Abrupt onset of suture granuloma 27 years after hemithyroidectomy

Suture granuloma is a rare complication after thyroidectomy and usually manifests as a chronic inflammation mimicking cancer or even tuberculous lymphadenitis and can be expected within the first 2 postoperative years. We report the case of a 53-year-old woman who presented, 27 years after her first hemithyroidectomy, with a sudden onset of a growing lump on the same site. Neck magnetic resonance imaging revealed a fast-growing tumor suggestive of a cancerous lesion. An excisional biopsy revealed only acute inflammation with pus formation. During surgery, we excised 20 thickly ligated sutures from the neck. These sutures were suggested to have caused the suture granulomas.

Detection of minimal residual disease (MRD) in colorectal cancer (CRC) patients UICC stage II/III by ultra-deep sequencing of cfDNA from post-surgery plasma

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Background: Detection of primary tumor mutations in cell-free DNA (cfDNA) of post-surgery plasma of patients with R0-resected not-metastasized solid tumors is a strong indicator of recurrence of disease. We explored whether ultra-deep sequencing of cfDNA could improve sensitivity and specificity with respect to time-to-progression. Methods: 84 CRC patients UICC stage II/III were recruited into the prospective, observational study “Molecular Signatures in Colorectal Cancer”. Matched tumor tissue samples, plasma depleted blood cells (PDBC), and cfDNA (drawn 1 to 34 days after R0-resection, median 7 days) were processed with the Roche AVENIO Tumor Tissue and ctDNA Surveillance Kits*. Samples of 79 patients passed all quality controls, in particular cfDNA was sequenced ultra-deep with a median of 180 Mio. instead of 50 Mio. reads/sample. Somatic variants were identified with AVENIO Oncology Analysis software 2.0*. PDBC informed germline variants were removed. If a tissue baseline variant was detected in cfDNA with a significant adjusted p-value, the patient was defined ctDNA+, and ctDNA- otherwise. Results: 8 ctDNA+ patients (28 variants, median AF = 0.15%) were identified of which 4 had a progression of disease at two years. Sensitivity was 44% (95% CI [0.137, 0.788]), specificity was 94% (95% CI [0.86, 0.984]), positive predictive value was 50% (95% CI [0.157, 0.843]), and negative predictive value was 93% (95% CI [0.843, 0.977]). Comparison of time-to-progression of ctDNA+ and ctDNA- patients using the log-rank test resulted in a p-value of 0.0058. Comparison of survival times of ctDNA+ and ctDNA- patients resulted in a p-value of 0.0333. Multivariate analyses of times-to-progression resulted in ctDNA-status (p = 0.0022, hazard ratio (HR) = 7.098) and neoadjuvant therapy (p = 0.0010, HR = 6.618) as significant parameters. Conclusions: Even in this small cohort of CRC UICC stage II/III patients, MRD detection in post-surgery plasma is the strongest predictor of shorter time to progression. Ultra-deep sequencing of cfDNA samples did not influence MRD detection on a patient-level. *for Research Use Only; not for use in diagnostic procedures.

Giant bilateral adrenal lipoma in a patient with congenital adrenal hyperplasia

SUMMARY

Apart from adrenal myelolipomas, adrenal lipomatous tumors are rare and only seldom described in the literature. We present the case of a 50-year-old man, with a classical form of congenital adrenal hyperplasia (CAH), which was well treated with prednisolone and fludrocortisone. The patient presented with pollakisuria and shortness of breath while bending over. On MRI, fat-equivalent masses were found in the abdomen (14 × 19 × 11 cm on the right side and 10 × 11 × 6 cm on the left side). The right adrenal mass was resected during open laparotomy and the pathohistological examination revealed the diagnosis of an adrenal lipoma. Symptoms were subdued totally postoperatively. This is the first report of a bilateral adrenal lipoma in a patient with CAH that we are aware of.

LEARNING POINTS

Macronodular hyperplasia is common in patients with congenital adrenal hyperplasia (CAH). Solitary adrenal tumors appear in approximately 10% of adult CAH patients and are often benign myelolipomas. The Endocrine Society Clinical Practice Guideline does not recommend routine adrenal imaging in adult CAH patients. Adrenal imaging should be performed in CAH patients with clinical signs for an adrenal or abdominal mass. Adrenal lipoma is rare and histopathological examinations should rule out a differentiated liposarcoma.

[Case volume and complications after thyroid gland surgery in Germany: an analysis of routine data from 48,387 AOK patients]

BACKGROUND

Many studies showed that hospital and surgeon volume have a significant influence on the complication rates of thyroid surgery. The present study investigates whether this relationship applies in subtotal as well as total lobe resections. Furthermore, it is still unclear which threshold for the hospital-related case volume can be determined, above which the risk of complications lies below the current national average.

