LIVER TRANSPLANT FOR METASTATIC NEUROENDOCRINE TUMORS: A SINGLE-CENTER REPORT

MELANOMAS, SARCOMAS, AND RENAL METASTASES IN THE LIVER: HOW TO TREAT?

Liver metastases from melanomas, sarcomas, and renal tumors are less frequent. Treatment and prognosis will depend on whether they are isolated or multiple, size and location, the presence or absence of extrahepatic neoplastic disease, age, stage of the initial disease, initial treatments instituted, time of evolution, and clinical condition of the patient. Recently, a high number of oncological therapies including monotherapy or in combination, neoadjuvants or adjuvants, and immuno-oncological treatments have been developed and tested, increasing disease-free time and survival.

INTERNATIONAL NORMALIZED RATIO AND ACTIVATED PARTIAL THROMBOPLASTIN TIME DO NOT PREDICT PLASMA TRANSFUSION IN LIVER TRANSPLANTATION

BACKGROUND

Blood loss during liver transplantation (LT) remains a major concern associated with increased morbidity and reduced patient and graft survival. The high complexity of the procedure associated with the multifaceted origin of the bleeding urges early identification of high-risk patients and proper monitoring of hemostasis disorders in order to improve results. The accuracy of international normalized ratio (INR) and activated partial thromboplastin time (aPTT) to evaluate coagulation status in cirrhotic patients has been doubted.

AIMS

The aim of this study was to investigate the applicability of these coagulation tests to indicate fresh frozen plasma transfusion in LT.

METHODS

This retrospective cohort study analyzed 297 cirrhotic patients submitted to LT. INR and aPTT were measured preoperatively and in each surgical phase. Hemostatic blood components were transfused only for coagulopathy indication. Patients were divided according to intraoperative plasma transfusion into transfused and non-transfused groups. The accuracy of INR and aPTT to predict plasma transfusions was investigated. The alert values of INR and aPTT unassociated with coagulopathy in each phase of surgery were identified.

RESULTS

Multivariate analysis showed that preoperative hematocrit (odds ratio [OR]=0.90, p<0.001), preoperative fibrinogen (OR=0.99, p<0.001), and absence of hepatocellular carcinoma (OR=3.57, p=0.004) were significant predictors of plasma transfusions.

CONCLUSIONS

INR and aPTT demonstrated poor accuracy in predicting plasma transfusions, irrespective of the cutoff adopted, highlighting the need for a more comprehensive approach to guide hemostatic therapy in LT to improve the outcome.

Liver Transplantation for the Cure of Neuroendocrine Liver Metastasis: A Systematic Review with Particular Attention to the Risk Factors of Death and Recurrence

BACKGROUND/OBJECTIVES

Neuroendocrine neoplasms (NEN) are heterogeneous entities. Despite considerable advancement in the field, almost 50% of patients have metastatic disease, when liver transplantation (LT) is one of the possible treatments offering a cure in well-selected patients.

METHODS

The present study aims to systematically review all the literature from 2000 onwards on using LT for patients with NEN-LM, with particular attention to the risk factors of death and recurrence.

RESULTS

LT offers 5-year OS ranging from 52 to 74% and 5-year TFS rates ranging from 39 to 62%, with even better results published from 2009 onwards. The main risk factors for patient deaths are related to unfavorable primary tumor pathology, higher liver involvement, and simultaneous LT and primary resection. Similarly, recurrence is higher related to poor tumor grade and differentiation, and in the case of an older recipient age.

CONCLUSIONS

Applying uniform criteria and a more in-depth understanding of the relevant prognostic factors contribute to a better selection of candidates for curative LT due to NEN metastases. LT for unresectable or liver-restricted NENs has a relevant place in the treatment algorithm and has achieved excellent results in recent decades, but more international efforts are needed to further improve outcomes.

GASTRIC NEUROENDOCRINE TUMOR: WHEN SURGICAL TREATMENT IS INDICATED?

BACKGROUND

Gastric neuroendocrine tumors are a heterogeneous group of neoplasms that produce bioactive substances. Their treatment varies according to staging and classification, using endoscopic techniques, open surgery, chemotherapy, radiotherapy, and drugs analogous to somatostatin.

AIMS

To identify and review cases of gastric neuroendocrine neoplasia submitted to surgical treatment.

METHODS

Review of surgically treated patients from 1983 to 2018.

RESULTS

Fifteen patients were included, predominantly female (73.33%), with a mean age of 55.93 years. The most common symptom was epigastric pain (93.3%), and the mean time of symptom onset was 10.07 months. The preoperative upper digestive endoscopy (UDE) indicated a predominance of cases with 0 to 1 lesion (60%), sizing ≥1.5 cm (40%), located in the gastric antrum (53.33%), with ulceration (60%), and Borrmann III (33.33%) classification. The assessment of the surgical specimen indicated a predominance of invasive neuroendocrine tumors (60%), with angiolymphatic invasion in most cases (80%). Immunohistochemistry for chromogranin A was positive in 60% of cases and for synaptophysin in 66.7%, with a predominant Ki-67 index between 0 and 2%. Metastasis was observed in 20% of patients. The surgical procedure most performed was subtotal gastrectomy with Roux-en-Y reconstruction (53.3%). Tumor recurrence occurred in 20% of cases and a new treatment was required in 26.67%.

CONCLUSIONS

Gastric neuroendocrine tumors have a low incidence in the general population, and surgical treatment is indicated for advanced lesions. The study of its management gains importance in view of the specificities of each case and the need for adequate conduct to prevent recurrences and complications.

AN EXPERIENCE ON LIVING DONOR LIVER TRANSPLANTATION FOR COLORECTAL LIVER METASTASIS IN SOUTH AMERICA: A NEW ERA IN TRANSPLANT ONCOLOGY

BACKGROUND:

Complete surgical resection is the treatment of choice for patients with liver metastases, but in some patients, it is not possible to obtain a complete R0 resection. Moreover, the recurrence rate is up to 75% after three years. After the experience of the Oslo group with cadaveric liver transplant, some centers are starting their experience with liver transplant for colorectal liver metastasis.

AIMS:

To present our initial experience with living donor liver transplant for colorectal liver metastasis.

METHODS:

From 2019 to 2022, four liver transplants were performed in patients with colorectal liver metastases according to the Oslo criteria.

RESULTS:

Four patients underwent living donor liver transplants, male/female ratio was 3:1, mean age 52.5 (42–68 years). All patients were included in Oslo criteria for liver transplant. Two patients had already been submitted to liver resection. The decision for liver transplant occurred after discussion with a multidisciplinary team. Three patients recurred after the procedure and the patient number 3 died after chemotherapy.

CONCLUSIONS:

Living donor liver transplant is a viable treatment option for colorectal liver metastasis in Brazil, due to a shortage of donors.