Correlation of pathological examination with indocyanine green (ICG) intensity gradients: a prospective study in patients with liver tumor

BACKGROUND

Intraoperative indocyanine green (ICG) fluorescence imaging has been shown to be a new and innovative way to illustrate the optimal resection margin in hepatectomy for hepatocellular carcinoma. This study investigated its accuracy in resection margin determination by looking into the correlation of ICG intensity gradients with pathological examination results of resected specimens.

METHODS

This was a prospective, single-center, non-randomized controlled study. Patients who had liver tumors indicating liver resection were recruited. The hypothesis was that the use of intraoperative near-infrared/ICG fluorescence imaging would be a promising guiding tool for removing hepatocellular carcinoma with a better resection margin. Patients were given ICG (0.25 mg/kg) 1 day before operation. Resected specimens were inspected under a fluorescent imaging system. Biopsies were taken from tumors and normal tissue. Color signals obtained from ICG fluorescence imaging were compared with biopsies for analysis.

RESULTS

Twenty-two patients were recruited for study. The median size of their tumors was 2.25 cm. One patient had resection margin involvement. Under ICG fluorescence, the tumors typically lighted up as yellow color, wrapped by a zone of green color. Tumors of 17 patients (77.3%) displayed yellow color and were confirmed malignancy, while tumors of 12 patients (54.5%) displayed green color and were confirmed malignancy. Receiver operating characteristic curve was used to measure the sensitivity and specificity of the green color to look for a clear resection margin. The area under the curve was 85.3% (p = 0.019, 95% confidence interval 0.696-1.000), with a sensitivity of 0.706 and specificity of 1.000.

CONCLUSION

The use of ICG fluorescence can be helpful in determining resection margins. Resection of tumor should include complete resection of the green zone shown in the fluorescence image.

Stage-by-stage analysis of the effect of blood transfusion on survival after curative hepatectomy for hepatocellular carcinoma-a retrospective study

OBJECTIVE

This study is to examine the impact of perioperative (intraoperative/postoperative) blood transfusion on the outcomes of curative hepatectomy for hepatocellular carcinoma. Hepatectomy is a well-established curative treatment for hepatocellular carcinoma, and blood transfusion cannot always be avoided in treating the disease.

METHODS

A retrospective study of patients having curative hepatectomy for hepatocellular carcinoma from January 2010 to December 2019 at a single center was conducted. The patients were stratified by their disease stage. Patients with and without perioperative blood transfusion were matched by propensity-score matching and compared for each disease stage. Univariate and multivariate analyses were performed to identify prognostic factors for overall survival for each stage.

RESULTS

A total of 846 patients were studied. Among them, 125 received perioperative blood transfusion and 720 did not. Patients with blood transfusion had worse disease-free and overall survival. After stratification and matching, the ratios of transfusion to non-transfusion were 33:165 (stage 1), 28:140 (stage 2), and 45:90 (stage 3). Perioperative blood transfusion was associated with a higher incidence of postoperative complications in all three disease stages (p = 0.004/0.006/0.017), and hence longer hospitalization (p < 0.001 in all stages), but had no significant impact on hospital mortality (p = 0.119/0.118/0.723), 90-day mortality (p = 0.259/0.118/0.723), disease-free survival (p = 0.128/0.826/0.511), or overall survival (p = 0.869/0.122/0.122) in any disease stage. Prognostic factors for overall survival included tumor size, tumor number, alpha-fetoprotein level, and postoperative complication of grade ≥ 3A.

CONCLUSION

Perioperative blood transfusion was associated with a higher incidence of complications but had no significant impact on survival after curative hepatectomy for hepatocellular carcinoma.

[Predictive value of aMAP risk score for early recurrence of small hepatocellular carcinoma after microwave ablation]

Objective: To explore the value of the aMAP risk score (age, male, albumin-bilirubin, and platelets) to predict early recurrence within one year after microwave ablation in patients with small hepatocellular carcinoma. Methods: This was a retrospective study that enrolled 142 patients diagnosed with hepatocellular carcinoma who were treated with microwave ablation in the Department of Hepatology Unit of Nanfang Hospital, Southern Medical University from July 2016 to July 2021. The cohort enrolled 121 male and 21 female patients, including 110 patients that were <60 years old. All the patients were followed-up after microwave ablation to evaluate residual tumor and recurrence of tumor by computed tomography or magnetic resonance imaging. The observation indices mainly included general data and imaging data of patients. Using the X-tile tools, patients were divided into two groups: a high aMAP score group and a low aMAP score group. Multivariate Cox regression analysis was conducted for comparison of independent risk factors. Results: Multivariate Cox regression showed that high aMAP score, maximum tumor diameter >20 mm, and high AFP were the independent risk factors of early recurrence (all P<0.05). Kaplan-Meier survival curves showed that the median recurrence-free survival was 25.5 months in the low aMAP score group and 6.1 months in the high aMAP score group (P=0.001). Conclusions: The aMAP score could predict the early recurrence within 1 year of small hepatocellular carcinoma after microwave ablation. Patients with high aMAP score should undergo rigorous postoperative follow-up evaluations..

Sequential transarterial chemoembolisation and stereotactic body radiotherapy followed by immunotherapy as conversion therapy for patients with locally advanced, unresectable hepatocellular carcinoma (START-FIT): a single-arm, phase 2 trial

BACKGROUND

The synergy between locoregional therapies and immune checkpoint inhibitors has not been investigated as conversion therapy for unresectable hepatocellular carcinoma. We aimed to investigate the activity of sequential transarterial chemoembolisation (TACE) and stereotactic body radiotherapy followed by avelumab (an anti-PD-L1 drug) for locally advanced, unresectable hepatocellular carcinoma.

METHODS

START-FIT was a single-arm, phase 2 trial in patients with locally advanced hepatocellular carcinoma who were not suitable for curative treatment, conducted in two hospitals in Hong Kong and one in Shenzhen, China. Eligible patients were those aged 18 years or older with an Eastern Cooperative Oncology Group performance status 0-1, Child-Pugh liver function score A5 to B7, tumour size of at least 5 cm, a maximum of three tumour lesions, and adequate hepatic, renal, and bone marrow function. Participants received TACE on day 1, followed by stereotactic body radiotherapy (27·5-40·0 Gy in five fractions) at day 28. Avelumab (10 mg/kg) was administered 14 days following stereotactic body radiotherapy and every 2 weeks thereafter. The primary endpoint was the proportion of patients deemed amenable to curative treatment, defined as those who had a sustained complete or partial treatment response for at least 2 months and if curative treatment could be performed (ie, resection, radiofrequency ablation, or transplantation), analysed by intention to treat. Safety was also analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov (NCT03817736) and has been completed.

FINDINGS

Between March 18, 2019, and Jan 27, 2021, 33 patients (32 [97%] men and one [3%] woman) were enrolled. The median sum of the largest diameters of lesions was 15·1 cm (IQR 8·3-14·9). 21 (64%) patients had macrovascular invasion (hepatic vein [n=13], branched portal vein [n=3], or both [n=5]). Median follow-up was 17·2 months (IQR 7·8-25·8). 18 (55%) patients were deemed amenable to curative treatment: four (12%) of 33 patients had curative treatment (resection [n=2] or radiofrequency ablation [n=2]), and 14 (42%) had a radiological complete response and opted for close surveillance. 11 (33%) of 33 patients had treatment-related adverse events that were grade 3 or worse. The most common treatment-related grade 3 or worse adverse event was transient increase in alanine aminotransferase or aspartate aminotransferase (five [15%]) after TACE. Five (15%) patients developed immune-related adverse events of grade 3 or worse (three had hepatitis, two had dermatitis).

INTERPRETATION

To our knowledge, this is the first prospective trial using the combination of immunotherapy and locoregional treatment as conversion therapy for locally advanced unresectable hepatocellular carcinoma, with promising results. Future randomised trials with larger cohorts of patients are warranted.

FUNDING

Merck.

Defining the surgical management for non-colorectal liver metastases

BACKGROUND

Surgical resection is indicated for resectable colorectal liver metastases (CLM), but it is controversial for non-colorectal liver metastases (NCLM). This study aimed to compare survival outcomes of patients with resection of NCLM versus CLM and to identify prognostic factors for resection of NCLM.

