Is There Really a Difference in Outcomes between Men and Women with Hepatocellular Cancer?

Hepatocellular carcinoma (HCC) is a male-dominated disease. Currently, gender differences remain incompletely defined. Data from the state tumor registry were used to investigate differences in demographics, comorbidities, treatment patterns, and cancer-specific survival (HSS) among HCC patients according to gender. Additional analyses were performed to evaluate racial differences among women with HCC. 2627 patients with HCC were included; 498 (19%) were women. Women were mostly white (58%) or African American (39%)-only 3.8% were of another or unknown race. Women were older (65.1 vs. 61.3 years), more obese (33.7% vs. 24.2%), and diagnosed at an earlier stage (31.7% vs. 28.4%) than men. Women had a lower incidence of liver associated comorbidities (36.1% vs. 43%), and more often underwent liver-directed surgery (LDS; 27.5% vs. 22%). When controlling for LDS, no survival differences were observed between genders. African American women had similar HSS rates compared to white women (HR 1.14 (0.91,1.41), p = 0.239) despite having different residential and treatment geographical distributions. African American race and age >65 were predictive for worse HSS in men, but not in women. Overall, women with HCC undergo more treatment options-likely because of the earlier stage of the cancer and/or less severe underlying liver disease. However, when controlling for similar stages and treatments, HCC treatment outcomes were similar between men and women. African American race did not appear to influence outcomes among women with HCC as it did in men.

A Neuroendocrine Tumor Specialty Center in New Orleans' (NOLANETS) Response to Patient Care During the COVID-19 Pandemic

This commentary outlines the steps taken by the New Orleans Louisiana Neuroendocrine Tumor Specialists to minimize the risk of patient exposure to SARS‐CoV‐2 but to continue to provide safe, high‐quality care during the COVID‐19 pandemic.

Specialized care improves outcomes for patients with cirrhosis who require general surgical operations

Background

General surgical operations on patients with cirrhosis have historically been associated with high morbidity and mortality rates. This study examines a contemporary series of patients with cirrhosis undergoing general surgical procedures.

Methods

A retrospective evaluation of 358 cirrhotic patients undergoing general surgical operations at a single institution between 2004–2015 was performed. Thirty- and 90-day mortality along with complications and subsequent transplantation rates were examined.

Results

358 cirrhotic patients were identified. The majority were Child-Turcotte-Pugh class (CTP) A (55.9%) followed by class B (32.4%) and class C (11.7%). Mean MELD score differed significantly between the groups (8.7 vs. 12.1 vs. 20.1; p<0.001). The most common operations were herniorrhaphy (29.9%), cholecystectomy (19.3%), and liver resection (14.5%). The majority of cases were performed semi-electively (68.4%), however, within the CTP C patients most cases were performed emergently (73.8%). Thirty and 90-day mortality for all patients were 5% and 6%, respectively. Mortality rates increased from CTP A to CTP C (30 day: 3.0% vs. 5.2% vs. 14.3%; p = 0.01; 90 day: 4.5% vs. 6.9% vs. 16.7%; p = 0.016). Additionally, 30-day mortality (12.8% vs. 2.3%; p<0.001), 90 day mortality (16.0% vs. 3.4%; p<0.001) were higher for emergent compared to elective cases. A total of 13 (3.6%) patients underwent transplantation ≤ 90 days from surgery. No elective cases resulted in an urgent transplantation.

Conclusion

Performing general surgical operations on cirrhotic patients carries a significant morbidity and mortality. This contemporary series from a specialized liver center demonstrates improved outcomes compared to historical series. These data strongly support early referral of cirrhotic patients needing general surgical operation to centers with liver expertise to minimize morbidity and mortality.

Antithymocyte Globulin Antibody Titer Congruent With Kidney Transplantation: Analysis of Incidence, Outcomes, Cost, and Alternative Targets

Rabbit antithymocyte globulin (rATG) use for immunosuppression induction is widespread but is contraindicated by the presence of anti-rATG antibodies. This study reports the incidence of positive anti-rATG antibody titers in patients before and after renal transplant and evaluates associated outcomes and costs. In addition, it will correlate CD40L and interleukin (IL)-21 with anti-rATG antibody titers.

METHODS

Clinical and billing records from the Indiana University Transplant Laboratory were reviewed for positive versus negative anti-rATG antibody titers, graft survival, and 7-day readmission costs between 2004 and 2018. Serum from patients with positive and negative rATG antibody titers were quantitated for CD40L and IL-21 by enzyme-linked immunosorbent assay.

RESULTS

On average, between 2004 and May 2018, 163 kidney transplants per year were performed. Anti-rATG antibody titers were ordered for 17 patients/year, of which 18.2% were positive at 1:100 titer either pre- or post-transplant. Time to graft loss correlated with a positive rATG titer at time of readmission. Moreover, second kidney transplant increased the anti-rATG positive rate. A weak correlation was observed between anti-rATG titer and recipient age. Seven-day readmission treatment costs were significantly lower in patients with positive anti-rATG titer. IL-21 and CD40L were significantly greater in patients with positive anti-rATG titers after transplant when compared with negative anti rATG patients.

CONCLUSIONS

Positive anti-rATG antibody titer is associated with a significant negative impact on outcomes. Monitoring of anti-rATG antibody titer is recommended to optimize treatment options in patients, especially in the setting of second transplants. Elucidation of the mechanisms associated with positive anti-rATG antibody is required. IL-21 and CD40L are potential targets for future study.

Prospective trial of functional liver image-guided hepatic therapy (FLIGHT) with hepatobiliary iminodiacetic acid (HIDA) scans and update of institutional experience

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Background: Functional liver image-guided hepatic therapy (FLIGHT) is a novel stereotactic body radiation therapy (SBRT) planning technique. A functional map, generated from hepatobiliary iminodiacetic acid (HIDA) scans, is used to maximize the functional residual capacity of liver receiving < 15 Gy (FRC15HIDA). We present initial results of a prospective trial evaluating FLIGHT vs standard planning and update our institutional experience. Methods: Eligible patients were ≥ 18 yo with 1o or 2o liver malignancy and Child-Pugh ≤ B7. Liver function was assessed with HIDA and blood chemistry at baseline, mid-treatment, and 3, 6, and 12 months post SBRT. Both standard and FLIGHT (optimized to avoid high functioning liver) plans were generated for each patient. Treating MDs were blinded to planning technique before selecting the treatment plan. The primary endpoint was to show > 5% increase in FRC15HIDA in 3/15 pts. Secondary endpoints included the rate FLIGHT plans were selected and changes in HIDA and other liver function tests. Prior institutional experience included 27 pts with FLIGHT planned retrospectively. Paired t-test was used to compare dosimetric endpoints for FLIGHT vs. standard plans, including: FRC15HIDA, mean liver dose, effective uniform dose (EUD), and functional EUD (FEUD). Results: Fifteen pts were enrolled. The primary endpoint was met, as 4/15 pts had > 5% improvement in FRC15HIDA (mean 5.2%, range -2.3-19.8%). Notably, the FLIGHT plan was selected in 11/15. The mean improvements in FRC15HIDA (5.2 vs 5.0%), mean liver dose (11.9 vs. 13.0%), EUD (5.1 vs 5.2%), and FEUD (6.9 vs 7.1%) were similar between prospective and retrospective cohorts (p > 0.5). In the entire cohort (n = 42), FLIGHT improved FRC15HIDA, mean liver dose, EUD, and FEUD ( p ≤ 0.001). There were > 5% improvements in FRC15HIDA in 15, mean liver dose in 31, EUD in 19, and FEUD in 27. Conclusions: FLIGHT with HIDA led to improvements in all analyzed dosimetric parameters. The extent of benefit was similar in both cohorts, and there was individual variation in the extent of benefit. Longer follow-up is required to determine the effect of FLIGHT on post-SBRT liver function. Clinical trial information: NCT03338062.

