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Liver fibrogenesis: Mechanisms and clinical relevance

Liver fibrosis represents a scarring response to either acute or chronic liver injury. After acute liver injury, parenchymal cells regenerate to successfully preserve hepatocellular mass and function. This acute process is associated with an inflammatory and fibrogenic response but with limited deposition of extracellular matrix (ECM). In contrast, prolonged liver injury leads to sustained production of growth factors, proteolytic enzymes, angiogenic factors, and fibrogenic cytokines. These…

Liver regeneration: Mechanisms and clinical relevance

Introduction to liver regeneration The ability of the liver to regenerate was recognized by the Greeks in the ancient myth of Prometheus, the Titan god of forethought, who gave fire to the mortals and angered Zeus. Prometheus was chained to the Caucasus mountains and each day he would be tormented by Zeus’ eagle Ethon as it devoured his liver. Each night, the damaged liver would be…

Liver blood flow: Physiology, measurement, and clinical relevance

Circulation in the liver is unique because of a dual afferent blood supply, derived from the hepatic artery (HA) and the portal vein (PV; see Chapter 2 ). The oxygen-rich arterial blood and the nutrient-rich PV blood merge in the hepatic parenchymal microcirculation to sustain the complex functions of the liver before returning to the heart through the hepatic veins (HVs). This chapter outlines how liver…

Assessment of hepatic function: Implications for perioperative outcome and recovery

The limits of hepatic resectability are constantly expanding with our increased understanding of hepatic anatomy and refinements in surgical technique (see Chapters 2 , 102 , and 118B ). In past years, partial hepatectomy was limited to anatomic resection and small-wedge resections, with a general consensus that two contiguous segments of hepatic parenchyma having adequate vascular inflow/outflow and biliary drainage was the minimum threshold for safe…

Pancreatic physiology and functional assessment

The pancreas is a complex retroperitoneal gland with both endocrine (e.g., glucose homeostasis) and exocrine (e.g., nutrient digestion) functions. An adult human pancreas measures approximately 15 cm in length and weighs between 60 to 100 g; however, its size can vary because of aging or pathologic conditions (e.g., pancreatitis, neoplasia). , It is of endodermal origin and arises from two independent primordia: a ventral bud (derived…

Surgical and radiologic anatomy of the liver, biliary tract, and pancreas

Anatomy overview Precise knowledge of the architecture of the liver, biliary tract, and pancreas and the related blood vessels and lymphatic drainage is essential for the successful performance of hepatopancreaticobiliary surgical operations. Liver The liver lies protected under the lower ribs, closely applied to the undersurface of the diaphragm and on top of the inferior vena cava (IVC) posteriorly ( Fig. 2.1 ). Most of the…

Embryologic development of the liver, biliary tract, and pancreas

Introduction The liver’s essential structure is one of layers of metabolically active hepatocytes arrayed along and around a vascular network carrying nutrient-rich blood derived from the products of intestinal absorption, otherwise semi-isolated from the systemic circulation. The biliary ducts are interleaved and intimate within this system and provide an excretory apparatus linking back with the intestinal tract. The pancreas, by contrast, has two completely independent functional…

Online Appendix

Historical Trials In the first Milan trial, patients with stage IIIA or IIIB breast cancer were given four cycles of doxorubicin and vincristine, followed by 60 Gy to the breast and a 10-Gy boost to the area of residual tumor. Patients who demonstrated a complete response were randomized to either no further treatment or six more courses of chemotherapy. The objective response rate to this neoadjuvant…

Psychosocial Consequences and Lifestyle Interventions

Psychosocial Aspects of Breast Cancer As early detection and treatment of breast cancer have improved, survival rates have increased to the extent that 89% of individuals with breast cancer now survive 5 years beyond diagnosis, and 83% of individuals survive at least 10 years. The majority of women are diagnosed with early-stage cancer localized to the breast, and the 5-year survival rate for this group is…