METHODS

Consecutive patients who underwent surgical resection of liver metastases at Queen Mary Hospital, Hong Kong from January 1989 to December 2019 were retrospectively reviewed. Patients with resected NCLM were compared to those with CLM. Overall and recurrence-free survival were determined. Subgroup analyses with patients grouped according to the year of liver resection, from 1989 to 2004 and from 2005 to 2019, were conducted. Univariate and multivariate analyses were performed to identify prognostic factors.

RESULTS

Among 674 patients included, 151 (22.4%) had NCLM while 523 (77.6%) had CLM. There were no statistically significant differences in median overall survival (65.2 vs 43.6 months, p = 0.555) and recurrence-free survival (12.5 vs 11.7 months, p = 0.425). The 1-year, 3-year, 5-year and 10-year overall survival rates were 89.8% vs 91.5%, 59.4% vs 58.8%, 50.6% vs 38.7% and 34.1% vs 26.3% in NCLM and CLM groups, respectively. Subgroup analyses demonstrated no statistically significant difference in overall survival between resection of NCLM versus CLM in both time intervals. In the NCLM group, better overall survival was found in liver metastasis of gastrointestinal stromal tumour (GIST) origin (hazard ratio (HR) 0.138, p = 0.003) and with a longer time interval from resection of primary tumour to resection of NCLM (HR 0.982, p = 0.042). Poor prognostic factors were presence of blood transfusion (HR 5.588, p = 0.013) and post-operative complications of Clavien-Dindo Grade IIIa or above (HR 74.853, p = 0.003).

CONCLUSIONS

Surgical resection of NCLM had comparable survival outcomes with CLM. With appropriate patient selection, the indication of liver resection could be expanded to NCLM.

[Research advances of metabolomics in early diagnosis of hepatocellular carcinoma]

Primary liver cancer is the second leading cause of death from malignant tumors in China, and hepatocellular carcinoma (HCC) is the main type. The disease stage at the time of HCC diagnosis largely determines the efficacy of subsequent treatment. Due to the HCC screening among high-risk population has not yet popularized, and the current diagnose method of early HCC is not satisfactory, the early HCC diagnosis rate is less than 30% in China. Metabolomics research emerging in recent years has promoted the research progress of HCC in many fields, such as elaborating the mechanism of occurrence and development, early prevention and diagnosis, exploring drug treatment targets. At the same time, a large number of serum metabolites with excellent sensitivity and specificity were discovered, which made up for the deficiency of traditional serological indicators and helped the early screening and early diagnosis of HCC. This review will summarize the studies on serum metabolomic markers of HCC in recent 5 years, explore the role of metabolomics in the early prediction and diagnosis of HCC and its application prospect.

[Multi-omics research contributes to early screening, diagnosis and treatment of liver cancer]

In 2016, the World Health Organization set an ambitious goal of reducing viral hepatitis-related deaths by 65% by 2030. The key to this goal is to reduce viral hepatitis-related HCC deaths. Liver cancer is the fourth most common malignant tumor and the second leading cause of cancer death in China. The onset of HCC is insidious, and most patients are already in the middle and late stage when diagnosed. Despite the great progress on management of HCC, the therapeutic effect and prognosis of HCC are still unsatisfactory. Therefore, multi-dimensional and comprehensive analysis of the mechanism of liver cancer, improving the early screening, diagnosis and treatment rate of liver cancer are the key points of reducing the harm of liver cancer in China. In recent years, multi-omics studies have been widely applied in the field of liver cancer, providing a basis for the pathogenesis of liver cancer, early detection and diagnosis, development of individual treatment strategies and prognosis assessment. This issue will focus on the application of genomics, proteomics, metabolomics and imaging omics in early screening, diagnosis and treatment of liver cancer.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma

BACKGROUND

The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown.

METHODS

A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center.

RESULTS

Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p < 0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p = 0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p = 0.50) and blood loss (0.2 vs. 0.2L, p = 0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p = 0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p = 0.003).

CONCLUSIONS

3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Impact of Time to Recurrence on Survival Outcome of Salvage Liver Transplantation

BACKGROUND

Salvage liver transplantation (SLT) is the ideal treatment for patients with recurrent hepatocellular carcinoma (HCC) and liver cirrhosis. The optimal timing for offering SLT was controversial. This study aimed at investigating the impact of time to recurrence and other prognostic factors on survival outcome after SLT.

METHODS

Between May 2000 and April 2019, patients who had undergone hepatectomy or ablation for HCC and later received SLT in Queen Mary Hospital were included. Clinico-pathological data during primary treatment and SLT were retrospectively reviewed. Kaplan-Meier analysis and log-rank test were used to determine overall and disease-free survival after SLT. Prognostic factors affecting overall and disease-free survival were determined by multivariate analysis using Cox regression analysis. P-value of less than 0.05 was considered statistically significant.

RESULTS

Fifty-three patients were identified within the specified period including 22 patients in early recurrence group (ER group, time to recurrence within 1 year) and 31 patients in late recurrence group (LR group, time to recurrence more than 1 year). The 1-, 5-, and 10-year overall survival after primary treatment was 100%, 76.6%, and 61.1% in the ER group and 100%, 90%, and 76.4% in the LR group (p = 0.59). There were no statistical differences in overall survival (p = 0.84) and disease-free survival (p = 0.85) after SLT between ER and LR group. Pre-transplant alpha-fetoprotein >  = 400 ng/mL (p = 0.007) and macrovascular invasion in explant (p = 0.002) were independent risk factors for shorter overall survival after primary treatment.

CONCLUSION

Time to recurrence after primary treatment of HCC did not affect survival outcome after SLT. With careful patient selection, SLT could be offered to patient with early or late tumor recurrence.

Routine use of ICG to enhance operative safety in emergency laparoscopic cholecystectomy: a randomized controlled trial

OBJECTIVE

To test the hypothesis that ICG fluorescence cholangiography (ICG-FC) helps to identify critical structures during laparoscopic cholecystectomy (LC) and hence reduce biliary injuries and conversions. In LC, biliary injury and conversion often happen if the biliary anatomy is misidentified.

METHODS

This was a single-center randomized controlled trial from 2017 to 2019. Patients with acute cholecystitis requiring LC were assessed for eligibility for the trial. Patients in the trial were randomized to undergo either conventional LC (conventional arm) or LC with ICG-FC (ICG arm). Conversion rate and biliary injury incidence were outcome measures.

RESULTS

Totally 92 patients participated (46 patients in each arm). The median age was 61 years in both arms (p = 0.472). The conventional arm had 22 men and 24 women; the ICG arm had 24 men and 22 women (p = 0.677). The two arms were comparable in all perioperative parameters. The time from ICG injection to surgery was 67 (16-1150) min. Both arms had an 8.7% conversion rate (p = 1.000). The median operative time was 140.5 min in the conventional arm and 149.5 min in the ICG arm (p = 0.086). The complication rate was 15.2% in the former and 10.9% in the latter (p = 0.536), and both had a 2.2% bile leakage rate. The median hospital stay was 3.5d in the former and 4.0d in the latter (p = 0.380).

CONCLUSION

ICG-FC did not make any difference in conversion or complication rate. Its routine use in LC is questionable. However, it may be helpful in difficult cholecystectomies and may be used as an adjunct.

TRIAL REGISTRATION

The trial was registered with the Institutional Review Board of University of Hong Kong/Hospital Authority Hong Kong West Cluster ( http://www.med.hku.hk/en/research/ethics-and-integrity/human-ethics ). Registration number: UW17-492.

Verifying the Benefits of Radical Treatment in Posttransplant Hepatocellular Carcinoma Oligo-recurrence: A Propensity Score Analysis

This study verified whether radical treatment for hepatocellular carcinoma (HCC) oligo-recurrence after liver transplantation conveys survival benefits. A retrospective study of 144 patients with posttransplant HCC recurrence was performed. Propensity score matching was performed to adjust for baseline covariates between patients who received radical and palliative treatments. The primary endpoint was postrecurrence survival. A total of 50 patients (35%) received radical treatment for recurrence, and 76 (53%) and 18 (13%) patients received palliative and supportive treatments, respectively. Compared with the radical group, patients who received palliative treatment had more early recurrences (time from transplant 17 versus 11 months; P = 0.01) and more extensive disease in terms of tumor numbers (1 versus 4; P < 0.001), size of largest tumor (1.8 versus 2.5 cm; P = 0.046), numbers of involved organs (interquartile range [IQR], 1-1 versus 1-2; P = 0.02), and alpha-fetoprotein (AFP) level (7 versus 40 ng/mL; P = 0.01). Multivariate Cox regression analysis revealed that early recurrence (time from transplant hazard ratio [HR], 1.02; 95% confidence interval [CI], 1.01-1.03; P = 0.001), larger recurrent tumor (HR, 1.12; 95% CI, 1.03-1.23; P = 0.01), liver recurrence (HR, 1.84; 95% CI, 1.17-2.90; P = 0.01), and log₁₀ AFP level at recurrence (HR, 1.27; 95% CI, 1.07-1.52; P = 0.01) predicted poor survival. Mammalian target of rapamycin inhibitor (HR, 0.331; 95% CI, 0.213-0.548; P < 0.001) and radical treatment (HR, 0.342; 95% CI, 0.213-0.548; P < 0.001) were associated with improved survival. After 2-to-1 propensity score matching for covariates, the 50 patients who received curative treatment survived significantly longer than the 25 matched patients who received palliative treatment (median survival time, 30.9 ± 2.4 versus 19.5 ± 3.0 months; P = 0.01). Radical treatment conveys survival benefits to HCC oligo-recurrence after liver transplantation.

