- Email: [email protected]
T1581 Adult Mesenchymal Hamartoma of the Liver: A Rare Tumor with Malignant Potential?
detection by blue dye only is feasible and results in a similar accuracy as compared to combined detection (nucleotid and blue dye) reported in the literature. In squamous cell cancer skip metastases seem to be frequent.
laparoscopic BIPOLAR RFA followed by 4 cycles chemotherapy prior to staged CHM resection was evaluated. Methods: Using a prospectively maintained hepatobiliary database, patients undergoing the above regimen were identified. Duration of LAP.COL-RFA procedure, RFAprocedure added time, liver treatment associated morbidity (LTAM) and treatment interval disease progression (TIDP) were assessed. Pathological evaluation of the resected liver specimens was reviewed for viable tumor in previously ablated areas and CASH. Results: Eight synchronous CHM were ablated at same setting LAP.COL in five high risk patients [age >65, ASA 3, rectal cancer (n=4)]. Mean RFA time/ lesion was 7min.±3. Thus far, 3/8 patients have completed treatment algorithm inclusive of staged CHM resection without evidence of TIDP. There was no LTAM identified after ablation (n=5) or after staged resection (n= 3). Pathologically, no evidence of CASH was identified in the resected specimens, and there was NO active tumor in previously ablated areas. Conclusion: This feasibility study supports the above strategy as a bridge to resection in high risk patients; with minimal impact on the length of procedure and without TIDP or LTAM. These observations support proceeding to a formal study with the intent to evaluate impact of diminished/abolished hepatic tumor load treated by initial ablation on the duration of subsequent systemic therapy, the potential impact on the duration of post-resection chemotherapy and evaluating post therapy sustained response.
T1577 Local Ablative Therapies for Hepatocellular Carcinoma: Does Immediate Contrast Enhanced Ultrasonography (CEUS) Predict Complete Necrosis At CT Follow Up? Andrea Ruzzenente, Mirko D'Onofrio, Silvia Pachera, Enrico Martone, Alessandro Valdegamberi, Tommaso Campagnaro, Calogero Iacono, Alfredo Guglielmi Background and Objective: The role of CT in follow up of hepatocellular carcinoma (HCC) after local ablative therapy have been demonstrated in many clinical experience, whereas the role of contrast enhanced ultrasonography (CEUS) is still under evaluation. The aim of this study is to evaluate the role of immediate CEUS in prediction 30-days CT follow up after single local ablative therapy with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI). Methods:100 consecutive patients with HCC treated 2006 to 2007 were prospectively included into the study. All the patients were treated with single session of PEI or RFA. After each single percutaneous procedure CEUS was performed in order to identify residual disease (persistence of contrast enhanced pattern). Three different CEUS patters were identified: 1-isovascular-hypervascular pattern, 2-ipovascular pattern, 3-avascular pattern. After 30 days complete necrosis of HCC was evaluated with contrast-enhanced CT scan in all cases. Results: Patients included into the study were submitted to RFA (43 patients) or PEI (57 patients) for HCCs with a mean diameter of 2.7 cm (range 1.5-5 cm). After RFA, isovascular pattern was found in 2% (1/43) of patients resulting in incomplete necrosis at CT; ipovascular pattern was found in 12% (5/43) patients that resulted in incomplete necrosis in 3/5 (60%); in 86% (37/43) avascular pattern was found with complete necrosis at CT in 28/37(76%) cases. Among the PEI group, isovascular pattern was found in 5% (3/57) of patients case resulting incomplete necrosis in 1/3 (33%) case; ipovascular pattern was found in 44% (25/57) of patients that resulted CT incomplete necrosis in 17/ 25(68%) ; in 19% (11/57) of patients avascular pattern was found with complete necrosis at CT in 2/11(18%) cases. Sensitivity, specificity, positive and negative predictive values for complete necrosis at CT of the CEUS avascular pattern after RFA were 93%, 31%, 76% and 67%,respectively, while the positive predictive value after PEI treatments was 18%. Conclusions Immediate CEUS control after percutaneous treatment of HCC have high predictive value after RFA where the avascular pattern is highly related with complete necrosis at 30 day CT. On the contrary predictive value of immediate CEUS after PEI is limited
T1581
