Liver Retransplantation for Hepatic Abscess Due to Hepatic Artery Thrombosis: A Case Report

INTRODUCTION

Hepatic artery thrombosis (HAT) is a well-recognized complication of liver transplantation (LT). HAT is an important risk factor for infectious, in particular hepatic abscess, which can cause graft loss and increasing morbidity and mortality.

CASE REPORT

We present a case report of complicated LT in a 52-year-old Caucasian man with primary sclerosing cholangitis. In 2007 the patient was included on the waiting list in Padua for LT. In 2012 the patient underwent percutaneous transhepatic biliary drainage for bile duct stricture, complicated with acute pancreatitis. A diagnostic laparoscopy was performed with choledochotomy and Kehr's T tube drainage. On February 14, 2012, the patient underwent LT with arterial reconstruction and choledochojejunostomy. The postoperative course was complicated with HAT, multiple liver abscesses, and sepsis associated with bacteremia due to Enterococcus faecium despite massive intravenous antibiotic therapy and percutaneous drainages. On November 28, 2012, the patient underwent retransplantation. Four years after transplantation the patient is still in good general condition.

CONCLUSION

Hepatic abscess formation secondary to HAT following LT is a major complication associated with important morbidity and mortality. In selected cases retransplantation should be considered as our case demonstrates.

Use of grafts from anti-HBc-positive donors in liver transplantation: a 5-year, single-center experience

INTRODUCTION

Liver transplantation (OLT) is the treatment of choice for advanced hepatic disease. The growing gap between waiting list patients and the number of donations has led to acceptance of less than optimal donors. The aim of this study was to evaluate the 5-year experience with anti hepatitis B core antigen (HBc)-positive liver donors.

PATIENTS AND METHODS

All recipients of anti-HBc-positive grafts from January 2005 to December 2010 were evaluated annually after OLT for liver disease etiology, Model for End-Stage Liver Disease (MELD) score, and the presence of hepatocellular carcinoma (HCC) liver biopsy histology and serology for hepatitis B virus (HBsAg, anti-HBs, HBV-DNA), hepatitis C virus, and hepatitis D virus as well as antiviral prophylaxis to prevent de novo HBV.

RESULTS

Among the 249 OLT performed from January 2005 to December 2010, (9.3%) cases used grafts from anti-HBc-positive donors. Etiologics of liver disease among the recipients were HBV (n = 13; 32.5%), HCV (n = 13; 32.5%) or other causes (n = 14; 35%). In 20 of the 40 patients (50%), HCC was found in the explanted organ. Of 40 recipients of anti-HBc-positive grafts 11 died, and 7 (17.5%) required retransplantation. Various regimens were employed as post-transplantation antiviral prophylaxis: (l) Immune globulin (25.8%); (2) Oral antiviral drugs (9.7%); and (3) combined prophylaxis (51.6%) or no treatment (12.9%). No difference was observed in patient or graft survival in relation to the etiology of liver disease, the MELD score, or the presence of HCC at the time of OLT, except graft survival was significantly reduced among recipient who underwent transplantation for non-HBV or non-HCV liver diseases compared with those engrafted due to viral hepatitis (P = .0062). No difference was observed in histologic features (grading and staging) compared with the antiviral prophylactic therapy; the 2 patients (5%) who developed de novo HBV had not received prophylaxis after OLT.

CONCLUSIONS

Matching anti-HBc-positive grafts to recipients without HBV infection before OLT, may be especially safe.

Use of grafts from anti-HBc-positive donors in liver transplantation: a 5-year, single-center experience

INTRODUCTION

Liver transplantation (OLT) is the treatment of choice for advanced hepatic disease. The growing gap between waiting list patients and the number of donations has led to acceptance of less than optimal donors. The aim of this study was to evaluate the 5-year experience with anti hepatitis B core antigen (HBc)-positive liver donors.

PATIENTS AND METHODS

All recipients of anti-HBc-positive grafts from January 2005 to December 2010 were evaluated annually after OLT for liver disease etiology, Model for End-Stage Liver Disease (MELD) score, and the presence of hepatocellular carcinoma (HCC) liver biopsy histology and serology for hepatitis B virus (HBsAg, anti-HBs, HBV-DNA), hepatitis C virus, and hepatitis D virus as well as antiviral prophylaxis to prevent de novo HBV.

