Toward more than 400 liver transplantations a year at a single center

BACKGROUND

For the first time at Asan Medical Center (AMC) we performed more than 400 liver transplantations (LTs) per year in 2011, despite same number of living donor liver transplantations (LDLTs).

METHODS

Our OLT program was started in 1992, but not activated well due to the scarcity of deceased donor organs. Since adult LDLTs using a left lobe and then a right lobe were successfully performed in 1997, we have developed several innovative techniques and approaches for adult LDLT, for example, modified right-lobe graft reconstructing middle hepatic branches in 1998, dual graft LDLT using 2 left lobes in 2000; new criteria for hepatocellular carcinoma (HCC); as well as ABO-incompatible LDLT, the first in the world. As a result, the number of LDLTs has increased rapidly but reached a plateau recently. Nationwide efforts to promote deceased donation increased the number of deceased donor liver transplantation (DDLT).

RESULTS

We have performed 317 LDLTs per year in 2010 and 2011, respectively. The number of LTs reached 403 in 2011. This large number was possible due to a remarkable increase of DDLTs from 50 in 2010 to 86 in 2011. Seventy-nine patients (68.1%) among 116 patients (28.8%) required an urgent LT receiving a DDLT. LT for HCC or ABO-mismatch comprised 50.3% (n = 150) or 8.7% (n = 35), respectively. In-hospital mortality rate in 2011 was 4.7%.

CONCLUSIONS

The increased LTs number at AMC was aided by the nationwide campaign.

Three cases of donor-derived pulmonary tuberculosis in lung transplant recipients and review of 12 previously reported cases: opportunities for early diagnosis and prevention

INTRODUCTION

Solid organ transplant recipients have a higher frequency of tuberculosis (TB) than the general population, with mortality rates of approximately 30%. Although donor-derived TB is reported to account for <5% of TB in solid organ transplants, the source of Mycobacterium tuberculosis infection is infrequently determined.

METHODS

We report 3 new cases of pulmonary TB in lung transplant recipients attributed to donor infection, and review the 12 previously reported cases to assess whether cases could have been prevented and whether any cases that might occur in the future could be detected and investigated more quickly. Specifically, we evaluate whether opportunities existed to determine TB risk on the basis of routine donor history, to expedite diagnosis through routine mycobacterial smears and cultures of respiratory specimens early post transplant, and to utilize molecular tools to investigate infection sources epidemiologically.

FINDINGS

On review, donor TB risk was present among 7 cases. Routine smears and cultures diagnosed 4 asymptomatic cases. Genotyping was used to support epidemiologic findings in 6 cases.

CONCLUSION

Validated screening protocols, including microbiological testing and newer technologies (e.g., interferon-gamma release assays) to identify unrecognized M. tuberculosis infection in deceased donors, are warranted.

Abstract P2-18-06: Preservation or division of the intercostobrachial nerve in axillary dissection for breast cancer: Meta-analysis of randomised controlled trials

Purpose: Management of the ICBN during axillary dissection is controversial and the division of ICBN is often trivialised.The effect of dividing the ICBN, and its association with sensory disturbance, is unclear. A systemic review and meta-analysis was performed to evaluate the effect of preserving the ICBN during axillary dissection.

Methods: A systemic literature review and meta-analysis was performed according to the PRISMA and Cochrane Collaboration guidelines. Two authors (SW and SH) independently searched Medline, Pubmed, Embase, Cochrane Database of Systemic Reviews and the Cochrane Controlled Trials Register from 1950 to December 2012 for studies comparing preservation or division of the ICBN in axillary dissection for breast cancer. The primary outcome of this meta-analysis was sensory disturbance, defined as objectively assessed change in sensation in the distribution of the ICBN after axillary dissection. The nature of sensory disturbance was assessed as a secondary outcome, categorised into two types: “hypersensitivity” and “hyposensitivity”.

Results: Three RCTs and four non-RCTs were reviewed. A meta-analysis demonstrated that the incidence of sensory disturbance was significantly lower with preservation of ICBN compared to division of the ICBN with Mantel-Haenzel combined odds ratio 0.31 (0.17-0.57, 95% CI). There was relatively low level of heterogeneity (I2 = 19%, c2 = 2.48, df = 2).

The sensory disturbance was more likely to be hyposensitivity when compared to hypersensitivity (p &lt;0.0001). No difference on number of lymph nodes dissected or operating time was noted.