Abstract 2644: Relative T regulatory cell populations are indicative of HCC in patients with underlying liver disease

Hepatocellular carcinoma continues to be an increasing burden to patients and the health care system despite recent advances in treatment of viral hepatitis. Since the vast majority of cancers develop in patients with underlying liver disease, we would expect that efforts to cull out the patients at highest risk for cancer emergence would be possible, yet we have struggled to do so. The difficulty lies in the complex microenvironment of the diseased liver that leads to striking aberrancies, many of which are related to inflammation and can overlap with biomarkers felt to be related to cancer. Our goal with lymphocyte profiling is to stratify patients with underlying liver disease into those with and without cancer. Improved surveillance modalities for patients at highest risk of developing HCC are required. Moreover, there is an increasing push to include immunology in cancer detection and treatment. To address these issues, we performed lymphocyte profiling in patients with underlying liver disease with and without HCC and living related renal donors (LRD) by selective cell marker staining and flow cytometry, in order to determine if lymphocytes, which are key to cancer immunology, are modulated concordant with HCC. Specifically, whole blood was stained in order to quantitate T helper (Th), T cytotoxic (Tctx), B cells, natural killer (NK), and T regulatory cells (Treg) by flow cytometry. Th, Tctx and B cells were significantly reduced and NK cells were significantly increased in patients with underlying liver disease. These changes were independent of HCC diagnosis. In contrast, Treg cell levels were dependent on HCC diagnosis. In patients with underlying liver disease without HCC, Treg levels, when compared to LRD (30±6cells/mm3), were significantly reduced (15±3), whereas in patients with underlying liver disease and HCC, Treg levels were increased when compared to patients without HCC and unchanged when compared to LRD (28±6). To correct for the observed lower T-cell levels associated with underlying liver disease, lymphocyte populations were expressed as a ratio when compared to total T-cell numbers. This conversion identified proportional Treg cells population as a marker of HCC. In patients without HCC the Treg/T cell ratio was unchanged when compared to living related donors (0.02±0.002, 0.02±0.002, P=0.3). In contrast, Treg/Tcell ratio was significantly increased in patients with HCC (0.08±0.02, P=0.001). Consequently, given that the primary function of Treg cells is to inhibit T cytotoxic cells, a proportional increase in Treg cells would be associated with immunologic escape for HCC cells. Therefore, surveillance of lymphocyte populations, in particular T cells and Treg, would evaluate changes in immunologic capacity and increased Treg/Tcell ratio would be indicative of an increased risk for HCC in patients with underlying liver disease.

Citation Format: Nicholas J. Skill, Mary A. Maluccio. Relative T regulatory cell populations are indicative of HCC in patients with underlying liver disease [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2644.

Computed Tomography Measures of Nutrition in Patients With End-Stage Liver Disease Provide a Novel Approach to Characterize Deficits

BACKGROUND

Patients with cirrhosis and end-stage liver disease (ESLD) develop severe nutrition deficits that affect morbidity and mortality. Laboratory measures of nutrition fail to fully assess clinical deficits in muscle mass and fat stores. This study employs computed tomography imaging to assess muscle mass and subcutaneous and visceral fat stores in patients with ESLD.

METHODS

This 1:1 case-control study design compares ESLD patients with healthy controls. Study patients were selected from a database of ESLD patients using a stratified method to assure a representative sample based on age, body mass index (BMI), sex, and model for end-stage liver disease score (MELD). Control patients were trauma patients with a low injury severity score (<10) who had a computed tomography scan during evaluation. Cases and controls were matched for age ± 5 years, sex, and BMI ± 2.

RESULTS

There were 90 subjects and 90 controls. ESLD patients had lower albumin levels (P < .001), but similar total protein levels (P = .72). ESLD patients had a deficit in muscle mass (-19%, P < .001) and visceral fat (-13%, P < .001), but similar subcutaneous fat (-1%, P = .35). ESLD patients at highest risk for sarcopenia included those over age 60, BMI<25.0, and female sex. We found degree of sarcopenia to be independent of model for end-stage liver disease score.

CONCLUSIONS

These results support previous research demonstrating substantial nutrition deficits in ESLD patients that are not adequately measured by laboratory testing. Patients with ESLD have significant deficits of muscle and visceral fat stores, but a similar amount of subcutaneous fat.

Abstract 4941: Lysophosphatidic acid receptor signaling and pancreatic adenocarcinoma tumor microenvironment

Introduction: Changes in lipid biosynthesis has attracted significant attention in the study of cancer. Its value in our understanding of pancreatic cancer has not yet been realized. This study examined lysophosphatidic acid (LPA) variant biosynthesis in patients with stage II-III pancreatic ductal adenocarcinoma (PDAC), evaluating serum, bile, and tissue levels of LPA, its receptors, and downstream metabolites. LPA, a product of phospholipase D activity of the enzyme autotaxin (ATX) is a potent mitogenic agent. Data suggests that changes in lipid biosynthesis contribute to the tumor microenvironment in PDAC.

Methods: PDAC, matched adjacent non-malignant tissues, gall bladder bile and serum samples were collected from patients with Stage II-III pancreatic cancer at the time of surgery. Control bile and serum were collected from patients undergoing cholecystectomy for benign disease and living renal donors respectively.

Results: Serum and biliary LPA levels were increased in patients with PDAC when compared to controls. ATX activity, and LPA receptors, LPAR1, LPAR2, and LPAR5 were greater in PDAC adjacent pancreatic tissue when compared to PDAC tissue. In contrast, TNFα receptors TNFα1 and TNFα2 and LPA receptor LPAR3 receptor expression was greater in PDAC lesions when compared to adjacent tissue.

Conclusion: PDAC patients display a modified LPA biosynthesis profile, when compared to non-PDAC patients, potentially providing a paracrine-signaling cascade to promote pancreatic tumorigenesis through increased expression of mitogenic cytokines and growth factors.