Alpha-Fetoprotein in Predicting Survival of Patients with Ruptured Hepatocellular Carcinoma after Resection

Background/Aim: Alpha-fetoprotein (AFP) had been used as a prognostic factor in hepatocellular carcinoma but it was unknown what level of AFP could predict the survival of patients with ruptured hepatocellular carcinoma (rHCC) after resection. This retrospective study was to identify the best cutoff value of AFP for this prediction.Methods: Data of patients having hepatectomy for rHCC from 1989 to 2015 were reviewed. The receiver operating characteristic curve and Youden's index were used to identify the cutoff value of AFP affecting survival. The patients were then divided into two groups by the cutoff for comparison.Results: Totally 114 patients were included. An AFP level of 256 ng/ml was found to affect survival (area under curve 63.1%, 95% confidence interval 0.514-0.748, p = 0.027; sensitivity 0.6, specificity 0.706). The 114 patients were divided into Group A (AFP < 256 ng/ml, n = 56) and Group B (AFP ≥ 256 ng/ml, n = 58). The median AFP level was 13.0 ng/ml (range, 2-253 ng/ml) in Group A and 11206.5 ng/ml (range, 259-481,000 ng/ml) in Group B (p < 0.001). Group A had a larger proportion of patients receiving transarterial embolization at the time of rupture, and the time to hepatectomy was longer in this group. Patients in Group B had more blood loss, more complications, larger tumors, and more cases of macrovascular/microvascular invasion. Overall survival (p = 0.013) and disease-free survival (p = 0.024) were significantly better in Group A. On multivariate analysis, AFP ≥ 256 ng/ml was an independent risk factor for overall survival.Conclusion: AFP ≥ 256 ng/ml had an adverse impact on the survival of patients with rHCC after resection.

Adjuvant transarterial chemotherapy for margin-positive resection of hepatocellular carcinoma-a propensity score matched analysis

BACKGROUND AND AIMS

Hepatectomy is a well-established curative treatment for hepatocellular carcinoma. However, the role of adjuvant therapy is controversial. This study examines the efficacy of adjuvant transarterial chemotherapy for hepatocellular carcinoma.

METHODS

The data of hepatocellular carcinoma patients undergoing curative hepatectomy was reviewed. Those with adjuvant transarterial chemotherapy were matched with those without using propensity score analysis, by tumour size and number, indocyanine green retention rate, disease staging and Child-Pugh grading. The groups were compared.

RESULTS

Eighty-seven patients with hepatocellular carcinoma who underwent hepatectomy received adjuvant transarterial chemotherapy (TAC group), and were matched with 870 patients who did not (no-TAC group). The groups were largely comparable in patient and disease characteristics, but the TAC group experienced more blood loss, higher transfusion rates, narrower margins and more positive margins. The two groups were found to be comparable in disease-free and overall survival rates. In margin-positive patients, those given TAC survived longer than those without, and margin-positive patients in the TAC group had overall survival rates similar to margin-negative patients in the no-TAC group.

CONCLUSIONS

Margin involvement is an adverse factor for survival in HCC. Adjuvant transarterial chemotherapy may offer survival benefits to hepatocellular carcinoma patients with positive surgical margins.

Role of C11-FDG dual-tracer PET-CT scan in metastatic screening of hepatocellular carcinoma-a cost-effectiveness analysis

Background

We aimed to identify predictive factors for positron emission tomography (PET)-detected hepatocellular carcinoma (HCC) metastasis and a cost-effective approach to preoperative PET-computed tomography (CT) for detecting metastasis.

Methods

Clinicopathological and survival data of HCC patients having PET-CT with 18F-fludeoxyglucose (FDG) and 11C-acetate (ACT) following contrast-enhanced CT/magnetic resonance imaging (MRI) for preoperative tumor staging were reviewed. Binary logistic regression was performed to identify predictive factors for PET-detected metastasis. A cost-benefit analysis model was built for the incurred costs and the impact of PET-CT findings on treatment strategy was studied.

Results

Totally 152 patients were analyzed. Dual-tracer PET-CT detected metastasis in 17 patients (11%). By multivariate analysis, alpha-fetoprotein (AFP) ≥400 ng/mL [relative risk (RR): 4.30, 95% confidence interval (CI): 1.41-13.15, P=0.011] and bilobar disease (RR: 3.94, 95% CI: 1.24-12.52, P=0.014) were independent predictive factors for PET-detected metastasis. PET-CT findings altered the treatment strategy for 12 patients (7.9%); three partial hepatectomies, eight episodes of transarterial chemoembolization (TACE) and one episode of ablation were avoided, with an estimated cost-saving of US $91,000, $150,000 and $10,600 respectively. Had the PET-CT been performed only for patients with AFP ≥400 ng/mL or bilobar disease (n=74), metastasis would have been confirmed in 14 patients (18.9%), and the cost-saving per patient was estimated at US $1,070.

Conclusions

Dual-tracer PET-CT is cost-effective and useful for preoperative HCC staging in patients with AFP ≥400 ng/mL or bilobar disease. Its routine use in preoperative workup for all HCC patients is not recommended. Unilobar disease with AFP <400 ng/mL can achieve good negative predictive value for PET-detected metastasis. Screening patients with either factor can avoid unnecessary procedures and is thus cost-effective for preoperative HCC workup.

Liver transplantation: would it be the best and last chance of cure for hepatocellular carcinoma with major venous invasion?

Background

Hepatocellular carcinoma (HCC) with portal vein tumour thrombus (PVTT) signifies advanced disease, whether LT confers any survival superiority over resection remains uncertain.

Methods

A propensity score matched (PSM) analysis of liver transplantation (LT) and liver resection (LR) for HCC with PVTT was performed.

Results

A consecutive series of 88 patients who received either LT (10 DDLTs and 3 LDLTs) or LR (n=75) respectively were recruited. Before PSM, the LT group has a higher MELD score (17.3 vs. 7.8, P<0.001), lower serum AFP levels (96 vs. 2,164 ng/mL, P=0.017) and smaller tumour size (4 vs. 10 cm, P<0.001). The 5-year overall survival for LT and LR were 55.4% and 15.9% respectively (P=0.007). After matching for serum AFP levels and tumour size, 1-, 3- and 5-year overall survival for LT were 81 ng/mL, 3.9 cm, 80%, 70% and 70% and the corresponding rates for LR were 1,417 ng/mL, 5.3 cm, 51.8%, 19,6% and 9.8% (P value =0.12, 0.27 and 0.009 respectively).

Conclusions

LT is associated with significantly better oncological outcomes in HCC patients with PVTT involving the lobar or segmental level. A modest expansion of selection criteria to include small HCC with segmental PVTT should be considered.

Critical appraisal of TNM versus HKU staging system for postoperative prognostic evaluation of hepatocellular carcinoma

Background

The 8^th edition of the American Joint Committee on Cancer tumor-node-metastasis staging system (AJCC 8^th) has been launched with modifications in T staging. The University of Hong Kong liver cancer staging system (HKUSS) has been proven to better categorize hepatocellular carcinoma (HCC) into different T stages. This study aimed to compare the two systems’ predictive ability for HCC recurrence after primary surgical resection.

Methods

Patients who had primary, curative resection for HCC between 1989 and 2017 were reviewed. The Kaplan-Meier plot was used to estimate disease-free survival (DFS), and the log-rank test was used for survival comparison between subgroups. The two systems’ prediction of recurrence was evaluated by the Cox regression model.