Conclusion: This meta-analysis demonstrates that division of the ICBN is associated with higher risk of sensory disturbance, and that the nature of this sensory disturbance is more likely to be hyposensitivity, attributable to reduced nerve function.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-06.

Abstract S2-06: Extracellular matrix stiffness modulates tissue inflammation to promote breast tumor aggression

Tumor progression is influenced by the dynamic interplay between the genetically-modified epithelium and the associated microenvironment. We previously showed that the extra-cellular matrix (ECM) progressively stiffens as mammary tumors evolve, and that stiffening the ECM promotes malignant transformation while inhibiting ECM stiffening reduces tumor progression (Levental et al., 2009; reviewed in Butcher et al., 2009). Yet breast cancers also exhibit elevated influx of inflammatory cells and tissue inflammation promotes tumor progression by fostering angiogenesis and enhancing tumor cell growth and motility (Ruffell et al., 2011). Tumor-associated macrophages additionally stimulate stromal fibroblasts, implying that tissue inflammation could promote malignancy by stiffening the ECM. To address this possibility, we explored the relationship between ECM tension and macrophages in human breast cancer and during mammary tumor development in transgenic mice. Using fresh and archived tissue samples, we quantified a progressive increase in ECM remodeling and stiffening as human breast tumors and mouse mammary cancers developed. We found that the ECM associated with triple negative breast cancers was almost twice as stiff as the ECM adjacent to ER+/PR+ tumors and that ECM stiffness correlated significantly with increased numbers of infiltrating activated macrophages. Consistently, we established a positive correlation between tumor progression, elevated mechanosignaling, ECM stiffness and tissue inflammation in both human and mouse tissue. However surprisingly, when macrophages were depleted from the mammary glands of MMTV-PyMT tumors, ECM tension did not change. Instead we found that inhibiting lysyl oxidase activity to decrease collagen cross-linking and ECM stiffness reduced the activation state of the macrophages within the mammary glands of 14-week old mice. Consistently, in vitro studies showed that ECM tension potentiates the expression of pro-inflammatory chemokines and increases levels of phosphoStat3 and that ECM tension directly modifies macrophage polarity. These findings suggest that ECM tension may promote malignancy either by directly regulating macrophage activity or indirectly through enhancing expression of pro-inflammatory chemokines. Further studies are now underway to explore these findings and to clarify their impact on tumor progression and response to therapy.

Acknowledgements: supported by W81XWH-05-1-0330 and R01 CA138818-01A1 to VMW, 1U01 ES019458-01 to VMW and ZW, and P50 CA 58207 to JG, VW, SH and LC, U54CA143836-01 to JL and VW, and Susan G. Komen for the Cure PSF12230246 to IA.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr S2-06.

Abstract P1-01-04: Nodal patterns of care in patients with invasive breast cancer treated with neoadjuvant systemic therapy: Results of a secondary analysis of TBCRC 017

Background: Neoadjuvant chemotherapy (NCT) to downstage locally advanced tumors and potentially allow breast conservation has increased. In parallel, the use of sentinel lymph node biopsy (SNB) and axillary node dissection has evolved. This analysis reports patterns of care for axillary evaluation at 8 NCI Comprehensive Cancer Centers in women receiving NCT.

Methods: Between 2002 and 2010, 770 women were retrospectively identified as having received NCT, 758 of who had nodal imaging either before or after NCT. Clinical, pathologic, and treatment data were collected. Univariate and multivariate analyses of covariates associated with axillary management were performed using logistic regression (SAS 9.2, Proc Logistic).

Results: Between 2002 and 2010, the odds of receiving a post-NCT SNB increased by 8% per year (p&lt;0.001). Rates of post-NCT SNB were significantly different in only one of eight institutions (p&lt;0.001), where pre-NCT nodal evaluation was made by SNB. The remainder of institutions used SNB following NCT. Of those who underwent post-NCT SNB, regardless of nodal status pre-NCT, 55% (171/314) had axillary lymph node dissection (ALND). Prior to NCT, 74% (564/758) of patients exhibited at least one abnormal lymph node on pretreatment imaging.