Citation Format: Nicholas J. Skill, Mary A. Maluccio. Lysophosphatidic acid receptor signaling and pancreatic adenocarcinoma tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4941. doi:10.1158/1538-7445.AM2017-4941

Survival in patients with hepatocellular carcinoma (HCC): A report of 1444 patients treated within a multidisciplinary program

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Background: The evolution of treatment for HCC has seen novel therapies emerge as front line treatment alternatives. The aim of this study was to report survival in HCC patients treated within the context of a robust multidisciplinary program and to identify patient and tumor specific factors that direct patient centered treatment decisions and optimize outcome. Methods: This is retrospective analysis of medical records identified through the cancer registry at our institution from 2000 to 2016. Variables analyzed for survival significance included patient factors (age, gender, race, tobacco history, alcohol history, and marital status) and tumor factors (tumor size, histology grade, AFP level, SEER stage, clinical and pathologic stage). Survival was estimated from the time of diagnosis to the last contact. Results: A total of 1444 consecutive patients with confirmed HCC were eligible for this analysis. Median follow-up was 45 months. Median survival was 18 months (95% CI: 11-25 months). The overall 1-, 3-, and 5-year survival rates were 63, 40, and 35%, respectively. Significant prognostic parameters were SEER stage (HR = 2.3, p = 2x10-16 local as the reference), pathologic stage (HR = 1.2, p = 3×10-9), tobacco history (HR = 1.2, p = 0.03), , and clinical stage (HR = 1.1, p = 4x10-5). Of a total of 380 patients resected, median and 3-year survival were 75 months and 63% (95% CI: 58-69%). The only significant prognostic parameter associated with survival in resection patients was SEER stage (HR = 1.7, p = 0.002). The 5 year survival for all patients versus those resected were 44% (95% CI: 40-48) /59% (95% CI: 53-65), 21% (95% CI: 17-27) /36% (95% CI: 24-54), and 11% (95% CI: 5-20) /25% (95% CI: 6-100) for localized, regional, and distant disease, respectively. Conclusions: Survival has improved for patients with HCC due to an increased number of available options and better methods to identify tumor and patients specific variables that individualize care. The significance of SEER stage suggests that early detection remains critical for survival.

Stereotactic body radiation therapy to generate comparable survival to surgery in treating hepatocellular carcinoma (HCC): Results of 756 patients

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Background: Stereotactic Body Radiation Therapy (SBRT) has emerged as a viable treatment option in patients with hepatocellular carcinoma (HCC). This study aimed to compare survival outcomes after SBRT with other front line local treatments for HCC. Methods: This is a retrospective analysis of patients identified through our cancer registry from 2000 to 2016. Patients treated with any local therapy alone were eligible: SBRT, surgery, conventional external beam radiation (CEBRT), and other local therapies including brachytherapy. Patients treated with combined therapies such as SBRT plus liver transplant were excluded. The primary endpoint was overall survival which was estimated from the time of diagnosis. Differences between the groups were compared using log-rank test. The data are presented as median (95%CI). Results: A total of 756 patients with a median follow-up of 45 months (mo) met the selection criteria: 116, 380, 43, and 217 patients received SBRT, surgery, CEBRT, and other local treatment, respectively. Median age was 61, 60, 61 and 60 years, respectively. The median overall survival/3 year overall survival rate were 49 (32-66) mo /53% (44-65%) for patients treated with SBRT, which were not significantly different from 75 (57-94) mo /63% (58-69%) of surgery (p = 0.27), non-significantly better than 22 (13-31) mo /41% (27-60%) of CEBRT (p = 0.13), significantly better than 15 (13-20) mo /26% (20-34%) of other local treatments (p = 3×10-7). After adjusting for significant prognostic factors including age, race, status of tobacco abuse, history of alcohol use, tumor size, histology grade and stage, the survival outcomes of SBRT remained to be insignificantly different from surgery (HR = 0.8, p = 0.2), have a trend of significant difference from CEBRT (HR = 1.4, p = 0.1) and remarkably superior to that of other local treatments (HR = 1.8, p = 2×10-4). Conclusions: This study suggests that SBRT is an excellent front line option for HCC, potentially comparable to surgical resection and associated with longer survival than other front line local treatments. Randomized studies are needed to validate these findings.

Prognosis after recurrence of hepatocellular carcinoma in liver transplantation: predictors for successful treatment and survival

There are no established prognostic factors or standardized therapies for hepatocellular carcinoma (HCC) recurrence in liver transplantation (LT). The aim of this study was to investigate impact of underlying patient condition on treatment and outcomes of recurrence of HCC after LT. The medical records of 268 LT patients with HCC were evaluated. Potential prognostic factors for survival after recurrence were evaluated, including recurrent tumor characteristics, medical/radiological/surgical therapies for recurrence, and an inflammatory marker (neutrophil/lymphocyte ratio). Laboratory tests at recurrence, including albumin, absolute lymphocyte count (ALC), prognostic nutritional index (PNI: ALC(/μL) × 0.005 + Albumin(g/dL) × 10), were evaluated as surrogate markers for underlying patient conditions. A total of 51 (19%) patients developed HCC recurrence. The use of sirolimus and sorafenib significantly improved outcome (p = 0.007 and 0.04), and better nutritional status (PNI ≥ 40) enhanced their efficacy. On multivariate analysis, low ALC (<500/μL) and albumin (<2.8 g/L) remained independent prognostic factors (p = 0.03 and 0.02; hazard ratio = 3.61 [Ref. >1000/μL] and 4.97 [Ref. >3.5 g/dL], respectively). Low PNI (<40) showed significantly lower survival rate after adjusting the risk (p = 0.006, hazard ratio = 3.29). Underlying patient conditions and nutritional status, represented by ALC and albumin, are important to successful cancer treatment and strong prognostic markers for survival after HCC recurrence.

Long-term safety and efficacy of stereotactic body radiation therapy for hepatic oligometastases

PURPOSE

To evaluate long-term outcome and toxicity of stereotactic body radiation therapy (SBRT) for hepatic oligometastases from solid tumors.

METHODS AND MATERIALS

Eligible patients had 1 to 3 liver metastases, maximum sum diameter 6 cm, without extrahepatic progression. We treated 106 lesions in 81 patients; 67% with colorectal primaries. Median dose was 5400 cGy in 3 to 5 fractions.

RESULTS

At median follow-up of 33 months (2.5-70 months), overall local control was 94% (95% confidence interval, not estimable); Kaplan-Meier estimated 96% at 1 year and 91% at 2, 3, and 4 years. Partial/complete response was observed in 69% of lesions with less than 3% progressing. Median survival time was 33.6 months (95% confidence interval, 29.1-38.4); Kaplan-Meier survival estimates at 1, 2, 3, and 4 years were 89.9%, 68.6%, 44.0%, and 28.0%, respectively. Grade 3 or greater liver toxicity was 4.9%.

CONCLUSION

SBRT is effective for selected patients with hepatic oligometastases with limited toxicities. A phase 3 trial comparing SBRT with "gold-standard" surgical resection is warranted.

Thalidomide ameliorates portal hypertension via nitric oxide synthase independent reduced systolic blood pressure

AIM: Portal hypertension is a common complication of liver cirrhosis and significantly increases mortality and morbidity. Previous reports have suggested that the compound thalidomide attenuates portal hypertension (PHT). However, the mechanism for this action is not fully elucidated. One hypothesis is that thalidomide destabilizes tumor necrosis factor α (TNFα) mRNA and therefore diminishes TNFα induction of nitric oxide synthase (NOS) and the production of nitric oxide (NO). To examine this hypothesis, we utilized the murine partial portal vein ligation (PVL) PHT model in combination with endothelial or inducible NOS isoform gene knockout mice.

METHODS: Wild type, inducible nitric oxide synthase (iNOS)^-/- and endothelial nitric oxide synthase (eNOS)^-/- mice received either PVL or sham surgery and were given either thalidomide or vehicle. Serum nitrate (total nitrate, NOx) was measured daily for 7 d as a surrogate of NO synthesis. Serum TNFα level was quantified by enzyme-linked immunosorbent assay. TNFα mRNA was quantified in liver and aorta tissue by reverse transcription-polymerase chain reaction. PHT was determined by recording splenic pulp pressure (SPP) and abdominal aortic flow after 0-7 d. Response to thalidomide was determined by measurement of SPP and mean arterial pressure (MAP).