RESULTS

Among the 249 OLT performed from January 2005 to December 2010, (9.3%) cases used grafts from anti-HBc-positive donors. Etiologics of liver disease among the recipients were HBV (n = 13; 32.5%), HCV (n = 13; 32.5%) or other causes (n = 14; 35%). In 20 of the 40 patients (50%), HCC was found in the explanted organ. Of 40 recipients of anti-HBc-positive grafts 11 died, and 7 (17.5%) required retransplantation. Various regimens were employed as post-transplantation antiviral prophylaxis: (l) Immune globulin (25.8%); (2) Oral antiviral drugs (9.7%); and (3) combined prophylaxis (51.6%) or no treatment (12.9%). No difference was observed in patient or graft survival in relation to the etiology of liver disease, the MELD score, or the presence of HCC at the time of OLT, except graft survival was significantly reduced among recipient who underwent transplantation for non-HBV or non-HCV liver diseases compared with those engrafted due to viral hepatitis (P = .0062). No difference was observed in histologic features (grading and staging) compared with the antiviral prophylactic therapy; the 2 patients (5%) who developed de novo HBV had not received prophylaxis after OLT.

CONCLUSIONS

Matching anti-HBc-positive grafts to recipients without HBV infection before OLT, may be especially safe.

European consensus on the histopathology of inflammatory bowel disease

The histologic examination of endoscopic biopsies or resection specimens remains a key step in the work-up of affected inflammatory bowel disease (IBD) patients and can be used for diagnosis and differential diagnosis, particularly in the differentiation of UC from CD and other non-IBD related colitides. The introduction of new treatment strategies in inflammatory bowel disease (IBD) interfering with the patients' immune system may result in mucosal healing, making the pathologists aware of the impact of treatment upon diagnostic features. The European Crohn's and Colitis Organisation (ECCO) and the European Society of Pathology (ESP) jointly elaborated a consensus to establish standards for histopathology diagnosis in IBD. The consensus endeavors to address: (i) procedures required for a proper diagnosis, (ii) features which can be used for the analysis of endoscopic biopsies, (iii) features which can be used for the analysis of surgical samples, (iv) criteria for diagnosis and differential diagnosis, and (v) special situations including those inherent to therapy. Questions that were addressed include: how many features should be present for a firm diagnosis? What is the role of histology in patient management, including search for dysplasia? Which features if any, can be used for assessment of disease activity? The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas.

Telomerase is an independent prognostic marker of overall survival in patients with colorectal cancer

Background:

Colorectal cancer (CRC) is an important cause of cancer-related death. Prediction of recurrence is an important issue in the treatment of disease, particularly for stage II patients. The level of telomere-specific reverse transcriptase (hTERT), the catalytic component of the telomerase complex, increases along with CRC progression, but its prognostic value is still unclear.

Methods:

One hundred and thirty-seven CRC patients were studied for hTERT expression in tumour cells by real-time PCR. hTERT level was evaluated as a prognostic factor of overall survival (OS) in all patients and of disease recurrence in a subgroup of 50 stage II patients.

Results:

The median hTERT level was 93.8 copies (interquartile range 48–254). Patients with high hTERT levels (above the median) showed a significantly worse survival than those with low hTERT levels (below the median; log-rank test P<0.0001; hazard ratio (HR)=3.30 (95% confidence interval (CI) 1.98–5.52); P<0.0001). The negative prognostic value of high hTERT level is independent of the pathological stage and microsatellite instability (HR=2.09 (95% CI 1.20–3.64), P=0.009). Moreover, in stage II CRC, high hTERT levels identified patients with a higher risk of disease recurrence (HR=3.06 (95% CI 1.03–9.04), P=0.043) and death (HR=3.24 (95% CI 1.37–7.71), P=0.008).

Conclusion:

hTERT level is an independent prognostic marker of OS in CRC patients. In addition, assessment of hTERT level could improve stratification of stage II CRC patients for the risk of disease recurrence.