Results

Totally 1,815 patients were included. With AJCC 8^th, the 5-year DFS was 58.9% for T1a, 52.3% for T1b, 30% for T2, 16.9% for T3, and 14.4% for T4. No survival difference was demonstrated between T1a and T1b (P=0.668) or between T3 and T4 (P=0.562). With HKUSS, the 5-year DFS was 57.7% for T1, 43.4% for T2, 28.9% for T3, and 15.7% for T4. The T staging in HKUSS showed significant survival differences (T1 vs. T2, T2 vs. T3, and T3 vs. T4; P<0.001). Using receiver operating characteristic curves to show the recurrence status in the two systems, HKUSS had the largest area under curve (AUC) (HKUSS: AUC =0.655, SE 0.014, P<0.001, 95% CI, 0.628–0.681; AJCC 8^th: AUC =0.652, SE 0.013, P<0.001, 95% CI, 0.625–0.677).

Conclusions

HKUSS showed better categorization of HCC. In the context of primary surgical resection, HKUSS may be more appropriate for stratification of patients with HCC with various T stages, and thus the choice of staging system when primary surgical resection is considered for patients of HCC.

[The roles of two HIV self-testing models in promoting HIV-testing among men who have sex with men]

Objective: To evaluate the roles between two different HIV self-testing models in promoting HIV-testing among men who have sex with men (MSM). Methods: This paper focuses on two HIV self-testing service models. The first; is the online self-testing model (HIV self-testing conventional model) with the sexual health promotion network platform. The other one is an innovative HIV self-testing model (secondary distribution model), based on the previous program. The two different self-testing models, including the number of indexes and alters, the positive rate, and the demographics of indexes and alters, are compared. The influence of volunteers with or without leadership on the number of HIV self-test kits distributed or self-use is analyzed through the leadership survey scale. Results: The return rates of HIV self-testing results in the two models are 94.7%(323/341) and 99.2%(1 141/1 150), respectively, within 30 days. The proportion of alters in the secondary distribution is significantly higher (45.9%,281/612) than the conventional HIV self-testing (6.3%,20/318). In the secondary distribution model, the difference between the number of indexes and alters indicators including age, marital status, residence, sex orientation, anal sex with men in the past six months, and HIV test are statistically significant (χ² test, all P<0.05). The opinion leader of MSM has significantly impacted the promotion of HIV self-testing (P<0.05). Conclusions: Both models can promote HIV self-testing, result return, and HIV positive detection among MSM. In terms of expanding the testing and detection of HIV positive, the secondary distribution mode shows more obvious advantages, which significantly promotes a large number of MSM who have never been tested for HIV to undergo HIV testing. Influential indexes have a significant effect on increasing the HIV testing rate and promoting HIV testing among MSM.

Defining the optimal bilirubin level before hepatectomy for hilar cholangiocarcinoma

Background

In the management of operable hilar cholangiocarcinoma (HC) patients with hyperbilirubinemia, preoperative biliary drainage is a measure to bring down the bilirubin to a certain level so as to avoid adverse postoperative outcomes that would otherwise result from hyperbilirubinemia. A cutoff value of bilirubin level in this context is needed but has not been agreed upon without controversy. This retrospective study aimed to identify a cutoff of preoperative bilirubin level that would minimize postoperative morbidity and mortality.

Methods

Data of patients having hepatectomy with curative intent for HC were analyzed. Discriminative analysis was performed to identify the preoperative bilirubin level that would make a survival difference. The identified level was used as the cutoff to divide patients into two groups. The groups were compared.

Results

Ninety patients received hepatectomy with curative intent for HC. Their median preoperative bilirubin level was 23 μmol/L. A cutoff preoperative bilirubin level of 75 μmol/L was derived from Youden’s index (sensitivity 0.333; specificity 0.949) and confirmed to be optimal by logistic regression (relative risk 9.250; 95% confidence interval 1.932–44.291; p = 0.005), with mortality shown to be statistically different at 90 days (p = 0.008). Patients were divided into Group A (≤75 μmol/L; n = 82) and Group B (> 75 μmol/L; n = 8). Group B had a higher preoperative bilirubin level (p < 0.001), more intraoperative blood loss (3.12 vs 1.4 L; p = 0.008), transfusion (100% vs 42.0%; p = 0.011) and replacement (2.45 vs 0.0 L; p < 0.001), more postoperative renal complications (p = 0.036), more in-hospital deaths (50% vs 8.5%; p = 0.004), and more 90-day deaths (50% vs 9.8%; p = 0.008). Group A had a longer follow-up period (p = 0.008). The groups were otherwise comparable. Disease-free survival was similar between groups (p = 0.142) but overall survival was better in Group A (5-year, 25.2% vs 0%; p < 0.001). On multivariate analysis, preoperative bilirubin level and intraoperative blood replacement were risk factors for 90-day mortality.

Conclusion

A cutoff value of preoperative bilirubin level of 75 μmol/L is suggested, as the study showed that a preoperative bilirubin level ≤ 75 μmol/L resulted in significantly less blood replacement necessitated by blood loss during operation and significantly better patient survival after surgery.

Pure laparoscopic versus open major hepatectomy for hepatocellular carcinoma with liver F4 cirrhosis without routine Pringle maneuver - A propensity analysis in a single center

BACKGROUND

/Aim: Laparoscopic hepatectomy has been gaining popularity but its evidence in major hepatectomy for cirrhotic liver is lacking. We studied the long-term outcomes of the pure laparoscopic approach versus the open approach in major hepatectomy without Pringle maneuver in patients with hepatocellular carcinoma (HCC) and cirrhosis using the propensity score analysis.

METHODS

We reviewed patients diagnosed with HCC and cirrhosis who underwent major hepatectomy as primary treatment. The outcomes of patients who received the laparoscopic approach were compared with those of propensity-case-matched patients (ratio, 4:1) who received the open approach. The matching was made on the following factors: tumor size, tumor number, age, sex, hepatitis serology, HCC staging, comorbidity, and liver function.

RESULTS

Twenty-four patients underwent pure laparoscopic major hepatectomy for HCC with cirrhosis. Ninety-six patients who underwent open major hepatectomy were matched by propensity scores. The laparoscopic group had less median blood loss (300 ml vs 645 ml, p = 0.001), shorter median hospital stay (6 days vs 10 days, p = 0.002), and lower rates of overall complication (12.5% vs 39.6%, p = 0.012), pulmonary complication (4.2% vs 25%, p = 0.049) and pleural effusion (p = 0.026). The 1-year, 3-year and 5-year overall survival rates in the laparoscopic group vs the open group were 95.2%, 89.6% and 89.6% vs 87.5%, 72.0% and 62.8% (p = 0.211). Correspondingly, the disease-free survival rates were 77.1%, 71.2% and 71.2% vs 75.8%, 52.7% and 45.5% (p = 0.422).

CONCLUSIONS

The two groups had similar long-term survival. The laparoscopic group had favorable short-term outcomes. Laparoscopic major hepatectomy without routine Pringle maneuver for HCC with cirrhosis is a safe treatment option at specialized centers.

Evaluation of Pancreatic Lesions With Endoscopic Ultrasound and Fine Needle Aspiration

Background. Endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) are commonly used for assessing pancreatic lesions. This study aimed to evaluate the diagnostic yield and accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in a single tertiary institution. Methods. Consecutive patients who underwent EUS-FNA of the pancreas at Queen Mary Hospital, Hong Kong, from January 2015 to March 2016 were retrospectively reviewed. Endoscopic findings and FNA results were analysed. For patients who subsequently underwent surgical resection of pancreatic lesion, EUS-FNA diagnoses were compared to histopathological findings of surgical specimens to determine its diagnostic accuracy. Results. One hundred twelve EUS-FNA were performed in 99 patients within the study time period and were included for analysis. Sixty-six (66.7%) pancreatic lesions were solid in nature and 33 (33.3%) were cystic. The overall diagnostic yield of EUS-FNA was 70.5% (n = 79). On multivariate analysis, more passes of needle were associated with a higher diagnostic yield (odds ratio = 2.000, P = .049). 57.1% (n = 64) of EUS-FNA results had an impact on management. Sixteen patients with diagnostic EUS-FNA subsequently underwent surgery for resection of the pancreatic lesion. Upon correlation to the histopathological findings of surgical specimens, there were 12 true-positive, 2 true-negative, 0 false-positive, and 2 false-negative cases. Sensitivity was 85.7%, specificity was 100%, positive predictive value was 100%, and negative predictive value was 50%. The diagnostic accuracy of EUS-FNA was 87.5%. Conclusion. EUS-FNA is accurate and reliable for diagnosing pancreatic lesions.