RESULTS: SPP, abdominal aortic flow (Qao) and plasma NOx were increased in wild type and iNOS^-/- PVL mice when compared to sham operated control mice. In contrast, SPP, Qao and plasma NOx were not increased in eNOS^-/- PVL mice when compared to sham controls. Serum TNFα level in both sham and PVL mice was below the detection limit of the commercial ELISA used. Therefore, the effect of thalidomide on serum TNFα levels was undetermined in wild type, eNOS^-/- or iNOS^-/- mice. Thalidomide acutely increased plasma NOx in wild type and eNOS^-/- mice but not iNOS^-/- mice. Moreover, thalidomide temporarily (0-90 min) decreased mean arterial pressure, SPP and Qao in wild type, eNOS^-/- and iNOS^-/- PVL mice, after which time levels returned to the respective baseline.

CONCLUSION: Thalidomide does not reduce portal pressure in the murine PVL model by modulation of NO biosynthesis. Rather, thalidomide reduces PHT by decreasing MAP by an undetermined mechanism.

Stereotactic body radiotherapy response and local control rates for hepatic oligometastases

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Background: Stereotactic body radiation therapy (SBRT) is a non-invasive, effective technique in the treatment of hepatic oligometastases from solid tumors. We present response and local control rates from our single institution experience. Methods: We treated 79 metastatic liver lesions from 64 different patients using stereotactic body radiation therapy. One colorectal cancer patient was treated three times and four patients were treated twice. Among the 79 metastatic liver lesions treated, 85% had prior chemotherapy. The primary cancer site included: Colorectal 66%, Non-colorectal GI 14%, Breast 6%, Ovarian 5%, NSCLC 3%, and other 6%. The mean GTV size was 37.3 (cc). The mean GTV diameter was 3.1 (cm). The median total dose was 54 (Gy) with the minimum and maximum total dose being 30 and 60 (Gy). Results: The overall local control rate was 94.2%, with estimates at 12, 24, 36, and 48 months being 96.1%, 87.9%, 87.9% and 87.9% following SBRT treatment. When comparing colorectal cancer patients vs all other primary cancer sites, the one year local control rate was 93.4% and 100%. The two and three year local control rates for colorectal cancer vs other primary cancer sites were 84.9% vs 90.9%. Best response was examined as a 4 level response (CR,PR,SD,PD) per the RECIST criteria. Overall, 67% of patients had a response, and less than 3% of patients had progression with SBRT treatment. For colorectal cancer patients, 79% had a response to treatment. Only 21% of colorectal cancer patients did not respond, however, the majority of these patients still had stable disease following treatment. Non-colorectal primary site cancers had a response in 50% of the lesions following SBRT treatment. The remaining 50% of non-colorectal primary cancers were stable following SBRT treatment and none progressed. The median dose for CR, PR, or SD was 54 Gy. The median dose for patients with progressive disease was less than 50 Gy. The observed CTC toxicities were limited with mostly grade 1-2 toxicity and only two grade 4 and one grade 5 toxicity. Conclusions: Stereotactic body radiation therapy is an effective treatment option for patients with hepatic oligometastases with a limited toxicity profile.

Abstract 2661: C11 Acetate and 18F FDG PET/CT imaging of MDR2-/- mouse model of hepatocellular carcinoma

Our previous research reveals a link between the enzyme autotaxin (ATX) and its product lysophosphatidic acid (LPA) in hepatocellular carcinoma (HCC). We have shown a shift in ATX levels and LPA variant biosynthesis associated with HCC in patients that was corrected by liver transplantation. Moreover we have demonstrated a reduction in hepatic tumor burden in the MDR2-/- mouse model of HCC by treatment with commercial ATX inhibitors. The purpose of this study was to establish the relevance of FDG PET versus 11C acetate imaging to monitor response to ATX inhibition in the in-vivo MDR2 /- mouse model of HCC whereby we would be able to test the impact of novel inhibitors on both the initiation and progression of HCC. Methods: Dynamic high-resolution Positron Emission Tomography (PET) images of 12 month MDR-/- mice and FVB controls were acquired using 18F-FDG or 11C-Acetate (N=3 per group). At the end of the PET imaging session whole body CT images were acquired. Image segmentation for discrete volumes of interests (VOI) was manually constructed from parametric images for the liver for 18F-FDG images while for 11C-Acetate VOIs were submitted to kinetic modeling, using a 3-compartment, 4-parameter model. Results. MDR2-/- mice had significant hepatic tumors at 12 month (7.9±1.8mm) whereas no tumors were observed in FVB controls. MDR2-/- mice had significantly higher hepatic 11C-Acetate uptake and metabolic rates when compared to FVB controls (0.6±0.04 vs 0.49±0.02ml/g/min P=0.038). In contrast there was no significant difference in 18F-FDG metabolism or uptake in the livers of MDR2-/- mice when compared to wild type FVB controls (1.1±0.23 v 1.32±0.2 and 3.61±0.97 vs. 4.3±0.6SUV respectively p=ns). Conclusion: The biology of HCC formation in MDR2-/- is better suited to 11C acetate PET/CT imaging than 18F FDG. 11C acetate is the most effective imaging method available to test response to treatment in an in-vivo model of HCC.

Citation Format: Nicholas J. Skill, Paul R. Territo, Amanda A. Riley, Brian P. McCarthy, Mary A. Maluccio. C11 Acetate and 18F FDG PET/CT imaging of MDR2-/- mouse model of hepatocellular carcinoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2661. doi:10.1158/1538-7445.AM2013-2661

Note: This abstract was not presented at the AACR Annual Meeting 2013 because the presenter was unable to attend.

Long-term outcomes comparing surgery to embolization-ablation for treatment of solitary HCC<7 cm

BACKGROUND

Resection has been the standard of care for patients with solitary hepatocellular carcinoma (HCC). Transarterial embolization and percutaneous ablation are alternative therapies often reserved for suboptimal surgical candidates. Here we compare long-term outcomes of patients with solitary HCC treated with resection versus combined embo-ablation.

METHODS

We previously reported a retrospective comparison of resection and embo-ablation in 73 patients with solitary HCC<7 cm after a median follow-up of 23 months. This study represents long-term updated follow-up over a median of 134 months.

RESULTS

There was no difference in survival among Okuda I patients who underwent resection versus embo-ablation (66 vs 58 months, p=.39). There was no difference between the groups in the rate of distant intrahepatic (p=.35) or metastatic progression (p=.48). Surgical patients experienced more complications (p=.004), longer hospitalizations (p<.001), and were more likely to require hospital readmission within 30 days of discharge (p=.03).

CONCLUSION

Over a median follow up of more than 10 years, we found no significant difference in overall survival of Okuda 1 patients with solitary HCC<7 cm who underwent surgical resection versus embo-ablation. Our data suggest that there may be a greater role for primary embo-ablation in the treatment of potentially resectable solitary HCC.