Imaging modalities used pretreatment to assess axillary lymph nodes Suspicious Nodes N (%)Ultrasound24 (4.3)Ultrasound+MRI218 (38.7)Ultrasound +MRI+CT103 (18.3)Ultrasound+MRI+CT+PET39 (6.9)Ultrasound+MRI+PET9 (1.6)Ultrasound+CT12 (2.1)Ultrasound+CT+PET8 (1.4)Ultrasound+PET3 (0.5)MRI36 (6.4)MRI+CT58 (10.3)MRI+CT+PET21 (3.7)MRI+PET9 (1.6)CT18 (3.2)CT+PET3 (0.5)CT+PET3 (0.5)TOTAL564 (100)

Of those, 52% (291/564) of the lymph nodes were sampled using fine needle aspiration (FNA) and 27% (149/564) were sampled with CNB. Odds of undergoing a core needle biopsy (CNB) at presentation for radiographically or clinically suspicious lymph nodes increased by 27% per year (p&lt;0.001). 57% (322/564) of all sampled lymph nodes were positive for malignant cells by either FNA or CNB. Of those with confirmed positive nodes at diagnosis, 26% (83/322) had nodal sampling with SNB after NCT. Of the 462 patients with pretreatment MRI suggesting an abnormal lymph node, 155 (33.5%) had a complete imaging response in the lymph nodes by MRI. Of those patients 32% (49/155) had SNB as their initial axillary evaluation after NCT, of which 45% (22/49) of those exhibited persistently positive nodes and underwent completion axillary node dissection.

Conclusions: Among a contemporary cohort of women receiving NCT, a significant trend was observed towards increased use of needle biopsy for patients with abnormal pretreatment nodal imaging at presentation and sentinel lymph node biopsy after NCT nodal evaluation. A trend was also observed over time towards greater use of post-NCT SNB in patients with confirmed pathologic positive nodes at presentation. These data demonstrate a trend towards less invasive assessment of suspicious lymph nodes both before and after NCT.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-04.

Abstract P4-03-05: Characterization of circulating tumor cells identified by high definition assay in patients with benign and malignant breast disease

Background: Identification of circulating tumor cells (CTC) has the potential for minimally invasive diagnosis and assessment of therapy response. Current CTC assay techniques rely on immunomagnetic bead isolation for CTC enrichment. However, these methods result in low cell yield, limiting the potential use in early stage where CTCs are thought to be less abundant. The high definition (HD)-CTC assay is a novel non-enrichment assay providing unique opportunities to identify single circulating epithelial cells (CepiCs) in patients before or at diagnosis. This study's goal is to determine feasibility and performance of the HD-CTC method for isolating CepiCs in women presenting for diagnostic breast biopsy. Methods: Women undergoing image-guided biopsy for BIRADS 4 and 5 mammographic abnormalities were selected from April 2012 onward at the Duke Breast Clinic. After obtaining informed consent, sample collection and shipping procedures were performed following specific standard operating procedures. Diagnosis was kept blinded during assay analysis. Quantitative measurements were used at the single-cell level to identify and enumerate CepiCs. We morphologically characterized specific high content screening variables including cytokeratin (CK) intensity and epithelial cell adhesion molecule (EpCAM) staining. Measurements included cellular size, shape, and staining pattern. For each draw, 4 monochrome images per frame from 4 stained slides were used for CK/EpCAM evaluation. Results: To date 34 women have been enrolled. Fourteen samples (41%) were drawn before biopsy and 20 (59%) after. Out of the 20, 2 (10%) were non-evaluable and a total of 18 (90%) have HD-CTC assay derived data available. The average diagnosis age was 54; 70% were Caucasian. Six (33%) out of 18 had benign disease (fibrocystic, fibroadenoma and apocrine), 10 (55%) had invasive (ductal or lobular), and 2 (12%) had atypical ductal hyperplasia and ductal carcinoma in situ. Five (83%) benign cases and 4 (40%) invasive had detectable CepiCs (Fisher exact test = 0.43). We found a borderline significant trend between the number of CepiCs and the nodes involved (P for trend = 0.06). No association found with ER, PR or ERBB2 status. The mean number of CepiCs/mL in invasive cases was 45.25 +/-96.65 (range 0 to 270.6) compared to 17.47 CepiCs/mL +/-27.8 (range 0 to 72.3) in benign. Additionally, all the CK(+) morphologically distinct cells were EpCAM(-). There is no significant difference between benign and malignant cases when analyzing draws after biopsy. Conclusion: HD-CTC technology is feasible for detection of CepiCs in early stage breast cancer, and in some cases, results in retrieval of a large number of them. Additional technology refinements including determination of appropriate thresholds are needed to improve discrimination of cancer patients from non-cancer, and follow up will help determine whether HD-CTC assay derived enumeration and characterization of CepiCs are associated with prognosis. These early results are promising and ongoing studies at Duke with TSRI will further evaluate the role of CepiCs in early stage breast cancer along with the isolation and analysis of DNA from single-CepiCs. New data will be available by time of presentation.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P4-03-05.

