Elevated soluble TNFα levels and upregulated TNFα mRNA expression in purified peripheral blood monocyte subsets associated with high-grade hepatocellular carcinoma

BACKGROUND

Chronic inflammation is involved in the initiation and progression of various cancers, including liver cancer. The current study focuses on the characterization of the peripheral immune response in hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) patients, before and after surgical procedure, in order to assess the effect of tumor resection in the immune system homeostasis and to determine possible prognostic factors associated with high-grade tumors. We developed a whole-blood assay to monitor immune alterations and functional competence of peripheral monocytes in a group of 10 healthy individuals (HG), in 20 HCC patients and 8 CCA patients, by multi-color flow cytometry, qRT-PCR, and ELISA techniques.

RESULTS

The qRT-PCR analysis showed an upregulation of TNFα expression by classical and intermediate monocytes purified from HCC patients presenting tumors in grade G3-G4 as compared to G1-G2 HCC patients. Moreover, ELISA assay confirmed elevated serum levels of TNFα in G3-G4 compared to G1-G2 HCC patients. A significant decrease of circulating non-classical monocytes was detected in both CCA and HCC patients before and after surgical procedure. In addition, a functional defect in circulating classical and intermediate monocytes was observed in both groups of cancer patients when compared to the HG, with partial recovery after the surgical intervention.

CONCLUSIONS

This integrated analysis permitted the identification of altered functional competence of monocyte subsets in CCA and HCC patients. In addition, our results point to a potential role of TNFα as a prognostic peripheral biomarker in HCC patients, indicating the presence of high-grade tumors that should be further validated.

Functional and Phenotypic Characterization of Tumor-Infiltrating Leukocyte Subsets and Their Contribution to the Pathogenesis of Hepatocellular Carcinoma and Cholangiocarcinoma

Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA) represent the most common primary liver malignancies whose outcome is influenced by the immune response. In the present study, we evaluated the tumor-infiltrating leukocyte (TIL) populations in 21 HCC patients and 8 CCA patients by flow cytometry immediately after the surgical procedure. Moreover, CD4⁺ T cells, CD8⁺ T cells, monocytes, and macrophages were purified by cell sorting for further analysis of gene expression by quantitative reverse-transcription polymerase chain reaction. Regarding tumor-infiltrating macrophages, we observed a significantly higher expression of markers associated with M2 phenotype and a higher expression of PD-L1 in patients with HCC in comparison to CCA. In addition, for HCC patients, we found a significant increase in the expression of CD200R in macrophages from tumors that were in grade G3-G4 as compared to tumors in grade G1-G2. Besides, a significantly higher frequency of tumor-infiltrating lymphocytes, CD8⁺CD56⁺ T cells, and natural killer cells was detected in HCC biopsies in comparison to CCA. In summary, this study has revealed functional and phenotypic differences in TIL cell subpopulations between CCA and HCC, as well as among different histopathological grades and tumor aggressiveness degrees, and it has provided evidence to better understand the tumor immune microenvironment of CCA and HCC.

Influence of Ischemia Time in Injury of Deep Peribiliary Glands of the Bile Ducts Graft: A Prospective Study

The deep peribiliary glands (DPBG) are a niche of progenitor cells in the wall of the biliary duct (BD) and are the second line of multiplication when severe lesion of the epithelium occurs. Previous studies have identified DPBG injury as a cause of post-liver transplant (LT) biliary stenosis; this complication is a major cause of post-LT morbidity. The incidence of biliary stenosis in our center is high (38.1%). This study evaluates the lesion of DPBG in response to ischemia. Graft BD was collected in adult LT between August 2016-July 2017, from donation after brain death. Samples of 45 grafts were collected at 2 moments: BD1-during graft preparation and BD2-before biliary anastomosis. Histological analysis of the samples was performed and then classified according to degree of lesion (0, ≤50%, and >50%). A comparison was made between the degree of lesion and graft ischemia, graft histology, donor, and procurement variables. The DPBG lesion was more frequent in BD2 (20.9% vs 7%, P = .079). BD2 lesions with DPBG lesions had higher medians and means at all times of ischemia. The difference was greater in the warm ischemia time (0: 43.3 ± 12.53 minutes vs ≤50%: 52.4 ± 14.38 minutes, P = .068). The group of BD1 with DPBG lesion presented superior median cold ischemia time (CIT). In the analysis of the remaining variables there were also no statistically significant differences. We concluded that during the period of CIT there is already lesion of the DPBG, which increases after reperfusion of the graft, in greater association with longer warm ischemia time.