Stereotactic body radiotherapy (SBRT) in patients with hepatocellular carcinoma with Child-Pugh class B

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Background: Stereotactic body radiotherapy (SBRT) is a promising therapeutic modality in hepatocelular carcinoma (HCC). A Phase I trial was conducted at Indiana University (IU) in patients with Child Pugh Class (CPC) A and B. Based on our results, patients with CPC-B patients with score <=7 continued enrollment in the phase II. We now present an interim analysis for this patient population. Methods: 14 patients with HCC with liver cirrhosis, CPC-B, were treated with SBRT in a Phase I-II trial at IU. All patients were scheduled to receive five fractions, 800 cGy per fraction (total dose 4000 cGy), 1-2 fractions per week. Dose was prescribed to the 80-90% isodose line covering the planning target volume (PTV). A modified RECIST criterion was used to determine local failure. Demographics, clinical variables, treatment –related toxicities within 90 days of end of treatment, and local control (LC) at 6 and 12 months were tabulated. Progression Free Survival (PFS), Time to Progression (TTP), and Overall Survival (OS) estimates were calculated using Kaplan-Meier methodology. This was an unplanned interim analysis. A formal interim analysis will take place later. Results: There were 13 males and 1 female; median age of 56.5 years (range 49-69). All patients had 1 treated lesion. Median (range) for gross tumor volume (GTV) (cc) was 40.1 (8.0-74.6); PTV volume (cc) was 120.1 (34.7-210.0); and uninvolved liver volume (cc) was 2137.9 (973.0-2796.0). There were 3 grade 4 toxicities, 1 each of hyperbilirubinemia, hypokalemia, and thrombycytopenia. Four patients underwent orthotopic liver transplant. Local control at 6 and 12 months were 90% [95% C.I. (55.5%, 99.8%)] and 87.5% [95% C.I. (47.4%, 99.7%)], respectively. Median PFS is 11.0 months (95% CI: 3.9 months, 17.4 months). Ten patients died or progressed including 4 patients who died without progressing. Median TTP is 17.4 months (95% CI: 5.3 months, upper limit not estimable). Median OS is 19.8 months (95% CI: 4.0 months, upper limit not estimable). Conclusions: in carefully selected patients with hepatocellular carcinoma in the context of CPC B liver cirrhosis, score less or equal than 7, SBRT is an effective therapy with a good toxicity profile. Phase II is ongoing.

Evaluation of response after stereotactic body radiotherapy for hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is increasing in incidence due to hepatitis C. Stereotactic body radiotherapy (SBRT) is a noninvasive, effective therapy in the management of liver malignancies. The authors evaluated radiological response in 26 patients with HCC treated with SBRT at Indiana University.

METHODS

Between March 2005 and June 2008, 26 patients with HCC who were not surgical candidates were enrolled in a phase 1 to 2 trial. Eligibility criteria included solitary tumors ≤ 6 cm or up to 3 lesions with sum diameters ≤ 6 cm, and well-compensated cirrhosis. All patients had imaging before, at 1 to 3 months, and every 3 to 6 months after SBRT.

RESULTS

Patients received 3 to 5 fractions of SBRT. Median SBRT dose was 42 Gray (Gy) (range: 24-48 Gy). Median follow-up was 13 months. Per Response Evaluation Criteria in Solid Tumors (RECIST), 4 patients had a complete response (CR), 15 had a partial response (PR), and 7 achieved stable disease (SD) at 12 months. One patient with SD experienced progression marginal to the treated area. The overall best response rate (CR + PR) was 73%. In comparison, by European Association for the Study of the Liver (EASL) criteria, 18 of 26 patients had ≥ 50% nonenhancement at 12 months. Thirteen of 18 demonstrated 100% nonenhancement, being > 50% in 5 patients. Kaplan-Meier 1- and 2-year survival estimates were 77% and 60%, respectively.

CONCLUSIONS

SBRT is effective therapy for patients with HCC with an overall best response rate (CR + PR) of 73%. Nonenhancement on imaging, a surrogate for ablation, may be a more useful indicator than size reduction in evaluating HCC response to SBRT in the first 6 to 12 months, supporting EASL criteria.

Evidence of aberrant lipid metabolism in hepatitis C and hepatocellular carcinoma

OBJECTIVES

Lipids are linked to many pathological processes including hepatic steatosis and liver malignancy. This study aimed to explore lipid metabolism in hepatitis C virus (HCV) and HCV-related hepatocellular carcinoma (HCC).

METHODS

Serum lipids were measured in normal, HCV and HCV-HCC patients. Whole-genome microarray was performed to identify potential signature genes involved in lipid metabolism characterizing normal vs. HCV vs. HCV-HCC conditions.

RESULTS

Serum cholesterol was significantly reduced in HCV and HCV-HCC patients compared with normal controls, whereas there was no difference in glucose and triglycerides. Microarray analysis identified 224 probe sets with known functional roles in lipid metabolism (anova, 1.5-fold, P ≤ 0.001). Gene-mediated fatty acid (FA) de novo synthesis and uptake were upregulated in HCV and this upregulation was further enhanced in HCC. Genes involved in FA oxidation were downregulated in both the HCV and HCC groups. The abnormality of cholesterol metabolism in HCV was associated with downregulation of genes involved in cholesterol biosynthesis, absorption and transportation and bile acid synthesis; this abnormality was further intensified in HCC.

CONCLUSIONS

Our data support the notion that HCV-related lipid metabolic abnormalities may contribute to hepatic steatosis and the development of cancer. Identification of these aberrations would stratify patients and improve treatment algorithms.

Autotaxin expression and its connection with the TNF-alpha-NF-kappaB axis in human hepatocellular carcinoma

BACKGROUND

Autotaxin (ATX) is an extracellular lysophospholipase D that generates lysophosphatidic acid (LPA) from lysophosphatidylcholine (LPC). Both ATX and LPA have been shown to be involved in many cancers. However, the functional role of ATX and the regulation of ATX expression in human hepatocellular carcinoma (HCC) remain elusive.

RESULTS

In this study, ATX expression was evaluated in tissues from 38 human HCC and 10 normal control subjects. ATX was detected mainly in tumor cells within tissue sections and its over-expression in HCC was specifically correlated with inflammation and liver cirrhosis. In addition, ATX expression was examined in normal human hepatocytes and liver cancer cell lines. Hepatoma Hep3B and Huh7 cells displayed stronger ATX expression than hepatoblastoma HepG2 cells and normal hepatocytes did. Proinflammtory cytokine tumor necrosis factor alpha (TNF-alpha) promoted ATX expression and secretion selectively in Hep3B and Huh7 cells, which led to a corresponding increase in lysophospholipase-D activity. Moreover, we explored the mechanism governing the expression of ATX in hepatoma cells and established a critical role of nuclear factor-kappa B (NF-kappaB) in basal and TNF-alpha induced ATX expression. Further study showed that secreted enzymatically active ATX stimulated Hep3B cell invasion.

CONCLUSIONS

This report highlights for the first time the clinical and biological evidence for the involvement of ATX in human HCC. Our observation that links the TNF-alpha/NF-kappaB axis and the ATX-LPA signaling pathway suggests that ATX is likely playing an important role in inflammation related liver tumorigenesis.