Vascular resection and reconstruction in hilar cholangiocarcinoma

BACKGROUND

The aggressive approach of vascular resection plus reconstruction in curative resection of hilar cholangiocarcinoma (HC) remains controversial. This retrospective study investigated its short- and long-term outcomes.

METHODS

Data of HC patients from 1989 to 2016 were reviewed. Operated patients were divided into two groups (with and without vascular resection) and compared in terms of perioperative results. Patients who had unresectable HC were also compared with patients who had been operated.

RESULTS

Ninety patients underwent curative HC resection. They were divided into group A (without aggressive approach, n = 68) and group B (with aggressive approach, n = 22). The groups were comparable in all parameters including rates of overall and major complication and in-hospital, 30-day and 90-day mortality except that group B had more patients with more advanced disease (P = 0.008), more patients with tumour invasion of the vasculature (40.9% versus 7.4%, P = 0.001), and fewer patients with blood transfusion (27.3% versus 52.9%, P = 0.036). The groups had similar disease-free survival (group A: median, 17.9 months, 5 years, 27.4%; group B: median, 11.7 months, 5 years, 14.3%; P = 0.427) and overall survival (group A: median, 22.0 months, 5 years, 26.5%; group B: median, 26.5 months, 5 years, 14.7%; P = 0.90). Two hundred patients with unresectable HC were compared with patients who had received operation and found to have worse survival outcomes (P < 0.001).

CONCLUSIONS

Vascular resection plus reconstruction in HC resection was feasible and safe and might improve the long-term survival of patients with advanced HC. This aggressive approach should be adopted if the expertise is available and the patient's condition allows.

[Cost-effectiveness of HIV self-testing strategy in men who have sex with men]

Objective: To analyze the cost-effectiveness and willingness-to-pay of HIV self-testing (HIVST) strategy and facility-based HIV rapid testing (HIV-RDT) strategy in men who have sex with men (MSM) in Zhuhai, and provide scientific evidence for making health policy. Methods: From the perspective of health service providers, the data of the costs and effectiveness of two HIV testing strategies in MSM in Zhuhai during January-September 2019 were collected, and a decision-tree model of cohort of 10 000 MSM was constructed by using software TreeAge Pro 2019 to measure the cost-effectiveness ratio (CER) and the incremental cost-effectiveness ratio (ICER). One-way and probability sensitivity analysis was performed for the uncertainty of the parameters in the model, and the cost-effectiveness and affordability curve was introduced to estimate the affordability of two strategies. Results: After the mobilization of MSM community-based organization through Internet and social media, 2 303 MSM had HIVST, in whom 33 were HIV positive (1.7%), and 816 MSM received HIV-RDT, in whom 35 were HIV positive (4.3%). The cost for per screening was 60.45 yuan and 240.43 yuan (RMB) respectively, and the cost for per positive screening was 4 218 yuan and 5 606 yuan (RMB) rerspectively. The results of the decision-tree model showed that the mean cost for a MSM using HIVST and using HIV-RDT was 44.67 yuan and 148.42 yuan (RMB) respectively, and the ICER was negative. HIVST strategy was a more cost-effective option when the willing-to-pay was below 6 528 yuan (RMB) for per positive screening, and HIV-RDT strategy was a more cost-effective option when the investment was higher than 6 528 yuan (RMB). Conclusion: HIVST strategy in Zhuhai is a public health project with economic value, and policy makers should strengthen the support to MSM community-based organization to promote the application of HIVST among MSM.

Survival analysis of breast cancer liver metastasis treated by hepatectomy: A propensity score analysis for Chinese women in Hong Kong

BACKGROUND

Survival of patients with breast cancer liver metastasis is very poor. This study aimed to analyze the survival outcome of hepatectomy for this patient population.

METHODS

From January 1995 to December 2014, 2522 patients with liver cancer received hepatectomy at our hospital. Twenty-one of them, all female, received the operation for breast cancer liver metastasis. Performance was compared with patients with colorectal liver metastasis treated with hepatectomy after propensity score analysis in a ratio of 1:3.

RESULTS

Twenty-one patients received hepatectomy for breast cancer. After propensity score matching, 63 patients who had hepatectomy for colorectal cancer were selected for comparison. There was no significant difference in immediate or short-term outcomes between the two groups of patients in terms of operative time, blood loss and surgical morbidities. All patients with breast cancer had R0 resection. No hospital death occurred. After hepatectomy, the 1-, 3- and 5-year overall survival rates were 100.0%, 58.9% and 58.9% respectively in patients with breast cancer. The 1-, 3- and 5-year overall survival rates were 95.0%, 57.2% and 39.7% respectively in patients with colorectal cancer (P = 0.572). On multivariate analysis, triple negative status was the only independent poor prognostic factor in breast cancer liver metastasis (OR = 6.411; 95% CI: 1.351-30.435; P = 0.019).

CONCLUSIONS

Hepatectomy is a safe and effective way of treating breast cancer liver metastasis at experienced centers where multidisciplinary adjuvant treatments are available. It can be considered more frequently as part of the multidisciplinary care for this patient population.

Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis

BACKGROUND

Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking.

AIM

To evaluate the impact of small-for-size liver grafts on medium-term and long-term graft survival in adult to adult LDLT.

METHODS

A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted.

RESULTS

This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies.

CONCLUSION

SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.

Impact of small-for-size liver grafts on medium-term and long-term graft survival in living donor liver transplantation: A meta-analysis

BACKGROUND

Small-for-size grafts (SFSGs) in living donor liver transplantation (LDLT) could optimize donor postoperative outcomes and also expand the potential donor pool. Evidence on whether SFSGs would affect medium-term and long-term recipient graft survival is lacking.

AIM

To evaluate the impact of small-for-size liver grafts on medium-term and long-term graft survival in adult to adult LDLT.

METHODS

A systematic review and meta-analysis were performed by searching eligible studies published before January 24, 2019 on PubMed, EMBASE, and Web of Science databases. The primary outcomes were 3-year and 5-year graft survival. Incidence of small-for-size syndrome and short term mortality were also extracted.

RESULTS

This meta-analysis is reported according to the guidelines of the PRISMA 2009 Statement. Seven retrospective observational studies with a total of 1821 LDLT recipients were included in the meta-analysis. SFSG is associated with significantly poorer medium-term graft survival. The pooled odds ratio for 3-year graft survival was 1.58 [95% confidence interval 1.10-2.29, P = 0.014]. On the other hand, pooled results of the studies showed that SFSG had no significant discriminatory effect on 5-year graft survival with an odds ratio of 1.31 (95% confidence interval 0.87-1.97, P = 0.199). Furthermore, incidence of small-for-size syndrome detected in recipients of SFSG ranged from 0-11.4% in the included studies.

CONCLUSION

SFSG is associated with inferior medium-term but not long-term graft survival. Comparable long-term graft survival based on liver graft size shows that smaller grafts could be accepted for LDLT with appropriate flow modulatory measures. Close follow-up for graft function is warranted within 3 years after liver transplantation.

Prognostic value of preoperative alpha-fetoprotein (AFP) level in patients receiving curative hepatectomy- an analysis of 1,182 patients in Hong Kong

Background

The value of alpha-fetoprotein (AFP) as a prognostic indicator in patients with hepatocellular carcinoma (HCC) has been proposed in recent studies, but the evidence so far is still contradictory. This analysis aims to evaluate the prognostic value of preoperative AFP level in patients undergoing curative resection.

Methods

This retrospective study reviewed the prospectively collected data of all patients who underwent initial liver resection for HCC at Queen Mary Hospital during the period from March 1999 to March 2013. Patients with palliative resection, positive margin after pathological examination or distant metastasis were excluded from the study. Survival of patients with AFP level of <20, 20-400 and >400 ng/mL were compared with Kaplan-Meier analysis. Subgroup analysis was performed according to tumour stage (7^th edition UICC staging) and tumour size. The optimal cutoff value was determined by area under receiver operating characteristic curve.

Results

A total of 1,182 patients were included. Best overall (OS) and disease free survival (DFS) was observed in patients with AFP level <20 ng/mL. Progressively worse outcomes were seen for patients with increasing level of AFP. The median OS were 132.9, 77.2 and 38.4 months for patients with AFP <20, 20-400 and >400 ng/mL respectively (P<0.001). The median DFS for these three groups were 55.6, 25 and 8.4 months respectively (P<0.001). There was significant difference in both OS and DFS among all 3 groups. With subgroup analysis according to tumour stage (stage I and II versus stage III and IV) and tumour size (5 cm or less versus larger than 5 cm), such difference was still observed and remained statistically significant. Optimal cutoff value by discriminant analysis was 12,918.3 ng/mL for OS and 9,733.3 ng/mL for DFS.