Rehabilitation

According to the National Cancer Institute and National Coalition for Cancer Survivorship, an individual is considered a cancer survivor from the time of cancer diagnosis through the balance of his or her life. With improved diagnostics and treatment plans, the “balance of life” has been steadily increasing with an estimated 3.676 million female breast cancer survivors in the United States in 2018. As a result of…

Management of Menopause in Breast Cancer Survivors

What is the Experience of Menopause in Women With Breast Cancer? The median age of breast cancer diagnosis is 63 years; therefore most women experience natural menopause prior to starting their cancer journey. However, the number of premenopausal women diagnosed with breast cancer has increased over the past decade, and more than 12,000 women under age 40 years are diagnosed with invasive breast cancer each year…

Lymphedema in the Postsurgical Patient: Pathophysiology and Nonoperative Management

Lymphedema is the most dreaded complication of breast cancer surgery. It may result in functional, esthetic, and psychological problems, thereby affecting the quality of life of the breast cancer patient. It also predisposes patients to development of infections, decreased functional ability and range of motion, and potential development of malignant lymphangiosarcoma (Stewart-Treves syndrome). It adversely affects quality of life, job performance, and health care costs. Lymphedema…

Quality Measures and Performance Improvement for Breast Cancer Surgery

The first 15 years of the 21st century witnessed an exponential increase in the emphasis on quality and performance measurement for providers, as well as hospital systems. Furthermore, payers of care, including the United States government, have proposed shifting US medical reimbursement policy to payments that are tied to quality and performance instead of the number of services provided or procedures performed. For instance, the Department…

Fertility Preservation for Women With Breast Cancer

Introduction Nearly 100,000 reproductive-age women are diagnosed with cancer annually in the United States, with the most common malignances being breast, hematologic, gynecologic, and central nervous system cancers. Approximately 25,500 cases of breast cancer are diagnosed annually among reproductive-aged women, with the majority of women having local (64%) or regional (27%) disease at the time of diagnosis. Almost all of these women require chemotherapy with or…

Bone-Modifying Agents in Early Breast Cancer

Introduction Bisphosphonates inhibit osteoclast-mediated bone resorption. Denosumab is a RANK ligand inhibitor that prevents bone turnover. As a result, these medications have several therapeutic roles. Primarily, they were used as antiosteoporosis medications. Later, these drugs were used to prevent or delay skeletal-related events such as fractures and bone pain in patients with metastatic cancers with disease in the bones. Bisphosphonates are also used to prevent bone…

General Considerations for Follow-Up

With advances in screening, early detection, and treatment modalities, most women who are diagnosed with and treated for localized early-stage breast cancer will be long-term survivors. From 1989 to 2017, the breast cancer death rate continued to decline, dropping by 40% overall. The 5-year survival rate of localized breast cancer after treatment is about 90%. Survivorship may mean different things to different people, but it is…

Creating a Breast Cancer Survivorship Plan and Clinic

Background As of January 2019, there were 16.9 million cancer survivors in the United States, of which women with a history of breast cancer made up 3.8 million (22.5%). Breast cancer remains the most common cancer affecting women, with greater than 260,000 cases diagnosed annually. Cancer survivor and cancer survivorship were initially defined by the National Coalition for Cancer Survivors (NCCS) in 1986. The original definition…

Unknown Primary Presenting With Axillary Lymphadenopathy

Breast cancer can rarely present as isolated axillary adenopathy without any evidence of a primary breast mass, creating many diagnostic and therapeutic challenges. Occult breast cancer is defined as isolated axillary adenocarcinoma without detectable tumor in the breast by either physical examination or with imaging such as mammogram, ultrasound, or magnetic resonance imaging (MRI). Occult breast cancer, although rare, has been acknowledged for more than 100…

Carcinoma of the Breast in Pregnancy and Lactation

Pregnancy-associated breast cancer (PABC) is often defined as breast cancer during pregnancy or within 1 year postpartum. Outcomes first reported in the early decades of the 20th Century were dismal. In 1929 Kilgore and Bloodgood reported a 16% (n = 8/49) survival rate among patients with PABC at a median of 13 years. Harrington reported a 15% 5-year survival rate in 1937, and White reported a…