Hepatic Surgery for Colorectal Cancer Metastasis — Possibilities and Prerequisites
Colorectal cancer is among the most frequent malignant tumours. Liver metastases develop in 70–75% of patients affected by colorectal carcinoma. Nowadays, surgical treatment can significantly improve the 5-year survival ranging 40–58% of the patients undergoing liver surgery. The operation extent ranges from nonanatomic minor resection to major hepatectomy. Recently, liver transplantation has been performed for metastatic colorectal cancer. Laparoscopic approach and robotic surgery can be used by experienced specialists. The prerequisites for successful surgical treatment include exact radiologic diagnostics to determine the number and size of metastases and their association with anatomic structures; individual anatomic peculiarities and remnant liver volume, ranging 20–40% in respect to functional liver status. Magnetic resonance imaging is the most sensitive method that has marked advantages in the diagnostics of lesions smaller than 1 cm and metastases on the background of liver steatosis. Computed tomography is an acceptable alternative that benefits from high spatial resolution and optimal reconstructions to evaluate the anatomy. Additional information can be obtained from tumour markers, including traditional, e.g., carcinoembryonic antigen (CEA) and novel, e.g., microRNAs. To ensure that each colorectal cancer patient receives the best care, the medical society should be well informed about the possibilities in the treatment of liver metastases of colorectal cancer regarding the methods, indications and limits.
Part of the book: Recent Advances in Liver Diseases and Surgery
Diagnostic Algorithm of Hepatocellular Carcinoma: Classics and Innovations in Radiology and Pathology
In the global cancer statistics, hepatocellular carcinoma (HCC) ranges sixth by incidence and second by oncological mortality. The risk factors comprise hepatitis B and C virus infection, non-alcoholic steatohepatitis, as well as long-lasting peroral exposure to alcohol or aflatoxins. Liver cirrhosis is the most important single predisposing factor. Ultrasonography once per 6 months is recommended for surveillance in cirrhotic patients. Computed tomography (CT) and magnetic resonance imaging (MRI) represent the gold standard of non-invasive diagnostics while core biopsy and/or immunohistochemistry (IHC) are indicated for controversial and non-cirrhotic HCC cases. Molecular classification is under development. At present, classics of HCC diagnostics is based on evaluation of risk factors, surveillance in cirrhotic patients, preference for CT or MRI-confirmed non-invasive diagnosis and biopsy proof in equivocal cases. Diffusion-weighted imaging and hepatobiliary phase contrasting represent significant recent developments in MRI. Contrast-enhanced ultrasonography is recommended by some but not all guidelines. Positron emission tomography is advocated before liver transplantation to detect extrahepatic metastases but has limited role in the initial diagnostic evaluation of liver nodule. Innovations are expected in the field of molecular diagnostics, including IHC panels and novel antigens, e.g. clathrin and bile salt export pump protein, and development of molecular classification.
Part of the book: Hepatocellular Carcinoma
Systemic Inflammatory Response in Pancreatic Ductal Adenocarcinoma
Pancreatic ductal adenocarcinoma induces systemic inflammatory response (SIR), which can be assessed either by ratios between blood cell counts (neutrophil to lymphocyte ratio, NLR; platelet to lymphocyte ratio, PLR) or concentrations of acute phase proteins, clotting factors and albumins. These tests are biologically justified by multiple events including bone marrow activation, development of immune-suppressing immature myeloid cells, generation of pre-metastatic niches and neutrophil extracellular trap formation from externalised DNA network in bidirectional association with platelet activation. Despite biological complexity, clinical assessment of SIR is widely available, patient-friendly and economically feasible. In this chapter, we present a review on NLR, PLR, Glasgow prognostic score and fibrinogen, recently reported to have a prognostic role regarding overall survival, cancer/progression free and cancer-specific survival in early and advanced pancreatic ductal adenocarcinoma. Practical consequences abound, including preference for surgical or combined, active or sparing treatment, as well as prediction of non-resectability or chemotherapy response. In this chapter, we also scrutinise the main controversies including different cut-off levels, hypothetic correlation with tumour burden and morphology, negative findings and discussions on the best marker. Future developments should include elaboration of complex scores as will be described here.