Differential function of natural killer cells in the liver graft perfusate of Korean population

BACKGROUND

Liver perfusate (LP) lymphocytes show unique subsets compared with peripheral blood (PB) lymphocytes. LP natural killer (NK) and NKT cells may display unique cytotoxicity and cytokine production, thus leading to distinct roles in liver transplantation. In this study, we sought to evaluate the functions of graft perfusate NK and NKT cells in clinical liver transplantation.

METHODS

The living donor right lobe graft was initially washed with 1 L of histidine-tryptophan-ketoglutarate solution to collect the perfusate. We also collected donor PB. Lymphocytes separated by the Ficoll-Hypaque density gradient method underwent immunophenotyping using multicolor flow cytometry. To assess cytokine secretion, we performed the enzyme-linked immunosorbent assay.

RESULTS

There were more NK and NKT cells in LP confirming previous reports. In particular, CD56(bright)CD16(low) NK cells accounted for approximately 50% of total NK cells compared with 5% to 10% among PB NK cells. In response to cytokine stimulation LP NK cells produce tumor necrosis factor-α at different levels and less interleukin-10 compared with PB NK cells. The major source of interferon-γ production upon stimulation with liver caner cells were CD56(dim) NK cells and CD56(-)CD3(-) cells rather than NKT or T cells. Unlike PB NK cells, LP CD56(bright)CD16(low) NK cells along with CD56(dim)CD16(high) NK cells and NKT cells were efficient killers against Korean liver cancer cells.

CONCLUSION

LP NK and NKT cells showed unique functions in cytotoxicity and cytokine production.

Unification venoplasty to cope with recipient portal vein anomaly during living donor liver transplantation

PURPOSE

To cope with recipient portal vein (PV) anomalies, such as early branching of the right posterior section (RPS), during living donor liver transplantation (LDLT) surgery, we performed a simulation study to standardize the surgical technique for unification portal venoplasty.

METHODS

This study included an observational analysis of conventional methods utilizing RPS PV, simulation-based design of a new surgical technique, and clinical application of this new technique.

RESULTS

In a case encountering RPS PV, a mild anastomotic PV stenosis was persistent over 6 months postsurgery, indicating the need for technical refinement. After computational simulation analysis, we found that simple suturing of the PV branch patch automatically resulted in a funnel-shaped elongation. A prospective recipient study (n = 30) indicated that usual PV reconstruction via the PV bifurcation method is feasible in the absence of unusual donor or recipient PV anomaly. Retrospective living donor PV anatomy analysis (n = 20) revealed that 20-mm-long limbs of the first-order PV branches are necessary to make a 10- to l5-mm-long funneled PV stump. This technique of unification venoplasty for an anomalous recipient PV was applied to an adult patient undergoing LDLT with a right liver graft, for which it was shown to be technically feasible and effective.

CONCLUSIONS

A simplified unification venoplasty technique was developed to cope with a recipient PV anomaly in adult LDLT.

Successful experiences of ABO-incompatible adult living donor liver transplantation in a single institute: no immunological failure in 10 consecutive cases

ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) is a feasible therapeutic option for countries with a scarcity of deceased donors. This report presents our initial experiences in ABOi ALDLT in 10 patients between December 2008 and September 2009. The mean age of recipients was 48.5 ± 5.7 years (range, 40-54 years). The mean Model for End-stage Liver-Disease score was 13.9 ± 4.0 (range, 9-22). All patients were administered preoperative rituximab once and plasma exchanges according to the hemagglutinin titer. The spleen was preserved in all cases. For local infusion therapy, hepatic arterial infusion was performed in 9 patients and portal vein infusion in 1 subject. The 10 patients experienced no in-hospital mortality. At a mean follow-up period of 31.8 ± 2.9 months (range, 4.1-34.9 months), 1 patient has died (postoperative month 4 due to sepsis following a biliary stricture. The 3-month patient and graft survivals were 100%, and 1- and 2-year survivals, 90.0%. There was no episode of antibody-mediated rejection. The promising results of our initial experience may have been due to the use of preoperative rituximab and the good preoperative conditions of the patients.