Introduction Mesenchymal hamartoma of the liver (MHL) is an uncommon, benign lesion occurring primarily in the pediatric population. While the exact pathogenesis of the tumor is not certain, the most common theory relates to aberrant primitive mesenchyme development of the portal tract likely pertaining to the bile ducts. As rare as MHL is in children, there have only been 30 adult cases reported in the literature. Recent cytogenetic studies have shown that genetic rearrangements at chromosome 19q13.4 are linked to the development of hamartomatous tissue, as well as potentially linking MHL to malignant undifferentiated embryonal sarcoma (UES). Methods A 53-year-old white female was evaluated for a liver mass that was found incidentally during an evaluation for ureteral stones. Initial CT scan showed a cystic lesion in the right lobe of the liver and a laboratory evaluation was unremarkable. Follow up imaging revealed an increase in the size of the mass with changes in its characteristic - solid and cystic components. Percutaneous biopsy was nondiagnostic. In view of the recent change of the lesion and a nondiagnostic biopsy, the decision was made to extirpate the lesion. Results The patient underwent a right trisegmentectomy and cholecystectomy. The pathological report was a 9cm x 9cm x 7.5cm, well-circumscribed, pink-yellow-tan, gelatinous mass, with a 1 cm clear surgical margin. The mass was cystic in the central portion and contained 30 mL of clear, yellowish fluid. Histologically, the mass consisted of rare benign dilated bile ducts corresponding to the cystic areas noted grossly, as well as myxoid stroma with spindle cells showing smooth muscle differentiation confirmed by positive staining for vimentin, smooth muscle actin and desmin. CD34 and hormone receptor studies were negative, thus excluding solitary fibrous tumor and angiomyxoma. The patient's hospital course was uneventful and was discharged home on postoperative day five. Conclusion MHL of the liver in adults is a rare and potentially premalignant lesion that presents as a solid/cystic neoplasm. Symptoms are typically nonspecific, though abdominal pain predominates. Laboratory results are non-contributory and radiographic imaging is variable and inconclusive. Needle biopsy is rarely diagnostic and surgical excision of symptomatic or enlarging lesions is recommended to exclude the possibility of malignancy and establish a further diagnosis. The emerging literature supports a relationship between MHL and UES in regards to cytogenetic analysis, as well as histological similarities supporting a recommendation of aggressive surgical management when feasible.
T1579 Bile Duct Hamartomas: Results of Surgical Treatment On Symptomatic Patients Elliot B. Tapper, N. Volkan Adsay, Diego R. Martin, Bobby Kalb, David Kooby, Thomas G. Heffron, Juan M. Sarmiento Introduction: Bile duct hamartomas (BDH) are benign liver lesions that have been attributed to malformations of the bile duct plate, leading to focal areas of hepatic tissue containing multiple, malformed and dilated bile ducts which are set in the background of fibrous stroma. BDH are considered a spectrum of fibropolycystic liver disease, which includes congenital hepatic fibrosis, autosomal dominant polycystic disease, and Caroli disease. Methods: We reviewed all patients who had an MRI suggestive of BDH located in the last 2 years (2007-2008); for inclusion in the study, patients needed confirmatory histologic evidence of this diagnosis. Every patient was offered an operation based on symptoms; unresected patients were excluded. Patients with florid Polycystic disease of the liver were also excluded. Whenever feasible, the laparoscopic approach (fenestration) was preferred; however, segmental resections were done to avoid recurrence of the BDH. Follow-up was achieved through clinic outpatient visit. Results: Twenty patients met the inclusion criteria (M:F 15:5). Average age was 61.3 yr (SD 12.5). Symptoms prompting the operation were abdominal pain (n=18), jaundice (n=1), hepatic abscess (n=1); the last 2 complications were related to previous interventional manipulation of the cyst. 7 patients had history and histologic evidence of previous bleeding (presently or immediately past). 8 patients received a laparoscopic approach, 4 were started laparoscopically and converted to open (3 for hemostasis, 1 for bile duct exploration) and 8 received an open approach due to the complexity of the cyst, its location or the complication related to it (jaundice, infection). LOS was 2.4 d (SD 1.8) for the laparoscopic approach, 4 d (SD 1) for the conversion and 9.2 d (SD 4.6) for the open procedures. Complications included wound infection, biloma, intraoperative hypotension, renal failure, abdominal abscess (1 each one), all patients with open approaches. Of 18 patients available for follow-up (the other 2 have less than 4 wk FUP), all patients resolved the symptom that prompted the operation. Postoperative imaging ruled out recurrence of the BDH. Conclusions: BDH are benign conditions occurring in the liver that respond very well to operative treatment. Whenever possible, laparoscopic fenestration and/or resection are the preferable choice. Intensive interventional manipulation of the cyst results in complications, both for the approach and postoperative period.