Conclusions

This study demonstrates that AFP is a significant prognostic indicator in HCC. Despite tumour stage and size, high level of AFP is associated with poorer OS and DFS. Whether the level of AFP should be included in current staging systems, or treatment protocols, is yet to be determined.

Validated model for prediction of recurrent hepatocellular carcinoma after liver transplantation in Asian population

BACKGROUND

Liver transplantation (LT) is regarded as the best treatment for both primary and recurrent hepatocellular carcinoma (HCC). Post-transplant HCC recurrence rate is relatively low but significant, ranging from 10%-30% according to different series. When recurrence happens, it is usually extrahepatic and associated with poor prognosis. A predictive model that allows patient stratification according to recurrence risk can help to individualize post-transplant surveillance protocol and guidance of the use of anti-tumor immunosuppressive agents.

AIM

To develop a scoring system to predict HCC recurrence after LT in an Asian population.

METHODS

Consecutive patients having LT for HCC from 1995 to 2016 at our hospital were recruited. They were randomized into the training set and the validation set in a 60:40 ratio. Multivariable Cox regression model was used to identity factors associated with HCC recurrence. A risk score was assigned to each factor according to the odds ratio. Accuracy of the score was assessed by the area under the receiver operating characteristic curve.

RESULTS

In total, 330 patients were eligible for analysis (183 in training and 147 in validation). Recurrent HCC developed in 14.2% of them. The median follow-up duration was 65.6 mo. The 5-year disease-free and overall survival rates were 78% and 80%, respectively. On multivariate analysis, alpha-fetoprotein > 400 ng/mL [P = 0.012, hazard ratio (HR) 2.92], sum of maximum tumor size and number (P = 0.013, HR 1.15), and salvage LT (P = 0.033, HR 2.08) were found to be independent factors for disease-free survival. A risk score was calculated for each patient with good discriminatory power (c-stat 0.748 and 0.85, respectively, in the training and validation sets). With the derived scores, patients were classified into low- (0–9), moderate- (> 9–14), and high-risk groups (> 14), and the risk of HCC recurrence in the training and validation sets was 10%, 20%, 54% (c-stat 0.67) and 4%, 22%, 62% (c-stat 0.811), accordingly. The risk stratification model was validated with chi-squared goodness-of-fit test (P = 0.425).

CONCLUSION

A validated predictive model featuring alpha-fetoprotein, salvage LT, and the sum of largest tumor diameter and total number of tumor nodule provides simple and reliable guidance for individualizing postoperative surveillance strategy.

Adjuvant chemotherapy improves oncological outcomes of resectable intrahepatic cholangiocarcinoma: A meta-analysis

OBJECTIVE

To define the role of adjuvant chemotherapy in the management of resectable intrahepatic cholangiocarcinoma (ICC) by performing a meta-analysis.

SUMMARY BACKGROUND DATA

Oncological benefit of adjuvant chemotherapy in resectable ICC remains controversial, high-level evidence in such context is lacking.

METHOD

A comprehensive search using Pubmed, EMbase, and Web of Science was performed from inception to October 2018. Studies compared the survival of patients receiving adjuvant chemotherapy versus surgery alone were included. Data were analyzed using random effect model. Quality of each study and presence of publication bias were assessed by Newcastle-Ottawa score (NOS) and funnel plot with Egger test respectively.

RESULTS

The present meta-analysis included 15 studies (all were retrospective series) and 5060 patients. Adjuvant chemotherapy was administered either intravenously or intra-arterially in the form of trans-arterial chemo-embolization (TACE). The average NOS for the included studies was 6.5. Pooled analysis of the included studies demonstrated significant advantage in the adjuvant chemotherapy group (HR 0.66, 0.55-079, P <.001, I-square [I] = 20.8%). After 2 studies were removed for heterogeneity, advantage of adjuvant chemotherapy remained (HR 0.72, 0.62-0.84, P <.001, I = 0%). Funnel plot suggested no significant publication bias (Egger test, 2-tailed P = .203). Subgroup analyses suggested that intravenous route of chemotherapy injection (P <.001) and use of gemcitabine base regimen (P = .004) are associated with improved overall survival. Adjuvant chemotherapy did not improve disease-free survival in subgroup analysis (P = .94).

CONCLUSION

Adjuvant chemotherapy is associated with improved overall survival and should be considered in patients with ICC following curative resection and in particular to patients with advance disease.

Pneumocystis jirovecii-related spontaneous pneumothorax, pneumomediastinum and subcutaneous emphysema in a liver transplant recipient: a case report

BACKGROUND

Pneumocystis pneumonia (PCP) is a common opportunistic infection caused by Pneumocystis jirovecii. Its incidence at 2 years or more after liver transplant (LT) is < 0.1%. PCP-related spontaneous pneumothorax and/or pneumomediastinum is rare in patients without the human immunodeficiency virus, with an incidence of 0.4-4%.

CASE PRESENTATION

A 65-year-old woman who had split-graft deceased-donor LT for primary biliary cirrhosis developed fever, dyspnea and dry coughing at 25 months after transplant. Her immunosuppressants included tacrolimus, mycophenolate mofetil, and prednisolone. PCP infection was confirmed by molecular detection of Pneumocystis jirovecii,in bronchoalveolar lavage. On day-10 trimethoprim-sulphamethoxazole, her chest X-ray showed subcutaneous emphysema bilaterally, right pneumothorax and pneumomediastinum. Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema. She was managed with 7-day right-sided chest drain and a 21-day course of trimethoprim-sulphamethoxazole before discharge.

CONCLUSION

Longer period of PCP prophylaxis should be considered in patients who have a higher risk compared to general LT patients. High index of clinical suspicion, prompt diagnosis and treatment with ongoing patient reassessment to detect and exclude rare, potentially fatal but treatable complications are essential, especially when clinical deterioration has developed.

Anterior Approach to Major Resection for Colorectal Liver Metastasis

PURPOSE

The aim of this study was to examine the merits of the anterior approach, if any, in colorectal liver metastasis (CRLM) resection.

METHODS

Data of patients who underwent partial hepatectomy for CRLM were reviewed. Patients treated by the anterior approach were compared with patients treated by the conventional approach.

RESULTS

Ninety-eight patients had right hepatectomy, extended right hepatectomy, or right trisectionectomy. Among them, 71 patients underwent the conventional approach (CA group) and 27 underwent the anterior approach (AA group). The two groups were comparable in demographic, pathological, and perioperative characteristics except that the AA group had higher levels of aspartate transaminase (median, 41 vs. 31 U/L; p = 0.006) and alanine transaminase (median, 27 vs. 22 U/L; p = 0.009), larger tumors (median, 7 vs. 4 cm; p = 0.000), and more extensive resections (p < 0.001). The median overall survival was 40 months (range, 0.69-168.6 months) in the CA group and 33.7 months (range, 0.95-99.8 months) in the AA group (p = 0.22), and the median disease-free survival was 9.7 months (range, 0.62-168.6 months) in the CA group and 6.2 months (range, 0.72-99.8 months) in the AA group (p = 0.464). Univariate and multivariate analyses identified 4 independent prognostic factors for overall survival: lymph node status of primary tumor (HR 1.352, 95% CI 0.639-2.862, p = 0.034), intraoperative blood loss (HR 1.253, 95% CI 1.039-1.510, p = 0.018), multiple liver tumor nodules (HR 1.775, 95% CI 1.029-3.061, p = 0.039), and microvascular invasion (HR 2.058, 95% CI 1.053-4.024, p = 0.035).

CONCLUSIONS

The two approaches resulted in comparable survival outcomes even though the AA group had larger tumors and more extensive resections. The anterior approach allows better mobilization and easier removal of large tumors once the liver is opened up.

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

BACKGROUND

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones.

METHODS

To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed.

RESULTS

CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8 mm, and 85 patients with cystic duct diameter ≥ 5 mm. The mean time for CBD stone extraction was 25.3 min, with the operative time ranged from 63 to 170 min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5 mm. Estimated blood loss during surgery was 10-120 ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months.