Tumor necrosis factor alpha signaling in the development of experimental murine pre-hepatic portal hypertension

The cytokine tumor necrosis factor alpha (TNFa) has previously been identified in the development of portal hypertension (PHT) by facilitating portal venous and systemic hyperemia. TNFa is reported to contribute to hyperemia via endothelial nitric oxide synthase (eNOS) induction and nitric oxide (NO) production. This study examines this hypothesis by utilizing TNFa receptor knockout mice and a murine model of pre-hepatic PHT. Plasma TNFa and NOx and tissue TNFa mRNA levels were determined in wild-type mice 0-7d post induction of pre-hepatic PHT by partial portal vein ligation (PVL). TNFa receptor knockout mice also received PVL or sham surgery and splenic pulp pressure, abdominal aortic flow and portal-systemic shunting were recorded 7d following. Portal pressure and systemic hyperemia developed rapidly following PVL. Plasma NOx was increased temporarily 2-3 days following PVL and returned to baseline by day 7. Circulating TNFa was below detectable limits of the ELISA used, as such no increase was observed. Hepatic and vascular TNFa mRNA levels were transiently changed after PVL otherwise there was no significant change. TNFa receptor targeted gene deletion did not ameliorate plasma NOx following PVL and had no effect on the development of PHT. TNFa receptor signaling plays no detectable role in the development of systemic hyperemia in the murine model of pre-hepatic PHT. Consequently, increased TNFa observed in intra-hepatic inflammatory models (CCl(4)) and in patients is probably related to inflammation associated with intra-hepatic pathology. Alternatively, TNFa may be signaling via a TNFa receptor independent mechanism.

A comparison of outcomes from treating hepatocellular carcinoma by hepatic artery embolization in patients younger or older than 70 years

BACKGROUND

: The objective of this study was to compare the morbidity, mortality, and survival of patients aged <70 years and aged > or =70 years who underwent hepatic arterial embolization (HAE) for the treatment of hepatocellular carcinoma (HCC).

METHODS

: Between 1997 and 2007, 386 patients underwent HAE for HCC at a single center. Two hundred patients were aged <70 years (153 men; median age, 60 years), and 186 patients were aged > or =70 years (128 men; median age, 75 years). Patients underwent a total 965 embolization procedures (median, 2 procedures per patient). Patient demographics, morbidity, mortality, length of hospital stay, and survival were analyzed. Complications were categorized using Common Terminology Criteria for Adverse Events, version 3.0 guidelines. Survival was calculated by using the Kaplan-Meier method.

RESULTS

: There were no significant differences between younger and older groups in the incidence of infectious, hepatobiliary, renal, vascular, or miscellaneous complications (P > or = .05); complication severity (P = .82); procedural mortality (P = .63); length of hospitalization (P = .55); intensive care unit admission (P = .64); or overall survival (P = .30). There were more cardiopulmonary complications in the older group (P = .04), but the association of age and likelihood of a cardiopulmonary complication lost significance after adjusting for the presence of more cardiovascular comorbidities in the older group (P = .08).

CONCLUSIONS

: Survival and mortality outcomes of HAE for the treatment of HCC were similar whether patients were aged <70 years or > or =70 years. Although patients aged > or =70 years with cardiovascular comorbidities more often had a cardiopulmonary complication, other morbidity measures, including complication severity, need for intensive care unit admission, and length of hospitalization, were similar between groups. Cancer 2009. (c) 2009 American Cancer Society.

Role of endothelial nitric oxide synthase in the development of portal hypertension in the carbon tetrachloride-induced liver fibrosis model

Portal hypertension (PHT) is a complication of liver cirrhosis and directly increases mortality and morbidity by increasing the propensity of venous hemorrhage. There are two main underlying causations for PHT, increased hepatic resistance and systemic hyperdynamic circulation. Both are related to localized aberrations in endothelial nitric oxide synthase (eNOS) function and NO biosynthesis. This study investigates the importance of eNOS and systemic hyperdynamic-associated hyperemia to better understand the pathophysiology of PHT. Wild-type and eNOS(-/-) mice were given the hepatotoxin CCl(4) for 4-12 wk. Hepatic fibrosis was determined histologically following collagen staining. Portal venous pressure, hepatic resistance, and hyperemia were determined by measuring splenic pulp pressure (SPP), hepatic portal-venous perfusion pressure (HPVPP), abdominal aortic flow (Qao), and portal venous flow (Qpv). Hepatic fibrosis developed equally in wild-type and eNOS(-/-) CCl(4)-exposed mice. SPP, Qao, and Qpv increased rapidly in wild-type CCl(4)-exposed mice, but HPVPP did not. In eNOS(-/-) CCl(4) mice, Qao was not increased, SPP was partially increased, and HPVPP and Qpv were increased nonsignificantly. We concluded that the systemic hyperemia component of hyperdynamic circulation is eNOS dependent and precedes increased changes in hepatic resistance. Alternative mechanisms, possibly involving cyclooxygenase, may contribute. eNOS maintains normal hepatic resistance following CCl(4)-induced fibrosis. Consequently, increased portal pressure following chronic CCl(4) exposure is linked to hyperdynamic circulation in wild-type mice and increased hepatic resistance in eNOS(-/-) mice.

NF-kappaB inhibition in human hepatocellular carcinoma and its potential as adjunct to sorafenib based therapy

Nuclear factor-kappaB (NF-kappaB) has been shown to play an important role in the development and progression of cancer. In this study, we systematically examined NF-kappaBp65 signaling pathway in both human hepatocellular carcinoma (HCC) tissue and HCC cell lines. NF-kappaBp65 signaling pathway is aberrantly expressed and activated in both human HCC tissue and HCC Hep3B cells. Inhibition of NF-kappaB activity significantly reduced proliferation and invasion of Hep3B cells as well as down-regulated the expression of invasion-related molecules including matrix metalloproteinase (MMP)-2, MMP-9, membrane type-1 MMP (MT1-MMP), urokinase plasminogen activator (uPA) and vascular endothelial growth factor (VEGF). Hep3B cells exhibited a dose-dependent increase in apoptosis after receiving sorafenib treatment. Inhibition of NF-kappaB activity strongly sensitized Hep3B cells to sorafenib-induced cell death. Mechanistically, combined treatment of sorafenib and NF-kappaB inhibition enhanced inhibition of MAPK signaling and down-regulation of anti-apoptotic protein Mcl-1 expression. These observations indicate that inhibition of NF-kappaB may be a potential antineoplastic therapy for HCC, especially the combination of NF-kappaB inhibition and sorafenib provides a novel therapeutic strategy for patients with advanced-stage HCC.

Is autotaxin (ENPP2) the link between hepatitis C and hepatocellular cancer?

INTRODUCTION

Hepatitis C is the most significant risk factor for development of hepatocellular carcinoma. Inflammation, fibrosis, and liver cell proliferation may contribute to cancer development either through malignant hepatocyte transformation or extracellular matrix remodeling within the tumor microenvironment. The study objective was to investigate differences in gene expression between patients with Hepatitis C (+/- cancer) and normal that might explain the increased cancer risk.

METHODS

Liver tissue was collected from three patient groups: 1) healthy patients, 2) Hepatitis C patients without cancer, 3) patients with Hepatitis C and hepatocellular carcinoma. Microarray analysis was performed on samples from each group. Western blot and real-time polymerase chain reaction (PCR) analyses corroborated the microarray data. A p value of 0.05 was set as significant.

RESULTS

Microarray analysis showed overexpression of autotaxin in patients with cancer versus hepatitis patients or normal patients. Rho GTPase binding proteins (Cdc42s) associated with lysophosphatidic acid signaling were also overexpressed in cancer patients. Real-time polymerase chain reaction showed overexpression of several factors associated with autotaxin in patients with Hepatitis C (+/- cancer) versus normal patients.