T1582 Pancreatic Neuroendocrine Tumors: Direct Comparison of EUS FNA to Helical CT for Tumor Detection and Impact On Patient Care Ferga C. Gleeson, Michael J. Levy, Suresh T. Chari, Jonathan E. Clain, Amy C. Clayton, Michael Henry, Michael L. Kendrick, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Santhi Swaroop Vege, Naoki Takahashi, Geoffrey B. Thompson, Mark D. Topazian, Kenneth K. Wang Background:Currently, the role of EUS FNA in pancreatic neuroendocrine tumors (pNETs) is primarily for tumor detection and tissue diagnosis. However, few data exist regarding the comparative features of CT to EUS FNA. Aims: In patients undergoing evaluation of a suspected pNET, to compare EUS FNA to pancreatic protocol CT in terms of: 1.) tumor detection, and 2.) disease extent as it potentially impacts the surgical approach and extent of resection. Methods: From a prospectively maintained EUS database, all patients undergoing pNET staging FNA from 01/01/99 to 10/01/08 were identified. Clinical, radiologic, EUS, cytologic, and surgical data were abstracted and analyzed. Results: EUS FNA was performed to confirm and stage 108 patients (56.8 ±13.9 years, 52.8% female) with suspected pNETs, n=96 (88.9%) of which had a CT within 30 days of the EUS exam. CT identified a pNET in only 47 (49%) patients. In the remaining patients, CT was interpreted as normal in 15 (15.6%), inconclusive in 14 (14.6%), non-specific pancreatic cystic disease in 11 (11.5%), and misinterpreted the findings as adenocarcinoma in 9 (9.4%) patients, respectively. EUS more often identified multiple lesions, (p=0.008) and EUS and CT findings were similar in terms of lesion size, the presence of a cystic component and in the determination of locally advanced or metastatic disease. EUS detected multiple lesions in 19/108 (17.6%) patients among whom CT detected only one lesion. Among this group, the additional lesion(s) identified by EUS were located remote from the lesion seen with CT in 12% patients, thereby potentially altering the surgical approach or extent of resection. In an additional 15 patients, in whom EUS FNA identified a pNET, the CT was negative with no pathology detected. Among this group, the EUS FNA identified lesions were ≤2cm in 14 (93.3%), were located within the body/tail in 9 (60%), had multiple lesions in 4 (26.7%), a cystic component in 1 (6.7%) and all 15 (100%) had locally confined disease. Thus, collectively in 27 of the 108 (25%) patients the EUS FNA findings potentially altered patient
T1580 Feasibility Study of Same Setting Laparoscopic Bipolar Radiofrequency Ablation and Laparoscopic Colectomy for Synchronous Colorectal Liver Metastasis As a Bridge to Hepatic Resection Cherif Boutros, Bing Yi, Ponnandai Somasundar, N. Joseph Espat Introduction: Resection of colorectal hepatic metastasis (CHM) is the gold standard, but its timing is controversial; particularly for synchronous disease. Simultaneous resection of CHM can add time and morbidity to 1ary colorectal procedure. MONOPOLAR radiofrequency ablation (RFA) is lengthy and cumbersome. Staged hepatic resection following systemic chemotherapy has been associated with chemotherapy associated steatohepatitis (CASH). In this feasibility study, a strategy of simultaneous laporoscopic colectomy (LAP.COL),
A-915
SSAT Abstracts
SSAT Abstracts
Adult Mesenchymal Hamartoma of the Liver: A Rare Tumor with Malignant Potential? Zachary Klaassen, Prakash R. Paragi, Ronald S. Chamberlain
laparoscopic BIPOLAR RFA followed by 4 cycles chemotherapy prior to staged CHM resection was evaluated. Methods: Using a prospectively maintained hepatobiliary database, patients undergoing the above regimen were identified. Duration of LAP.COL-RFA procedure, RFAprocedure added time, liver treatment associated morbidity (LTAM) and treatment interval disease progression (TIDP) were assessed. Pathological evaluation of the resected liver specimens was reviewed for viable tumor in previously ablated areas and CASH. Results: Eight synchronous CHM were ablated at same setting LAP.COL in five high risk patients [age >65, ASA 3, rectal cancer (n=4)]. Mean RFA time/ lesion was 7min.