Part of the book: Advances in Pancreatic Cancer
Mucinous Cystic Neoplasms of the Liver and Extrahepatic Biliary Tract
Mucinous cystic neoplasms of the liver and extrahepatic biliary tree have recently been re-defined by WHO as epithelial cystic tumours with ovarian-type mesenchymal stroma. Correct recognition of these tumours can be difficult because of their rarity and, consequently, lack of awareness by the medical team. Radiological evaluation, including ultrasonography, computed tomography, magnetic resonance imaging and, upon necessity, positron emission tomography, can yield the correct diagnosis. Radical surgical resection with tumour-free margins is the mainstay of treatment. Adequate treatment approach can be very rewarding, bringing prolonged survival. Here we discuss the up-to-date concepts of definition and classification, theoretical views on tumour origin along with practical issues of clinical presentation, diagnostics, treatment and prognosis.
Part of the book: Topics in the Surgery of the Biliary Tree
Thyroid Nodules in Diagnostic Pathology: From Classic Concepts to Innovations
Thyroid nodules are frequent in general population, found in 3.7–7% of people by palpation and 42–67% by ultrasonography (US). The differential diagnosis ranges from papillary (PC), follicular (FC) and medullary (MC) carcinomas to follicular adenoma (FA) and colloid goitre. Cancer risk in thyroid nodules varies: 5% in masses found by palpation, 1.6–15% by US, 3.9–11.3% by computed tomography (CT), 5–6% by magnetic resonance imaging (MRI) and 30–50% by positron emission tomography (PET). The final diagnosis depends on fine needle aspiration (FNA) findings and histopathology. The recent WHO classification (2017) is based on classic morphology, including assessment of invasion and nuclei. New entities are defined to designate tumours with doubtful invasion or controversial nuclear features. By immunohistochemistry, PC expresses HBME-1, TROP-2, CITED1 and CK19. Notably, PC can stain for CD20. MC is recognised by neuroendocrine differentiation. To distinguish FA vs. FC, evaluation of HBME-1, p27 and galectin has been suggested. Regarding miRNAs, miR-146b, miR-222, miR-221 and miR-181b are upregulated, while miR-145, miR-451, miR-613 and miR-137 are downregulated in PC. FC features downregulated miR-199a-5p and upregulated miR-197 and miR-346. In MC, miR-21 and miR-129-5p are downregulated. In addition, increased systemic inflammatory reaction can be poor prognostic factor in thyroid cancer. The aim of this chapter is to review classic and innovative histopathology of thyroid nodules for diagnostic pathology practice and research in multidisciplinary thyroid teams.
Part of the book: Histopathology
Innovative Blood Tests for Hepatocellular Carcinoma: Liquid Biopsy and Evaluation of Systemic Inflammatory ReactionView all chapters
Hepatocellular carcinoma (HCC) is an aggressive tumour associated with dismal prognosis. To improve the outcome, early diagnostics is important. At present, classical HCC diagnostics is based on evaluation of risk factors, surveillance in cirrhotic patients, preference for non-invasive diagnosis by computed tomography or magnetic resonance imaging and biopsy confirmation in controversial cases. However, ambiguous radiological presentation, biopsy-related complications or insufficient representation of the pathology in the tissue core are well-known problems. Panel assessment of microRNAs has diagnostic and prognostic value; thus, in future, microRNA-based liquid biopsy could partially reduce the need for core biopsies. Systemic inflammatory reaction (SIR), characterised mainly by neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and Glasgow prognostic score, may have prognostic value and can be incorporated in criteria for certain treatment approaches, e.g., becoming an adjunct to Milan criteria. Thus, innovations in HCC diagnostics are expected in the field of miRNA-based liquid biopsy for diagnosis/prognosis and SIR for prognosis/selection of treatment.
Part of the book: Hepatocellular Carcinoma