Search

Adrenocortical carcinoma is a rare and aggressive tumour. The only curative treatment is surgery with negative margins. In most series, the average lesion size ranges from 5.5 to 15 cm.We report the case of a 27-year-old female with hyperandrogenism and Cushing syndrome due to a right adrenocortical carcinoma of 19.7 cm.The tumour abutting on liver and vena cava and the presence two nodules in liver required extensive surgery including a right posterior sectionectomy and an en bloc resection of the adrenal mass together with the right kidney and the gallbladder. The vena cava was also resected with a reconstruction using a pericardial patch since it was invaded on its border. Pathological examination confirmed an adrenocortical carcinoma, with tumour invasion of vessels, tumour capsule, vena cava and two metastases in the liver (pT4N0M1). All margins were negative. Three months after surgery, two lung nodules, cardio-phrenic and internal mammary adenomegalies were noticed on a PET/CT scan, justifying the initiation of chemotherapy, alongside with mitotane. After a 10-month follow-up, CT scan was stable excepted for a lung nodule growing from 4 to 7 mm. Targeted stereotaxic radiotherapy was then administered. Twenty-two months after surgery, the patient has improved considerably and all signs of hyperandrogenism and Cushing syndrome have resolved.This case of adrenocortical carcinoma illustrates one of the largest tumours among those reported. It demonstrates the feasibility and effectiveness of a multimodal approach in its treatment even if it is giant and at high risk.

Background: Second look surgery, complete cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has the rational to treat patients with high recurrence risk, at an early stage with low peritoneal carcinomatosis index (PCI) score and give a better chance of cure. The purpose of this study is to evaluate our results in terms of morbidity and oncologic benefit for the patient. Materials and Methods: Data were retrospectively collected from all patients with second look surgery and HIPEC between April 2012 and May 2018. Twelve patients with limited carcinomatosis initially resected or perforated tumour (in the literature, 70% and 50% of risk for peritoneal recurrence respectively) were identified (colorectal n=8 and appendicular cancer n=4). At second look a HIPEC was systematically proposed, even if there was no evidence of macroscopic recurrence. Results: Median follow-up from initial diagnosis was 24,8 months (range 9 -67). The mean PCI score was 1 (range 0 – 8). Only 2 patients out of 12 had PCI score other than 0 but histopathology showed peritoneal disease in 3 patients. Three patients were explored by laparoscopy and HIPEC was performed by mini laparotomy. One 90 days, Dindo-Clavien grade IIIb complication occurred (8%) and no mortality. Mean hospital stay was 14 days (range 8 -29). All patients are alive in the follow up but 5 of them presented recurrent disease (42%): 1 peritoneal with redo HIPEC, 1 hepatic with partial hepatectomy, 1 pulmonary resected, 1 multisite recurrence. Conclusions: In our series of 12 patients, with a theoretical risk of 50 to 70% of peritoneal relapse, we only identified 1 (8%) of peritoneal recurrence suggesting that this strategy can be considered as an essential weapon in the management of colorectal cancer and this with an acceptable morbidity.

BACKGROUND The prevalence of chemotherapy associated liver injuries (CALI), especially SOS (sinusoidal obstruction syndrome) and NRH (nodular regenerative hyperplasia) might be reduced since the introduction of routine use of biological agents with chemotherapy in colorectal liver metastases (CRLM). METHODS One hundred patients with CRLM having undergone at least one liver segment resection were prospectively included, and chemotherapy data recorded. Specimens were reviewed by a single pathologist and CALI were described. Prevalence of CALI was compared to our previous experience published in 2013. NRH diagnosis was performed on reticulin special stain, by contrast to our previous study. Postoperative outcome was analysed. RESULTS Bevacizumab was more frequently administrated in patients of the present study: 53/100 (53%) compared to 20/151 (13%), p

Background The survival of colorectal cancer patients is frequently determined by the extent of metastatic invasion to the liver; in cases of major involvement, therapeutic strategies are limited because the liver is necessary for drug metabolism. Material and methods We have reviewed articles about the pharmacokinetic profiles of each drug used in colorectal cancer patients with hepatic dysfunction to determine which of these treatments are most feasible. Results Some drugs appear to be feasible options for patients with hepatic insufficiency. Agents such as 5-fluorouracil and oxaliplatin, as well as monoclonal antibodies such as bevacizumab, cetuximab, and panitumumab, can potentially be used in these cases. On the other hand, irinotecan and regorafenib cannot be recommended because of the risk of increased toxicity. Conclusion Treatment of patients with colorectal cancer and liver dysfunction represents a major challenge because the prognosis is usually very poor and alteration of liver function is normally an exclusion criterion in clinical trials. In this review, we present evidence regarding the use of each drug in patients with colorectal cancer and hepatic impairment.

Background : Transanal endoscopic microsurgery (TEM), first described by Buess enables a less aggressive approach of benign rectal lesions, or even early rectal cancer in a curative intent.Materials and methods : The SILS Port, initially designed for laparoscopic surgery, was successfully used for 20 TEM procedures in 16 patients. Local resection was sufficient in 15 procedures (benign tumours or pT1) out of 20, whereas 5 TEM operations required additional surgery: 3 rectal resections (pT1Nx, pT1sm3Nx and pT2N1) and 1 TEM revision (1 patient refused the rectal resection (pT1Nx).Postoperative complications following Dindo-Clavien were: grade II in 4 patients (pain: 2; fever: 1; bleeding: 1) and grade IIIb in 2 patients (bleeding). No long term faecal incontinence was noted.Conclusion : TEM using the SILS Port is a safe and effective procedure for local resection of benign and certain malignant tumours. Using such a cheaper device, TEM procedure could be available in any operating theatre.

Intraoperative cholangiography (IOC), used routinely or selectively, is the standard method for bile duct imaging during cholecystectomy. Laparoscopic ultrasonography (LUS) has emerged as a possible, safe and quick alternative. This study examined the evolving use and the performance of these two methods as primary technique for routine bile duct imaging, so as to detect common bile duct stones (CBDS) and to prevent common bile duct injury (CBDI). A prospective database permitted to evaluate the results of the two methods in 968 consecutive cholecystectomies. Nine hundered and twenty five were performed by laparoscopy, 18 (1.9%) by laparotomy and 25 (2.6) necessitated a conversion. The systematic use of the IOC was gradually replaced by a systematic use of the LUS. The success to delineate and evaluate the CBD, the detection of a CBDS, any type of bile duct complication, especially of CBDI, were registered. All the CBDS suspected by LUS were controlled by IOC. The patients were followed during 1 and 6 months. Six hundred and eighty five IOC and 269 LUS were performed. The procedure was technically unsuccessful in 35 IOC (5.1%) (mainly due to difficulty in catheterising the cystic duct) and in 2 LUS (1%) (due to steatosis). Concerning the detection of CBDS, 31 were detected by IOC (4.5%) and 16 by LUS (6%). Five IOC were considered as false positive, 1 as false negative (sensitivity and specificity of 96,9 and 99,2%) and 1 LUS as false positive (sensitivity and specificity of 100 and 99,6%). Five CBDI were detected in the complete seria: 2 during the dissection before the IOC, 1 thermic injury, 1 late stenosis, 1 lateral stenosis by the cystic clip detected by LUS. However none of these CBDI could have been prevented by IOC. In our experience, in this prospective study, LUS has been certainly as effective as IOC as a primary imaging technique for bile duct. It permitted to detect CBDS with a high specificity and sensitivity, and CBDS and was not followed by an increase in CBDI.