CONCLUSIONS

Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

Diagnostic and Prognostic Role of 18-FDG PET/CT in the Management of Resectable Biliary Tract Cancer

OBJECTIVES

Role of 18-FDG PET/CT had been well established in other more prevalent malignancies such as colorectal and lung cancer; however, this is not as well defined in cholangiocarcinoma. Literature focusing on the prognostic values of preoperative PET/CT for resectable cholangiocarcinoma is scarce.

METHOD

This is a retrospective cohort of 66 consecutive patients who had received curative resection for cholangiocarcinoma from 2010 to 2015. All patients had preoperative 18-FDG PET/CT performed. Accuracy of metastatic lymph node detection of PET/CT and the prognostic value of maximum standard uptake value (SUV-max) was explored.

RESULTS

There were 38 male and 28 female recruited, and the median age was 66. Intrahepatic cholangiocarcinoma (ICC) constituted the majority (59.1%) of the cases, followed by hilar cholangiocarcinoma (22.8%), gallbladder cancer (13.6%) and common bile duct cancer (4.5%). The 3-year disease-free survival (DFS) and overall survival (OS) of the whole population were 27.1 and 39.2%, respectively. The median follow-up duration was 27 months. The accuracy of PET/CT in metastatic lymph node detection was 72.7% (P = 0.005, 95% CI 0.583-0.871) and 81.8% (P = 0.011, 95% CI 0.635-0.990) in whole population and ICC subgroup analysis, respectively. SUV-max was shown by multivariate analysis to be an independent factor for DFS (P = 0.007 OR 1.16, 95% CI 1.04-1.29) and OS (P = 0.012 OR 1.145, 95% CI 1.030-1.273) after resection. SUV-max of 8 was shown to be a discriminant cut-off for poor oncological outcomes in patients with early cholangiocarcinoma (TNM stage I or II) after curative resection (3-year DFS: 21.2 vs. 63.2%, P = 0.004, and 3-year OS: 29 vs. 74% P = 0.048, respectively).

CONCLUSION

PET/CT is a reliable imaging modality for metastatic lymph node detection in cholangiocarcinoma. Tumour SUV-max is an independent factor for oncological outcomes in patients with resectable disease. For patients who have TNM stage I or II cholangiocarcinoma, tumour SUV-max over 8 is associated with significantly inferior disease-free and overall survival even after curative resection.

Defining Optimal Surgical Treatment for Recurrent Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Salvage liver transplantation (sLT) and repeated resection (RR) are effective treatments for recurrent hepatocellular carcinoma (HCC), and comparisons of the oncological outcomes between these 2 modalities were scarce. Consecutive patients admitted for either sLT or RR for recurrent HCC were recruited. All patients in the present series received either prior hepatectomy, ablative therapy, or both before RR or sLT. Patient demographic, perioperative, and outcome data were analyzed. A survival analysis was performed after propensity score matching. There were 277 eligible patients recruited, and 67 and 210 of them underwent sLT and RR, respectively. Significant differences in preoperative hemoglobin, albumin, Model of End-Stage Liver Disease (MELD) score, and tumor number were found between the sLT and RR groups. After 1:3 propensity score matching, there were 36 sLT and 108 RR patients for comparison. The median age, MELD, alpha fetoprotein, and tumor size and number of the matched population were 57 years, 7.5, 16 ng/mL, 2.5 cm, and 1, respectively. There was no difference in the hospital mortality and complication rate (Clavien IIIa or above) between the groups. The recurrence rate after RR was significantly higher than for the patients who received sLT (72.2% versus 27.8%; P < 0.001). Following RR, 3 patients received liver transplantation for further recurrence, and 54.6% of the patients developed nontransplantable recurrence. The 5-year disease-free survival (DFS) and overall survival (OS) were both superior in the sLT group (DFS, 71.6% versus 32.8%, P < 0.001; OS, 72.8% versus 48.3%, P = 0.007). In conclusion, sLT is superior to RR for treatment of recurrent HCC in terms of DFS and OS. The high rate of nontransplantable recurrence after reresection underscores the importance of timely sLT.

Hepatitis B Vaccination in Patients Receiving Oral Antiviral Therapy Without Hepatitis B Immunoglobulin After Liver Transplant

Our study aimed to determine if a double-dose pre-S containing hepatitis B virus (HBV) vaccination (Sci-B-Vac) could elicit an adequate and sustainable immune response in HBV patients who developed spontaneous hepatitis B surface antibody (anti-HBs) response after liver transplant.

PATIENTS AND METHODS

All patients who received transplants for HBV-related disease for >1 year with normal graft function and hepatitis B surface antigen seronegativity were evaluated. They received a 40-μg HBV vaccine if they were responders in our previous vaccine trial, if anti-HBs was positive for >1 year after liver transplant (LT), or if a peak anti-HBs at any time point after LT was >100 mIU/mL. Primary endpoint was the development of anti-HBs ≥ 10 mIU/mL from previous negative value or a 1-log increase from baseline.

RESULTS

A total of 86 patients were recruited; 5 were responders from a previous trial; 45 patients had detectable anti-HBs >1 year after LT, and 36 patients had an anti-HBs >100 mIU/mL. All (5/5, 100%) previous responders responded to booster vaccination. For the remaining 81 patients, 10 of 81 (12.3%) responded.

CONCLUSION

All previous responders responded to booster vaccination, implying durability and memory of HBV immune response, which is an important prerequisite for definitive host immunity for HBV. In patients who had spontaneous anti-HBs production after LT, a single vaccination can induce response in 12.3% of patients.

Pure laparoscopic hepatectomy with augmented reality-assisted indocyanine green fluorescence versus open hepatectomy for hepatocellular carcinoma with liver cirrhosis: A propensity analysis at a single center

INTRODUCTION

Laparoscopic hepatectomy is considered an acceptable treatment of choice in selected patients with primary hepatocellular carcinoma (HCC). Whether indocyanine green (ICG) immunofluorescence, a new technology, may improve surgery outcomes has yet to be tested. The aim of the present study was to investigate and compare the effect of ICG fluorescence imaging on the outcomes of pure laparoscopic hepatectomy and open hepatectomy for primary HCC with background cirrhosis.

METHODS

From January 2015 to June 2016, 20 patients with HCC and liver cirrhosis underwent laparoscopic hepatectomy with ICG immunofluorescence. The outcomes of pure laparoscopic hepatectomy with ICG immunofluorescence were compared with those of open hepatectomy. To avoid selection bias, patients were propensity score matched in a ratio of 1 : 6, with 20 patients in the laparoscopic group and 120 in the open group.

RESULTS

The laparoscopic group had 20 patients, and the open group had 120 patients. The laparoscopic group had less blood loss (125 vs 450 mL, P < 0.001), a shorter operation time (200 vs 250 min, P = 0.003), and a shorter hospital stay (5 vs 6 days, P < 0.001). The complication rate was 0% in the laparoscopic group compared to 15.0% in the open group (P = 0.135). All patients in the laparoscopic group had negative margin involvement. Four patients (3.3%) in the open resection group had positive margin involvement. Two patients in the ICG immunofluorescence group had additional lesions identified and resected during operation.

CONCLUSION

Pure laparoscopic hepatectomy with ICG immunofluorescence for primary HCC can be carried out safely with favorable short-term outcomes even in cirrhotic patients. Better identification of the bile duct structure and better assessment of the tumor resection margin and perfusion are advantages of this new technique.

A new formula for estimation of standard liver volume using computed tomography-measured body thickness

The objective of this article is to derive a more accurate and easy-to-use formula for finding estimated standard liver volume (ESLV) using novel computed tomography (CT) measurement parameters. New formulas for ESLV have been emerging that aim to improve the accuracy of estimation. However, many of these formulas contain body surface area measurements and logarithms in the equations that lead to a more complicated calculation. In addition, substantial errors in ESLV using these old formulas have been shown. An improved version of the formula for ESLV is needed. This is a retrospective cohort of consecutive living donor liver transplantations from 2005 to 2016. Donors were randomly assigned to either the formula derivation or validation groups. Total liver volume (TLV) measured by CT was used as the reference for a linear regression analysis against various patient factors. The derived formula was compared with the existing formulas. There were 722 patients (197 from the derivation group, 164 from the validation group, and 361 from the recipient group) involved in the study. The donor's body weight (odds ratio [OR], 10.42; 95% confidence interval [CI], 7.25-13.60; P < 0.01) and body thickness (OR, 2.00; 95% CI, 0.36-3.65; P = 0.02) were found to be independent factors for the TLV calculation. A formula for TLV (cm³ ) was derived: 2 × thickness (mm) + 10 × weight (kg) + 190 with R² 0.48, which was the highest when compared with the 4 other most often cited formulas. This formula remained superior to other published formulas in the validation set analysis (R² , 5.37; interclass correlation coefficient, 0.74). Graft weight/ESLV values calculated by the new formula were shown to have the highest correlation with delayed graft function (C-statistic, 0.79; 95% CI, 0.69-0.90; P < 0.01). The new formula (2 × thickness + 10 × weight + 190) represents the first study proposing the use of CT-measured body thickness which is novel, easy to use, and the most accurate for ESLV. Liver Transplantation 23 1113-1122 2017 AASLD.