CONCLUSIONS

Patients with Hepatitis C and hepatocellular carcinoma show differential expression of various components of the autotaxin pathway versus normal patients. This merits further investigation in the context of early diagnosis.

Cholecystosteatosis: an explanation for increased cholecystectomy rates

INTRODUCTION

Over the past decade, obesity has become epidemic, and the number of cholecystectomies as well as the percentage with acalculous cholecystitis have increased. We have recently reported that congenitally obese mice and lean mice fed a high fat diet have increased gallbladder wall lipids and poor gallbladder emptying. Therefore, we tested the hypothesis that compared to patients with a normal gallbladder, patients with both acalculous and calculous cholecystitis would have increased gallbladder wall fat.

METHODS

Sixteen patients who underwent cholecystectomy for acalculous cholecystitis were identified. Sixteen nondiseased controls who underwent incidental cholecystectomy during surgery for liver or pancreatic disease and 16 diseased controls whose gallbladder was removed for chronic calculous cholecystitis were chosen to match the acalculous patients for gender and Body Mass Index. Pathology specimens were reviewed in a blinded fashion for gallbladder wall fat, thickness, and inflammation.

RESULTS

Acalculous cholecystitis patients were younger (p < 0.01) than nondiseased or diseased controls. Gallbladder wall fat was significantly increased (p < 0.02) in the acalculous and calculous cholecystitis patients compared to the nondiseased controls. Gallbladder wall thickness (p < 0.02) and inflammatory score (p < 0.01) were highest in the calculous cholecystitis patients.

CONCLUSIONS

These data suggest that compared to nondiseased controls, (1) patients with acalculous cholecystitis are younger and have increased gallbladder fat and (2) patients with calculous cholecystitis have increased gallbladder fat and inflammation. We conclude that increased gallbladder fat may lead to poor gallbladder emptying and biliary symptoms. Thus, cholecystosteatosis may explain, in part, the increased need for cholecystectomy and the higher percentage of these patients with acalculous cholecystitis.

Treatment of metastatic sarcoma to the liver with bland embolization

BACKGROUND

The authors evaluated the impact of bland particle embolization on survival in patients with metastatic sarcoma to the liver.

METHODS

Twenty-four patients with liver-dominant metastases from sarcoma were treated with particle embolization from 1996 to 2002. Primary tumors included 16 gastrointestinal stromal tumors (GISTs), 7 intestinal leiomyosarcomas, and 1 liposarcoma. Thirteen patients had known extrahepatic disease. Embolization was performed by using polyvinyl alcohol or trisacryl microspheres to effect stasis in the target vessel(s). Follow-up images to assess response were obtained 4 weeks after the procedure. Decrease in the size of the target lesion by >25% or development of >50% necrosis on follow-up imaging was considered a treatment response.

RESULTS

Nineteen patients had metachronous liver metastases, and the median disease-free interval was 22 months (range 10-156 months) from resection of the primary tumor. Ten patients underwent prior liver resection for metastatic disease. Of 15 evaluable patients, 9 patients (60%) had a radiographic response. The median follow-up for all patients was 21 months. The median follow-up for surviving patients was 59 months. Overall survival from the time of initial embolization was 62% at 1 year, 41% at 2 years, and 29% at 3 years. Patients who had radiographic evidence of response survived significantly longer than patients who did not respond (63 months vs. 19 months; P < .007). Patients with GIST survived significantly longer than patients with visceral leiomyosarcoma (median, 36 months vs. 18 months; P < .03).

CONCLUSIONS

Bland embolization was efficacious in some patients with metastatic sarcoma to the liver. Radiographic evidence of response was correlated with improved survival. This regional therapy may enter the treatment algorithm for patients who have unresectable disease or disease that has failed conventional therapies.

Particle embolization of recurrent hepatocellular carcinoma after hepatectomy

BACKGROUND

Complete surgical resection is the mainstay of treatment for patients with hepatocellular carcinoma (HCC). Unfortunately, most patients ultimately develop disease recurrence and the median survival from the time of recurrence is <1 year. The purpose of the current study was to review the authors' experience using bland hepatic arterial embolization to treat recurrent HCC after definitive surgical resection.

METHODS

The authors reviewed their single-center hepatic embolization database from 1995 through 2004 to identify patients who underwent bland hepatic arterial embolization for disease recurrence. Data analyzed included patient demographics, Okuda stage and Child score, imaging findings, and embolization variables. Recurrence-free survival (from surgery to disease recurrence) and survival time (from recurrence to last follow-up) were calculated using the Kaplan-Meier method.

RESULTS

The authors identified 45 patients treated with bland embolization for recurrent HCC after resection. Six patients also underwent ablative therapy after embolization. Of the 45 patients, 42 (93.3%) patients had Okuda Stage 1 disease. The median time to recurrence was 13 months. The median survival after embolization was 46 months, and actuarial survival rates at 1 year, 2 years, and 5 years after recurrence were 86%, 74%, and 47%, respectively, with a median follow-up of 31 months. Patients who developed disease recurrence with a solitary lesion had a significantly improved survival (P = .03) At the time of last follow-up, 3 patients (6.6%) were alive with no evidence of viable disease.

CONCLUSIONS

Bland arterial embolization was found to be an effective method of salvage therapy for patients with good liver function with recurrent HCC after prior surgical resection. Patients whose disease recurred with a solitary lesion appear to have a significantly increased survival compared with patients who develop disease recurrence with multiple tumors. A small proportion of patients can be rendered without evidence of viable disease.

The use of computed tomography for the diagnosis of acute appendicitis in children does not influence the overall rate of negative appendectomy or perforation

BACKGROUND

Computed tomography (CT) has been used more frequently to diagnose acute appendicitis in children. The purpose of this study was to determine whether the use of CT has any influence on negative appendectomy or perforation rates.

METHODS

Review of a prospective database of children having appendectomy for suspected acute appendicitis. Negative appendectomy and perforation rates were determined by correlation with final pathology reports.

RESULTS

Eighty-five consecutive patients underwent appendectomy for the suspicion of acute appendicitis. The overall negative appendectomy rate was 17.6%, being 19.4% in females and 16.6% in males (p = 0.75). The overall accuracy, sensitivity and positive predictive value of CT were 75%, 91%, and 81%, respectively. Patients that had CT did not have a significantly lower rate of negative appendectomy (17.9% vs. 19.3%, p > 0.99) or perforation (26% vs. 17%; p = 0.53).

CONCLUSIONS

The use of CT for the diagnosis of appendicitis in children does not change the negative appendectomy rate. Results of studies performed in adults may not be extrapolated to the evaluation of children with suspected acute appendicitis.

A prospective evaluation of the use of emergency department computed tomography for suspected acute appendicitis

BACKGROUND

Computed tomography (CT) is used increasingly to evaluate suspected cases of acute appendicitis (AA) in the emergency department (ED). This prospective study was performed to test the hypothesis that the evaluation of AA by CT in the ED remains suboptimal and that erroneous interpretation diminishes its utility.

METHODS

Consecutive patients 18 years of age or older were enrolled prospectively if AA was among the first three differential diagnoses listed in the record of patients undergoing evaluation of abdominal pain in the ED. Imaging of the abdomen and pelvis was obtained at the discretion of the ED staff or consultant surgeon. Initial CT interpretation was by a radiology resident or fellow along with the surgical staff, but final review by an attending radiologist occurred later. Age, gender, presenting symptoms, white blood cell (WBC) count, final CT results, and final pathology (for patients undergoing operation) were recorded. X +/- SEM, p < 0.05 by chi(2), ANOVA, or MANOVA was used for statistical analysis as appropriate.