Microwave thermal ablation for hepatocarcinoma: six liver transplantation cases

Surgical resection for malignant hepatic tumors, especially hepatocarcinoma (HCC), has been demonstrated to increase overall survival; however, the majority of patients are not suitable for resection. Radiofrequency ablation (RFA) is the most widely used modality for radical treatment of small HCC (<3 cm). It improves 5-year survival compared with standard chemotherapy and chemical ablation, allowing down-staging of unresectable hepatic masses. Microwave ablation (MWA) has been extensively applied in Asia and was recently introduced in the United States of America and Europe with excellent results, especially with regard to large unresectable HCC. Our single-center experience between May 2009 and October 2010 included application of MWA to 154 patients of median age ± standard deviation of 63.5 ± 8.5 years, 6 males, and 1 female, of mean Model for End-Stage Liver Disease (MELD) score (10.1 ± 3.8). The HCC included, hepatitis C virus (HCV)-related (n=70; 45.5%); alcool (ETOH)-related (n=42; 27%), hepatitis B virus (HBV)-related (n=16; 10.5%); and cryptogenic cases (n=26; 17%). The cases were performed for radical treatment down-staging for multifocal pathology or bridging liver transplantation to orthotopic (OLT) in selected patients with single nodules. A computed tomography (CT) scan was performed at 1 month after the surgical procedure to evalue responses to treatment. Among 6 selected patients who underwent OLT; 5 (83.3%) showed disease-free survival at one-year follow-up. The radical treatment achieved no intraoperative evidence of tumor spread or of pathological signs of active HCC among the explanted liver specimens. In conclusion, a MWA seemed to be a safe novel approach to treat HCC and could serve as a "bridge" to OLT and down-staging for patients with HCC.

Cell-free circulating DNA as a promising marker of colorectal cancer detection and progression

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Background: Since the pathologic stage is the most powerful prognostic factor for colorectal cancer (CRC), there is a strong need of non-invasive methods for early detection. Cell-free circulating DNA (cfDNA) released from cancer cells varies in size. It has been suggested that cfDNA (ALU repeats of 115 bp, representative of total DNA; ALU repeats of 247 DNA, representative of tumor DNA) may be associated with presence of tumor. Aim of this study was then to investigate whether the cfDNA may have a role as marker of CRC detection and progression. Methods: cfDNA was extracted from plasma samples from 136 patients with primary CRC at different stages [median age 64 yrs; male/female 78/58; stages I-II, 61; stages III-IV, 75], and from 24 patients with adenomas [median age 67 yrs; male/female 17/7)] and from 55 clean-colon healthy subjects [median age 56 yrs; male/female 13/43). cfDNA was assessed by quantitative real-time PCR (qPCR) of ALU repeats with 2 sets of primers (115 and 247 bp) amplifying different lengths of DNA. The levels of cfDNA (ALU-115, ALU-247) of CRC patients (stages I-II and stages III-IV) were compared with those of healthy subjects and patients with adenoma. Results: The median concentrations of total cfDNA (ALU115) in the plasma samples from patients with stages III-IV and stages I-II CRC, adenoma and normal controls were 52,4, 11.9; 1.9, and 1.7 ng/ml, respectively (p<.0001). The corresponding figures for tumor-related cfDNA (ALU247) were 48.8, 4.7, 2.2, and 0.7 ng/ml, respectively. (p<.0001). With a cut-off of 4.86 ng/ml, total DNA (ALU115) showed a sensitivity of 78.52 (95% CI 70.6–85.1) and a specificity of 86.08 (95% CI 76.4–92.8) in distinguishing patients with CRC from non-CRC [AUC: 0.860 (95% CI 0.81–0,90), p-value=.0001]. With a cut-off of 3.04, cfDNA tumor-related (ALU247) showed a sensitivity of 77.94 (95% CI 70.0–84.6) and a specificity of 82.28 (95% CI 72.1–90.0) in distinguishing patients with CRC from non-CRC [AUC: 0.864 (95% CI 0.81–0,91), p-value=.0001]. Conclusions: Both ALU115 and ALU 247 fragments of circulating cfDNA seem promising non-invasive molecular markers of detection and progression of CRC. The findings of the current study require to be confirmed on larger cohorts of patients with CRC and colonic adenoma.

