NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: How would you tell the patient about his prognosis and the variables that affect it? A: Resection of liver lesions is associated with the best survival when compared to other treat- ment modalities, and it should be recommended if the lesion is resectable. Patients with solitary lesions that are resected have a survival rate as high as 50% or more at 5 years . The survival of individuals with multiple lesions is lower. You decide to remove the liver lesion surgically. Q: What procedure and follow-up do you recommend? A: It is acceptable to resect a lesion with a formal hepatic lobectomy or segmentectomy or with a nonanatomic wedge resection, as long as a greater-than-1-cm margin is obtained . The principal reasons for surgical unresectability are inability to resect the lesion due to its location, multiple lesions, or evidence for metastasis outside the liver. The major surgical risk relates to uncontrollable hemorrhage related to technical prob- lems. With most experienced hepatic surgeons, the operative mortality is approximately 1%. Recurrence may assume the form of distant metastasis or occur at the original site of resection. CXR, serial CEA measurements, and abdominal ultrasound or CT are used to check for recurrence. Q: What management is appropriate for unresectable liver metastasis? A: There are other options for management of unresectable lesions with local methods. Most involve some form of ablation therapy with freezing–thawing techniques (cryotherapy), injection of absolute ethanol, or destruction with radiofrequency waves (RF ablation) . Destruction of lesions may also occur angiographically by chemoembolization . The hepatic artery is catheterized, and thrombotic substances such as Gelfoam® are saturated with chemotherapy and injected into the region of metastasis. Most of these methods are in various stages of clinical trials.

Case 8.28 Heme-Positive Stool with a Hard Lesion A 45-year-old presents with rectal bleeding. On examination, you find a hard lesion that involves the anal verge. Biopsy of the lesion indicates squamous cell carcinoma of the anus. Q: What regional nodes are most likely to be involved with metastasis? A: Squamous cell carcinomas (also called epidermoid carcinomas) are the most common tumor of the anal canal. Because the symptoms are nonspecific (e.g., bleeding, drainage, pain, pruritus), the diagnosis is often delayed while the patient is treated for a benign pro- cess. The diagnosis is made by biopsy. Squamous cell carcinomas commonly metastasize to the inguinal lymph nodes, but they also metastasize to the superior rectal lymph nodes in up to 50% of patients. Q: What staging system is best? A: The TNM system is used for staging, and treatment differs depending on the TNM stage (see Table 8-4). CT and transrectal ultrasound are warranted to determine the depth of invasion and the presence of nodal metastasis. SAMPLE