Liver retransplantation in patients with acquired familial amyloid polyneuropathy: a Portuguese center experience

In 1995 Furtado et al performed the first domino transplantation using a donor liver with familial amyloid polyneuropathy (FAP), thereby increasing the pool of donors. Our experience showed that the onset of FAP symptoms occurs earlier in some patients. Patients with FAP acquired by transplantation are candidates for liver retransplantation to minimize the progression of symptoms. Liver retransplantation is considered to be a high-risk procedure and has lower survival compared with the first transplantation. We evaluated the risk of liver retransplantation in patients with acquired FAP. We did a retrospective analysis of these patients based on the records of perioperative data. From 1995 to 2004 we carried out 81 domino transplantations, of which 10 were submitted to liver retransplantation because of acquired FAP. The better outcomes in this group lead us to think that the liver retransplantation in patients with acquired FAP is not associated with the same risks of liver retransplantation in candidates with graft failure.

Evaluation of operative risk in de novo familial amyloid polyneuropathy retransplantation

Familial amyloid polyneuropathy (FAP) is the most common hereditary amyloidosis, characterized by progressive peripheral sensory and motor neuropathy. The livers of patients with FAP are used in domino liver transplantation in selected cases to increase the number of grafts available. In our department 10 patients underwent liver retransplantation (ReLTx) in the absence of liver dysfunction by de novo FAP after domino liver transplantation. Our aim was to compare the differences in the consumption of blood products and intraoperative hemodynamic support among patients with FAP undergoing liver transplantation (LTx) and patients with de novo FAP undergoing ReLTx in the same time frame. The anesthetic records of all patients who underwent LTx for FAP and ReLTx for de novo FAP were analyzed, from January 2009 to May 2014. Patients were divided into 2 groups: group 1 patients with FAP, and group 2 patients with de novo FAP. Statistical differences in the value of preoperative creatinine were found. Hemoglobin levels, preoperative international normalized ratio (INR), use of blood products, aminergic support, and surgical time showed no statistical difference. Major bleeding rates would be expected in patients undergoing ReLTx. Changes in renal function, chronic immunosuppressive therapy, and age may contribute to the increase in intraoperative complications. We did not find statistically significant differences, leading us to the conclusion that de novo FAP does not seem to be a predictor of perioperative risk.

Infection with Leishmania (Leishmania) infantum of 0 to 18-Month-old children living in a visceral leishmaniasis-endemic area in Brazil

The diagnosis of Leishmania (Leishmania) infantum infection in children from birth may serve as a reference for the early identification of cases that would progress to classical visceral leishmaniasis (VL) in endemic areas. This study prospectively evaluated newborns of mothers living in the municipality of Paracatu, Minas Gerais, Brazil. The infants were followed up at 6-month intervals by clinical examination, serological tests (immunofluorescence [IIF] and enzyme-linked immunosorbent assay with rK39 [ELISA-rK39]) and polymerase chain reaction (PCR) until they had completed 18 months of age. A total of 166 pregnant women were included to evaluate the possible transfer of antibodies or even congenital transmission. Twenty-two of the women tested positive by IIF, four by ELISA-rK39, and one by PCR. Three infants of the 25 women with some positive test results were also positive in the first test (one by IIF, one by ELISA-rK39, and the third by ELISA-rK39 and PCR). One hundred and sixty infants were included in the study; of these, 43 had at least one positive sample over time. However, agreement between tests was low. Follow-up of children with a positive result in the tests studied revealed no progression to classical disease within a period of 18 months. In contrast, two children with negative IIF, PCR, and ELISA-rK39 results developed classical VL at 9 and 12 months of age. In conclusion, a positive test result was variable and sometimes temporary and agreement between tests was low. Therefore, the early diagnosis of Leishmania infection was not associated with the early identification of cases that would progress to classical VL in the endemic area studied.