RESULTS

A CT scan was performed in 104 patients (83% of those meeting entry criteria), 35 of whom were male (mean age, 37 +/- 2 years) and 69 of whom were female (mean age, 39 +/- 3 years). Thirty-five patients had pathologically proved appendicitis, 28 of whom were diagnosed prospectively by CT. There were seven false-negative scans. Sensitivity, specificity, and positive predictive value for the initial CT reading were 80%, 91%, and 82%, respectively. Gender (p < 0.03), WBC count (p < 0.0002), and a positive initial CT reading (p < 0.0001) correlated with operative management. However, although final CT interpretation did correlate with pathologic confirmation of AA (p < 0.0001), initial CT interpretation did not correlate with the presence of AA (p = 0.52).

CONCLUSION

The ability of CT to predict AA is dependent on the interpretative skill of the individual interpreting the images. Widespread use of CT in the evaluation of patients for AA should be implemented with caution until institution-specific protocols are validated.

Variant hepatic arterial anatomy revisited: digital subtraction angiography performed in 600 patients

PURPOSE

To evaluate and describe the prevalence of hepatic arterial variants seen at digital subtraction angiography in a large series of patients.

MATERIALS AND METHODS

Data were collected prospectively by using an arterial anatomy database questionnaire that was completed at the time each visceral angiographic examination was performed from May 1996 to October 2000.

RESULTS

Six hundred patients underwent at least one visceral angiographic examination at one institution during the study period. Three hundred sixty-eight (61.3%) patients had the standard hepatic arterial anatomy. One hundred nineteen (19.8%) patients had variant left hepatic arteries (LHAs), and 89 (14.8%) had variant right hepatic arteries (RHAs). Twenty-eight (4.7%) patients had a variant anatomy involving both the LHA and the RHA. Twenty-four (4.0%) patients had a variant origin of the common hepatic artery (CHA) arising from either the superior mesenteric artery (SMA) or the aorta. In two patients, the proper hepatic artery (PHA) was the first branch of the SMA and the gastroduodenal artery (GDA) was a branch of the celiac axis. Double hepatic arteries were seen in 22 (3.7%) patients. Trifurcation or quadrifurcation of the GDA was seen in 50 (8.3%) patients, and the GDA originated distal to one hepatic artery in 25 (4.2%) patients in whom both hepatic arteries originated from the CHA.

CONCLUSION

A replaced LHA was less common than has been previously reported, and in two cases, the PHA arose from the SMA. Digital subtraction visceral angiographic results are comparable to results of seminal angiographic studies in which the cut-film technique was used.

Dendritic cells armed with anti-CD3 mAbs reduce pulmonary metastases, prolong survival, and engender antitumor effector cells demonstrable by adoptive transfer

BACKGROUND

Dendritic cells (DCs) pulsed with tumor cells or peptides are effective antitumor agents in a number of tumor models. In light of our earlier demonstration that T-cell signaling via the CD3 proteins induces cytolytic activity and constrains tumor progression, we equipped DCs pulsed with tumor cells with anti-CD3 mAbs and tested their antitumor efficacy in a murine renal cell cancer pulmonary metastasis model.

METHODS

We investigated the antitumor efficacy of DCs pulsed with whole irradiated tumor cells (DC/R) or DCs pulsed with irradiated tumor cells and armed with anti-CD3 mAbs (DC/R/anti-CD3 mAbs). Experimental end points included the number of pulmonary metastases and survival of tumor-inoculated mice.

RESULTS

Our studies demonstrate that arming tumor-pulsed DCs with anti-CD3 mAbs results in a superior outcome compared to that from tumor-pulsed DCs alone in terms of reduction in the number of pulmonary metastases and survival times. Furthermore, adoptive transfer experiments revealed that the splenocytes from DC/R/anti-CD3 mAbs-treated mice are superior to splenocytes from DC/R-treated mice in reducing renal cancer pulmonary metastases in severe combined immunodeficient (SCID) beige mice.

CONCLUSION

Our data suggest that the therapeutic efficacy of DCs pulsed with tumor cells can be augmented by arming them with anti-CD3 mAbs. DC-based treatment regimens that currently are being pursued in clinical trials might be improved by equipping such cells with anti-CD3 mAbs.

Interpretation of computed tomography does not correlate with laboratory or pathologic findings in surgically confirmed acute appendicitis

BACKGROUND

Computed tomography (CT) is used increasingly to diagnose acute appendicitis, despite variable technique and interpretation. We hypothesized that CT interpretation would not reflect actual clinical-pathologic findings in all demographic patient groups.

METHODS

A prospective university hospital database of 625 consecutive patients (1995-1999), all of whom were operated on for appendicitis (261, or 41.8%, within 24 hours of discretionary CT), was reviewed. CT and pathology data were obtained from final, written reports. CT criteria included free fluid or air, appendiceal visualization, mesenteric fat stranding, and blurred pericecal fat. Appendix pathology included acute, gangrenous, and perforated organs. Statistics were performed with the Fisher exact test (coordinate data) and univariate analysis of variance (continuous data); multivariate analysis of variance for independent effects on dependent variable (positive CT or pathology; P <.05).

RESULTS

The mean age was 35 +/- 1 years with 46.6% being female patients. CT was done more often in women and after 1997 (both P <.05). The sensitivity and specificity of CT were 96.1% and 16.1%, respectively. The positive predictive value (PPV) and accuracy rate (A) were 90%, and 88%, respectively. After CT, the incidence of finding a normal appendix was lower (19.3% vs 12.3%, P <.05), especially if the white blood cell count (WBC) was normal (< or = 11K/microL, 6.1% vs 23.2%, P <.001). If the WBC was < or = 11K/microL with positive CT, PPV/A was 73. 7%/71.3%, whereas with WBC > 11K/microL and positive CT, PPV/A was 99.4%/93.3%. Multivariate analysis of variance showed that none of the individual variables used by the radiologist to determine a positive CT scan correlated with outcome determined by surgical pathology. A healthy appendix was predicted by a CT interpreted as negative and younger age (both P <.05), and especially by lower WBC (P <.0001), but not by gender or surgeon.

CONCLUSIONS

Although the negative appendectomy rate was decreased by CT, there was no correlation between CT findings and pathologically proved disease. Other factors such as more precise patient selection by clinical criteria may also be improving outcome. A positive CT scan in a patient with a normal WBC should be interpreted with caution.

Choledochal cysts in adults: a report of two cases and review of the literature

A choledocal cyst is a dilation of some component of the biliary tract that may include both intra- and extra-hepatic sites. They are classified into six types, all of which are relatively rare. Previously, choledochal cysts were treated with biliary-enteric bypass procedures. The current recommendation is to attempt complete excision to minimize the known risk of malignancy and the development of recurrent cholangitis or pancreatitis that may occur in patients with these cystic lesions. Two cases are discussed in which type I choledochal cysts presented. One was removed from a 31-yr-old man who presented with vague abdominal complaints the other from a 32-yr-old man who presented with pancreatitis. The epidemiology, diagnosis, surgical treatment, and risk of cancer in choledochal cysts is described.