±3. Thus far, 3/8 patients have completed treatment algorithm inclusive of staged CHM resection without evidence of TIDP. There was no LTAM identified after ablation (n=5) or after staged resection (n= 3). Pathologically, no evidence of CASH was identified in the resected specimens, and there was NO active tumor in previously ablated areas. Conclusion: This feasibility study supports the above strategy as a bridge to resection in high risk patients; with minimal impact on the length of procedure and without TIDP or LTAM. These observations support proceeding to a formal study with the intent to evaluate impact of diminished/abolished hepatic tumor load treated by initial ablation on the duration of subsequent systemic therapy, the potential impact on the duration of post-resection chemotherapy and evaluating post therapy sustained response.
T1577 Local Ablative Therapies for Hepatocellular Carcinoma: Does Immediate Contrast Enhanced Ultrasonography (CEUS) Predict Complete Necrosis At CT Follow Up? Andrea Ruzzenente, Mirko D'Onofrio, Silvia Pachera, Enrico Martone, Alessandro Valdegamberi, Tommaso Campagnaro, Calogero Iacono, Alfredo Guglielmi Background and Objective: The role of CT in follow up of hepatocellular carcinoma (HCC) after local ablative therapy have been demonstrated in many clinical experience, whereas the role of contrast enhanced ultrasonography (CEUS) is still under evaluation. The aim of this study is to evaluate the role of immediate CEUS in prediction 30-days CT follow up after single local ablative therapy with radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI). Methods:100 consecutive patients with HCC treated 2006 to 2007 were prospectively included into the study. All the patients were treated with single session of PEI or RFA. After each single percutaneous procedure CEUS was performed in order to identify residual disease (persistence of contrast enhanced pattern). Three different CEUS patters were identified: 1-isovascular-hypervascular pattern, 2-ipovascular pattern, 3-avascular pattern. After 30 days complete necrosis of HCC was evaluated with contrast-enhanced CT scan in all cases. Results: Patients included into the study were submitted to RFA (43 patients) or PEI (57 patients) for HCCs with a mean diameter of 2.7 cm (range 1.5-5 cm). After RFA, isovascular pattern was found in 2% (1/43) of patients resulting in incomplete necrosis at CT; ipovascular pattern was found in 12% (5/43) patients that resulted in incomplete necrosis in 3/5 (60%); in 86% (37/43) avascular pattern was found with complete necrosis at CT in 28/37(76%) cases. Among the PEI group, isovascular pattern was found in 5% (3/57) of patients case resulting incomplete necrosis in 1/3 (33%) case; ipovascular pattern was found in 44% (25/57) of patients that resulted CT incomplete necrosis in 17/ 25(68%) ; in 19% (11/57) of patients avascular pattern was found with complete necrosis at CT in 2/11(18%) cases. Sensitivity, specificity, positive and negative predictive values for complete necrosis at CT of the CEUS avascular pattern after RFA were 93%, 31%, 76% and 67%,respectively, while the positive predictive value after PEI treatments was 18%. Conclusions Immediate CEUS control after percutaneous treatment of HCC have high predictive value after RFA where the avascular pattern is highly related with complete necrosis at 30 day CT. On the contrary predictive value of immediate CEUS after PEI is limited
T1581
Introduction Mesenchymal hamartoma of the liver (MHL) is an uncommon, benign lesion occurring primarily in the pediatric population. While the exact pathogenesis of the tumor is not certain, the most common theory relates to aberrant primitive mesenchyme development of the portal tract likely pertaining to the bile ducts. As rare as MHL is in children, there have only been 30 adult cases reported in the literature. Recent cytogenetic studies have shown that genetic rearrangements at chromosome 19q13.4 are linked to the development of hamartomatous tissue, as well as potentially linking MHL to malignant undifferentiated embryonal sarcoma (UES). Methods A 53-year-old white female was evaluated for a liver mass that was found incidentally during an evaluation for ureteral stones. Initial CT scan showed a cystic lesion in the right lobe of the liver and a laboratory evaluation was unremarkable. Follow up imaging revealed an increase in the size of the mass with changes in its characteristic - solid and cystic