Hepatopancreatoduodenectomy for advanced hepatobiliary malignancies: a single-center experience

BACKGROUND

Hepatopancreatoduodenectomy is a complicated and challenging procedure but necessary for curative resection for advanced hepatobiliary malignancies. This retrospective study was to examine the safety and survival outcomes of hepatopancreatoduodenectomy in our center.

METHODS

Prospectively collected data of 12 patients who underwent hepatopancreatoduodenectomy for advanced hepatobiliary malignancies in our hospital from January 1998 to December 2014 were analyzed. The primary endpoints are treatment-related morbidity and mortality and the secondary endpoints are overall survival and disease-free survival.

RESULTS

Curative resection was achieved in 11 (91.7%) patients. Complications developed in 10 (83.3%) patients. Three hospital deaths resulted from multiorgan failure secondary to postoperative pancreatic fistula or hepaticojejunostomy leakage. Six of the nine remaining patients had disease recurrence. The nine patients had a median survival of 39.8 (5.3-151.8) months. The 1-, 3- and 5-year overall survival rates were 66.7%, 55.6% and 27.8%, respectively. The corresponding disease-free survival rates were 55.6%, 44.4% and 29.6%, respectively.

CONCLUSIONS

Morbidity and mortality after hepatopancreatoduodenectomy were significant. With R0 resection, the 5-year overall survival and disease-free survival rates were 27.8% and 29.6%, respectively.

Survival outcomes of hepatocellular carcinoma resection with postoperative complications - a propensity-score-matched analysis

Curative resection remains the only hope of cure for hepatocellular carcinoma (HCC), but postoperative complications can have a significant impact on long-term survival. However, only scarce data on such impact can be found in the literature.This retrospective study reviewed the prospectively collected data of patients who underwent primary liver resection for HCC at our hospital during the period from December 1989 to December 2014. Patients with and without postoperative complications were compared. A 1:1 propensity score matching was adopted by matching age, comorbidity, Model of End-stage Liver Disease score, tumor stage, and extent of resection.Totally 1710 patients were eligible for the study. Four hundred and sixty-one (27.0%) of them developed postoperative complications while 1249 (73.0%) did not. After propensity score matching, 922 patients were compared in a 1:1 ratio (461 with postoperative complications and 461 without). Patients who developed postoperative complications were demographically similar to patients who did not, but had more intraoperative blood loss and transfusion (both P < 0.001), longer hospital stay (17 vs 9 days; P < 0.001), worse hospital mortality (12.1% vs 0%; P < 0.001), and shorter overall survival (P < 0.001). On multivariate analysis, factors that might have affected overall survival were cancer stage (HR 1.22, P < 0.001), tumor size (HR 1.02, P = 0.005), tumor number (HR 1.08, P < 0.001), venous invasion (HR 1.38, P = 0.003), extent of resection (HR 1.19, P = 0.045), intraoperative blood loss (HR 1.11, P < 0.001), postoperative complication (HR 1.37, P < 0.001), and era effect (HR 1.27, P = 0.01).Patients should be monitored closely after HCC resection. Prompt treatment of postoperative complications may be salvational.

[CT study on the development of facial nerve canal in children]

Objective: To assess the characteristics of facial nerve canal between normal anatomy and dysplasia of children in different ages. Methods: A total of 492 health ears were divided into six groups, neonatal group (<1 m , n=42), infancy group(1 m-1 y, n=106), toddler group(1-3 y, n=102), preschool group (3-6 y, n=100), school group(6-10 y, n=60)and adolescent group (10-14 y, n=82). The length and diameter of facial nerve canal and that angles of first and second genu were measured with CT in each group. Results: ①The lengths of facial nerve canal in neonatal and infancy group were shorter than other four groups, especially in the mastoid segments of facial nerve canal. The lengths of mastoid segments in neonatal, infancy, toddler, preschool, school and adolescent groups were 5.03±0.84, 6.25±1.40, 8.34±1.38, 9.70±1.34, 10.84±1.41 and 12.17±1.83 mm, with P<0.05, respectively. After school age, the lengths of labyrinthine and tympanic segment grew slowly or developed completely (P>0.05). ② The diameter of labyrinth and tympanic segment in neonatal group were narrower than other five groups (P<0.05), but no significant difference among them in other groups (P>0.05). ③The dysplasia of facial nerve canal were occurred on 978 locations. Among them, the percentage of dehiscence, aberrance, partially expanding and bifurcation were 72.9%(713/978), 5.1%(50/978), 18.9%(185/978) and 3.1%(30/978) respectively. The percentage of dehiscence in geniculate fossa segment was decreased significantly with age (neonatal group 85.7%(36/42), infancy group 59.4%(63/106), toddler group 39.2%(40/102), preschool group 33%(33/100), school group 30%(18/60)and adolescent group 26.8%(22/82), with P<0.05). Except the dehiscence of geniculate fossa and mastoid segment, there was no significant difference in the occurrence rate of the other variants (P>O.05). Conclusions: The growth of length and dehiscence in labyrinth segment of facial nerve canal are significant in difference ages. The changes of diameter and angles of first and second genu in facial nerve canal, and the rate of other dysplasia are individual.

Strategic overview on the best treatment option for intrahepaitc hepatocellular carcinoma recurrence

INTRODUCTION

The long-term survival after hepatectomy for HCC remains unsatisfactory because of the high incidence of recurrence. The cumulative 5-year recurrence rate ranged from 60-100% in previous studies and majority of them remains intrahepatic recurrence. The therapeutic modalities commonly used for primary tumors, including surgical resection, liver transplantation, TACE, local ablative therapy and radiotherapy have been used to treat recurrent tumors in the liver remnant and the outcomes with the heterogeneous therapeutic options are reviewed. It is important to note that the level of evidence for most therapeutic options is limited to cohort investigations with few RCTs and most were limited due to enrollment of various tumor stages and did not compare treatment modalities for specific tumor stages.

AREAS COVERED

A literature search for recurrent HCC was performed using Medline and PubMed up to May 2016. Expert commentary: The long term survival results after re-resection for recurrent HCC were favourable and aggressive management of postoperative intrahepatic recurrence remains the most important strategy in prolonging the survival of patients after resection of HCC.

Short- and long-term impact of reoperation for complications after major hepatectomy for hepatocellular carcinoma

BACKGROUND

The impact of reoperation for complications after major liver resection for hepatocellular carcinoma was evaluated.

METHODS

In this retrospective study covering 25 years, patients with reoperation for complications after major liver resection for hepatocellular carcinoma were compared with patients without reoperation in terms of demographics, tumor characteristics, operative details, postoperative results, oncologic outcomes, and survival. Reasons for reoperation were also investigated.

RESULTS

Forty-nine out of 1,092 patients underwent reoperation within a median of 0.2 days (range, 0-6.9 days) after hepatectomy. Patients with and without reoperation had similar baseline characteristics and liver function. Nonetheless, patients with reoperation had a higher indocyanine green retention rate at 15 minutes (12.55% vs 10.5%, P = .015), more operative blood loss (1.4 L vs 1 L, P = .012), a higher blood transfusion rate (44.9% vs 29.2%, P = .029), longer hospital stay (21 days vs 11 days, P < .001), a higher hospital mortality (38.8% vs 3.0%, P < .001), and a higher 90-day mortality (38.8% vs 4.7%, P < .001). Hemorrhage was the most common cause for reoperation (26/49, 53.1%), mainly resulting from coagulopathic bleeding from raw areas (12/26, 46.2%) and bleeding from diaphragmatic veins (6/26, 23.1%). However, reoperation did not affect 5-year overall survival (50.2% vs 48.3%, P = .468).

CONCLUSION

Postoperative hemorrhage was associated with a high mortality, signifying the importance of meticulous hemostasis and careful perioperative management. Oncologic outcomes, however, were not affected by reoperation.