No significant financial relationships to disclose.

Proximal colon cancer in patients aged 51-60 years of age should be tested for microsatellites instability. A comment on the Revised Bethesda Guidelines

PURPOSE

The Bethesda guidelines suggest to perform microsatellite instability (MSI) test in early onset rectal cancer and not in patients>50 years with proximal colon cancer. The aim of the study was to evaluate whether the risk of high MSI (MSI-H) is greater in proximal colon cancer of patients 51-60 years old than in early-onset rectal cancer.

METHODS

Consecutive colorectal cancer (CRC) patients were evaluated. Tumor location, cancer family history, MSI status and histology were recorded. Mutations in MLH1/MSH2 were investigated in MSI-H tumors. Patients were subdivided into groups: group A, proximal colon cancer patients 51-60 years old and groups B, C and D, patients<or=50 years old, with rectal cancer, proximal and distal colon cancer, respectively.

RESULTS

Out of 409 CRC patients evaluated, 48 (12%) showed tumors with MSI-H. No MSI-H tumors were found in distal and rectal tumors of patients at sixth decade of life. Group A included 27 patients, eight (29.7%) MSI-H cancers, four missense mutations in MLH1/MSH2; groups B, C and D included 26, 11 and 11 patients with two (7.7%), two (18%) and two (18%) MSI-H cancers, respectively. One missense mutation on MSH2 in group B, one pathogenetic mutation on MSH1 in group C and one pathogenetic mutation on MSH2 in group D were found. Tumors of group A showed an increased probability to have MSI-H if compared to those of group B (OD=4.907, p=0.043).

CONCLUSIONS

The Bethesda criteria should be broadened to include patients 51-60 years old with proximal colon cancer.

High prevalence of isolated tumour cells in regional lymph nodes from pN0 colorectal cancer

BACKGROUND

The prevalence of isolated tumour cells (ITCs) in regional lymph nodes from colorectal cancer (CRC) is controversial and has never been prospectively assessed in large groups of consecutive patients. pN0 early-relapsing CRC can be explained by lymph node-ITC.

AIM

To assess the prevalence of ITCs in regional lymph nodes from 309 consecutive patients with pN0M0 (pathological (p)-tumour-node-metastasis (TNM) staging system) CRCs.

PATIENTS AND METHODS

ITCs were assessed by immunohistochemistry (MNF116 monoclonal antibody (1:100); Dako, Glostrup, Denmark) in two serial histological sections obtained from 5016 mesenteric lymph nodes from 309 patients with pN0 CRCs (mean number of lymph nodes per patient = 16.2; p-TNM stage 0, n = 25; p-TNM stage I, n = 123; and p-TNM stage II (A+B), n = 161). Tumour histology, vascular cancer invasion and pathological stage were also recorded.

RESULTS

ITCs were detected in the regional lymph nodes of 156 of 309 (50.5%) patients with CRC, mostly in nodes located within 3 cm from the neoplasia. ITC status correlated with (a) tumour p-TNM stage (Pearson's chi(2): p<0; ordered logistic regression: odds ratio (OR) = 4.6; 95% confidence interval (CI) = 2.88 to 7.33; p<0) and (b) pT value (Pearson's chi(2): p = 0; ordered logistic regression: OR = 4.9; 95% CI = 3.1 to 7.7; p<0). By multivariate analysis, including p-TNM stage, vascular invasion and ITC status, both stage (OR = 5.1; 95% CI = 2.9 to 8.9; p<0) and vascular invasion (OR = 4.2; 95% CI = 1.94 to 8.98; p<0) were found to be independent variables associated with ITC+ lymph nodes.

CONCLUSION

More than 50% of pN0-CRC patients have ITCs in the mesenteric lymph nodes. ITC status is significantly correlated with cancer stage and vascular cancer invasion. The clinicopathological effect of ITC remains to be prospectively evaluated.