Current situation and perspectives regarding human Chagas disease in midwestern of the state of Minas Gerais, Brazil

Recognising the importance of Chagas disease in Brazil, Bambuí set up epidemiological surveillance for Chagas disease in 1974 and was the first municipality to do so. To ascertain the current epidemiology of Chagas disease in this municipality, 1.782 blood samples from the general population were analysed; 7.7% of samples were found to be seropositive for Chagas disease. A strong positive correlation between increasing age and Chagas disease was evident in both genders, with the highest prevalence in individuals aged over 60 years. Clinically, the cardiodigestive form of Chagas disease was the most common in these samples. These data confirm the interruption of Trypanosoma cruzi transmission, in parallel with a still important residual morbidity of Chagas disease in the county, thus supporting political decisions that will prioritise epidemiological surveillance and medical treatment of Chagas disease in the coming years.

Peritoneal and hepatic hydatid disease causing major bile duct destruction

Echinococcosis is endemic in Mediterranean regions and is found primarily in the liver. Biliary fistula is a common complication, but major biliary duct involvement is very rare, and occurs in 0.47% of patients with hepatic hydatid disease. Cyst rupture causing secondary peritoneal hydatidosis is a rare but serious complication. We report the case of a 27-year-old man with multiple peritoneal and hepatic hydatid cysts. The patient came to our attention with cholestatic jaundice. Imaging exams showed numerous peritoneal cysts and massive hydatid disease of the liver, which involved the hepatic confluence, with destruction of the right hepatic duct and fistula formation to the left hepatic duct. The patient was treated with pre-operative albendazole therapy and radical surgery, which consisted of resection of all peritoneal cysts and extended right hepatectomy with biliary reconstruction. No recurrence was seen on CT investigations on the 12th month following surgery. Radical surgical approach remains the treatment of choice.

Sirolimus: efficacy in liver transplant patients with nephrotoxicity and renal insufficiency

Nephrotoxicity is a complication of patients undergoing orthotopic liver transplantation. Herein we present several factors that play an important role in this complication.

Total gastrectomy for gastric adenocarcinoma. Analysis of 115 consecutive patients

BACKGROUND/AIMS

There was a tendency to use more extensive operations for the treatment of gastric cancer during the last decade particularly in Europe. This retrospective study was carried out to review our recent experience with total gastrectomy for gastric adenocarcinoma.

METHODOLOGY

One hundred and fifteen patients treated for gastric cancer by total gastrectomy from 1987 to 1996 were analyzed. At the time of surgery 22.3% of patients were older than 70 years of age.

RESULTS

Fifty eight cancers (50.4%) were located in the distal third of the stomach, forty-seven (41%) were smaller than 6 cm and seventy-one (61.7%) were of the diffuse type. In 74.9% the tumor had penetrated through the serosa. The mortality and morbidity rates were 6.1% and 35.1% respectively. Age was a major determining factor with respect to hospital mortality and post-operative complications.

CONCLUSIONS

Irrespective of personal attitudes, gastrectomy does not have to be total to be curative, and many total gastrectomies performed in Western countries with "curative intent" are noncurative procedures. Nevertheless, to achieve a curative oncologic resection, total gastrectomy is required with growing frequency.

Total gastrectomy for gastric cancer in elderly patients

BACKGROUND/AIMS

The increased average life expectancy and the changing patterns in gastric carcinoma have resulted in a considerable rise in the number of older patients requiring total gastrectomy. Results of total gastrectomy for gastric cancer in elderly patients are presented.

METHODOLOGY

Between January 1987 and December 1996, 115 patients underwent total gastrectomy for gastric adenocarcinoma. At the time of surgery, 25 (21.8%) patients were older than 70 years. The results achieved in these patients were compared with those observed in 90 younger ones.

RESULTS

The hospital mortality and morbidity rates for the elderly patients were 16% and 56%, respectively; for the younger ones they were 3.3% and 30%, respectively. No difference was seen between the two age groups concerning the average post-operative hospital stay.

CONCLUSIONS

In our series, age was a major determinant with respect to post-operative morbidity and mortality. However, age alone could not be clearly defined as a determining risk factor considering that the accompanying illness and preexisting factors predispose for poor prognosis.