components. Percutaneous biopsy was nondiagnostic. In view of the recent change of the lesion and a nondiagnostic biopsy, the decision was made to extirpate the lesion. Results The patient underwent a right trisegmentectomy and cholecystectomy. The pathological report was a 9cm x 9cm x 7.5cm, well-circumscribed, pink-yellow-tan, gelatinous mass, with a 1 cm clear surgical margin. The mass was cystic in the central portion and contained 30 mL of clear, yellowish fluid. Histologically, the mass consisted of rare benign dilated bile ducts corresponding to the cystic areas noted grossly, as well as myxoid stroma with spindle cells showing smooth muscle differentiation confirmed by positive staining for vimentin, smooth muscle actin and desmin. CD34 and hormone receptor studies were negative, thus excluding solitary fibrous tumor and angiomyxoma. The patient's hospital course was uneventful and was discharged home on postoperative day five. Conclusion MHL of the liver in adults is a rare and potentially premalignant lesion that presents as a solid/cystic neoplasm. Symptoms are typically nonspecific, though abdominal pain predominates. Laboratory results are non-contributory and radiographic imaging is variable and inconclusive. Needle biopsy is rarely diagnostic and surgical excision of symptomatic or enlarging lesions is recommended to exclude the possibility of malignancy and establish a further diagnosis. The emerging literature supports a relationship between MHL and UES in regards to cytogenetic analysis, as well as histological similarities supporting a recommendation of aggressive surgical management when feasible.
T1579 Bile Duct Hamartomas: Results of Surgical Treatment On Symptomatic Patients Elliot B. Tapper, N. Volkan Adsay, Diego R. Martin, Bobby Kalb, David Kooby, Thomas G. Heffron, Juan M. Sarmiento Introduction: Bile duct hamartomas (BDH) are benign liver lesions that have been attributed to malformations of the bile duct plate, leading to focal areas of hepatic tissue containing multiple, malformed and dilated bile ducts which are set in the background of fibrous stroma. BDH are considered a spectrum of fibropolycystic liver disease, which includes congenital hepatic fibrosis, autosomal dominant polycystic disease, and Caroli disease. Methods: We reviewed all patients who had an MRI suggestive of BDH located in the last 2 years (2007-2008); for inclusion in the study, patients needed confirmatory histologic evidence of this diagnosis. Every patient was offered an operation based on symptoms; unresected patients were excluded. Patients with florid Polycystic disease of the liver were also excluded. Whenever feasible, the laparoscopic approach (fenestration) was preferred; however, segmental resections were done to avoid recurrence of the BDH. Follow-up was achieved through clinic outpatient visit. Results: Twenty patients met the inclusion criteria (M:F 15:5). Average age was 61.3 yr (SD 12.5). Symptoms prompting the operation were abdominal pain (n=18), jaundice (n=1), hepatic abscess (n=1); the last 2 complications were related to previous interventional manipulation of the cyst. 7 patients had history and histologic evidence of previous bleeding (presently or immediately past). 8 patients received a laparoscopic approach, 4 were started laparoscopically and converted to open (3 for hemostasis, 1 for bile duct exploration) and 8 received an open approach due to the complexity of the cyst, its location or the complication related to it (jaundice, infection). LOS was 2.4 d (SD 1.8) for the laparoscopic approach, 4 d (SD 1) for the conversion and 9.2 d (SD 4.6) for the open procedures. Complications included wound infection, biloma, intraoperative hypotension, renal failure, abdominal abscess (1 each one), all patients with open approaches. Of 18 patients available for follow-up (the other 2 have less than 4 wk FUP), all patients resolved the symptom that prompted the operation. Postoperative imaging ruled out recurrence of the BDH. Conclusions: BDH are benign conditions occurring in the liver that respond very well to operative treatment. Whenever possible, laparoscopic fenestration and/or resection are the preferable choice. Intensive interventional manipulation of the cyst results in complications, both for the approach and postoperative period.
