desquamation was the most common acute reaction (61%) with grade III in 5.5% followed by dry desquamation in 55.6% of grade I only. Grade I erythema was recorded in 41.7% and grade II in 11%. Fibrosis was the most frequent late reaction (44.3%) with grade II in 11% followed by telengectesia then pigmentation (41.7%, 33.3% respectively). Conclusion: The regimen used in this study appears promising with acceptable acute toxicities and convenient for our patients and has the advantage of economic use of radiation facilities. However, larger number of patients and longer period of follow-up are needed for further evaluation.

Germline polymorphisms of circadian genes and gastric cancer predisposition

Dear Editor,Gastric cancer represents a remarkable disease burden worldwide,ranking among the first five tumor types in incidence and mortality[1].Germline DNA variation has been extensively investigated in terms of predisposition to sporadic gastric cancer,which represents more than 90%of all cases[2].Currently available evidence shows that the fraction of disease burden that can be attributable to known risk polymorphisms is small(<20%)[2].Single germline variations of circadian genes(also called clock genes)have been associated with the predisposition of different tumor types[3].The circadian clock is a timetracking rhythmic biological system with a periodicity of about 24 hours that enables organisms to anticipate environmental changes and allow them to modify their behavior and physiological functions in the most efficient way.Circadian rhythms are controlled by proteins encoded by circadian genes,which have been discovered in all studied species.Remarkably,the disruption of these rhythms has been linked with risk of different diseases including cancer.In regards to the latter,a growing wealth of evidence supports the potential tumor suppressor role of the biological clock[3,4].

Treatment of liver metastases in patients selected for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal carcinomatosis

comCytoreductive surgery(CS)and hyperthermic intraperitoneal chemotherapy(HIPEC)have gained increasing consensus in treatment of peritoneal carcinomatosis from colorectal cancer.The presence of liver metastases is generally considered a contraindication for CS+HIPEC,as hepatic involvement no longer represents a loco-regional aspect of disease.Despite this,liver resection(LR)has been tested in selected cases in combination with CS+HIPEC for treatment of peritoneal carcinomatosis with liver metastasis.Relevant studies on this topic were identified through a search in the electronic PubMed database,using the appropriate keywords.CS+HIPEC+LR allows similar outcomes in terms of survival and morbidity with respect to CS+HIPEC,especially in patients with low tumor load.CS+HIPEC+LR represents a reasonable approach for patients with peritoneal carcinomatosis and liver metastases from colorectal cancer.Patients should be selected in high volume tertiary centres,preferably in the context of a prospective trial.

Ciinical value and cost-effectiveness of minimally invasive distal pancreatectomy

Minimally invasive pancreatic resection(MIPR)has gained popularity in the last decade and it is currently widely applied with selected indications in highly specialized centres worldwide.Distal pancreatectomy(DP),which lacks of a technical demanding and complex reconstruction phase,is the most suitable pancreatic resection for a minimal invasive approach and is therefore the most performed MIPR.Several non-randomized studies and meta-analyses suggested that a minimally invasive distal pancreatectomy(MIDP)could improve the short-term postoperative outcomes by reducing the intraoperative blood loss and the postoperative morbidity when compared to open distal pancreatectomy(ODP)(1).MIDP seems also to promote an earlier recovery and a reduction in the length of postoperative stays when compared to ODP without affecting the oncologic outcomes.Therefore,the diffusion of MIDP is increasing and a minimally invasive approach is generally recognized as a suitable approach to benign,borderline malignant lesions and to Pan-NENs.The value of MIDP for the surgical treatment of pancreatic ductal adenocarcinoma(PDAC)is still under evaluation despite its feasibility and safety in this setting have been demonstrated and similar long-term oncological outcomes were reported by several single and multicentre series(2).The recent published DIPLOMA study,a European retrospective propensity score-matched cohort study on minimally invasive versus open DP for PDAC,raised some concerns in terms of oncological adequacy of MIDP(3).