T1582 Pancreatic Neuroendocrine Tumors: Direct Comparison of EUS FNA to Helical CT for Tumor Detection and Impact On Patient Care Ferga C. Gleeson, Michael J. Levy, Suresh T. Chari, Jonathan E. Clain, Amy C. Clayton, Michael Henry, Michael L. Kendrick, Randall K. Pearson, Bret T. Petersen, Elizabeth Rajan, Santhi Swaroop Vege, Naoki Takahashi, Geoffrey B. Thompson, Mark D. Topazian, Kenneth K. Wang Background:Currently, the role of EUS FNA in pancreatic neuroendocrine tumors (pNETs) is primarily for tumor detection and tissue diagnosis. However, few data exist regarding the comparative features of CT to EUS FNA. Aims: In patients undergoing evaluation of a suspected pNET, to compare EUS FNA to pancreatic protocol CT in terms of: 1.) tumor detection, and 2.) disease extent as it potentially impacts the surgical approach and extent of resection. Methods: From a prospectively maintained EUS database, all patients undergoing pNET staging FNA from 01/01/99 to 10/01/08 were identified. Clinical, radiologic, EUS, cytologic, and surgical data were abstracted and analyzed. Results: EUS FNA was performed to confirm and stage 108 patients (56.8 ±13.9 years, 52.8% female) with suspected pNETs, n=96 (88.9%) of which had a CT within 30 days of the EUS exam. CT identified a pNET in only 47 (49%) patients. In the remaining patients, CT was interpreted as normal in 15 (15.6%), inconclusive in 14 (14.6%), non-specific pancreatic cystic disease in 11 (11.5%), and misinterpreted the findings as adenocarcinoma in 9 (9.4%) patients, respectively. EUS more often identified multiple lesions, (p=0.008) and EUS and CT findings were similar in terms of lesion size, the presence of a cystic component and in the determination of locally advanced or metastatic disease. EUS detected multiple lesions in 19/108 (17.6%) patients among whom CT detected only one lesion. Among this group, the additional lesion(s) identified by EUS were located remote from the lesion seen with CT in 12% patients, thereby potentially altering the surgical approach or extent of resection. In an additional 15 patients, in whom EUS FNA identified a pNET, the CT was negative with no pathology detected. Among this group, the EUS FNA identified lesions were ≤2cm in 14 (93.3%), were located within the body/tail in 9 (60%), had multiple lesions in 4 (26.7%), a cystic component in 1 (6.7%) and all 15 (100%) had locally confined disease. Thus, collectively in 27 of the 108 (25%) patients the EUS FNA findings potentially altered patient
T1580 Feasibility Study of Same Setting Laparoscopic Bipolar Radiofrequency Ablation and Laparoscopic Colectomy for Synchronous Colorectal Liver Metastasis As a Bridge to Hepatic Resection Cherif Boutros, Bing Yi, Ponnandai Somasundar, N. Joseph Espat Introduction: Resection of colorectal hepatic metastasis (CHM) is the gold standard, but its timing is controversial; particularly for synchronous disease. Simultaneous resection of CHM can add time and morbidity to 1ary colorectal procedure. MONOPOLAR radiofrequency ablation (RFA) is lengthy and cumbersome. Staged hepatic resection following systemic chemotherapy has been associated with chemotherapy associated steatohepatitis (CASH). In this feasibility study, a strategy of simultaneous laporoscopic colectomy (LAP.COL),
A-915
SSAT Abstracts
SSAT Abstracts
Adult Mesenchymal Hamartoma of the Liver: A Rare Tumor with Malignant Potential? Zachary Klaassen, Prakash R. Paragi, Ronald S. Chamberlain