MATERIAL AND METHODS

The study was based on nationwide routine data for persons insured with the Local General Sickness Fund (AOK) who had undergone thyroid surgery in 2014-2016. Permanent vocal cord palsy, bleeding and wound infection needing revision were recorded using indicators. The effect of the case volume on the indicators and the case number threshold was determined using logistic regression.

RESULTS

Permanent vocal cord palsy was observed in 1.3% and bleeding or wound infections needing revision in 1.6% and 0.3% of the cases. Compared to hospitals with >450 surgeries per year, the risk of permanent vocal cord palsy in hospitals with fewer than 201, 101 and 51 surgeries was significantly increased (OR [95% CI]: 1.5 [1.1-2.1]; 1.5 [1.1-2.1]; 1.8 [1.3-2.5]). The threshold needed to achieve a risk for permanent vocal cord palsy below the national average (1.3%) was 265 thyroid surgeries per year (95% CI: 110-420). For bleeding or wound infection in need of revision, no association between volume and outcome was found.

CONCLUSION

The present study showed that the risk of postoperative permanent vocal cord palsy decreased with increasing case volume. The broad confidence interval of the threshold makes clear case volume recommendation difficult. In order that the risk for a postoperative permanent vocal cord palsy is not likely above the national average, the annual case volume should reach 110 thyroid interventions.

Abstract 2960: Concordance of genomic single-nucleotide variations (SNV) by next-generation sequencing (NGS) in paired tumor tissue and plasma in colorectal cancer (CRC)

Introduction: Determining mutations in plasma (cfDNA) is a noninvasive method of profiling tumor genomic alterations. In this study, concordance of SNVs using NGS between matched plasma and formalin-fixed, paraffin-embedded (FFPE) tissue samples was investigated across all four stages of CRC. We focused primarily on stages I, II and III to determine the feasibility of using plasma for minimal residual disease (MRD) surveillance after surgical resection and for early detection of CRC.

Methods: From a CRC biobank of >9,000 subjects, 299 subjects (47 stage I, 131 stage II, 102 stage III, and 19 stage IV) were selected for whom paired treatment-naïve FFPE tumor tissue and 4mL of plasma was available. MSI was determined by PCR (Promega). DNA was isolated from plasma and FFPE using cobas® extraction kits. Sequencing was performed using the AVENIO ctDNA Surveillance Kit (Research Use Only) and AVENIO FFPET Surveillance kit (under development). The AVENIO kit detects four mutation classes. In this analysis only SNVs data is presented. Three different filtering methods for concordance were used for this analysis: (i) by adaptive call, (ii) by duplex support, and (iii) by single read. Concordance is defined as at least the presence of one identical SNV between matched tissue and plasma sample.

Results: The most frequently mutated COSMIC genes in the tumor tissues of this cohort are TP53, APC, KRAS, PIK3CA, and BRAF with frequencies of 59%, 53%, 20%, 19% and 17% respectively. Using the most sensitive method (“by single read”), overall concordance in this cohort was 79.26%. The concordance for various stages (Stage I to Stage IV) ranges from 50-100%. If a more stringent criterion of adaptive call is used, then the concordance ranges from 21-89%. The mean number of somatic variants for MSI-low tumors (n=247) was 5.2 compared to 15.5 in MSI-high tumors (n=52) p-value 3.3e-14. Multivariate analysis showed that in addition to the clinical stage, tumor size was the most important clinical variable associated with concordance of SNVs between the matched tissue and plasma.

Conclusions: This study demonstrated an overall concordance of 79.26%. Concordance was associated with the disease stage and most significantly with tumor size and T stage. High concordance for subjects with localized disease (stages IB; IIA-IIC, and IIIA-IIIC) suggests that cfDNA sequencing can be potentially used for surveillance monitoring of patients after surgery, in particular for the detection of MRD. High tissue-plasma concordance for localized CRC may allow the use of cfDNA sequencing for early detection. Prospective clinical studies are required for validation of this application.

Citation Format: Preeti Lal, John Lee, Hans-Peter Adams, Lijing Yao, Frederike Fuhlbrück1, Stephanie Yaung, Sylvie McNamara, Corinna Wöstmann, Sebastian Fröhler, LiTai Fang, Rainer Kube, Frank Marusch, Michael Heise, Thomas Steinmüller, Matthias Pross, René Mantke, John Palma, André Rosenthal1. Concordance of genomic single-nucleotide variations (SNV) by next-generation sequencing (NGS) in paired tumor tissue and plasma in colorectal cancer (CRC) [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 2960.

Early prediction of clinical outcomes in resected stage II and III colorectal cancer (CRC) through deep sequencing of circulating tumor DNA (ctDNA)

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Background: Adjuvant chemotherapy is offered to most pts with Stage III CRC, and to a subset with Stage II disease deemed at high-risk for recurrence. Nevertheless, risk stratification strategies remain suboptimal. Detection of minimal residual disease (MRD) through ctDNA analysis has been shown to identify pts at high recurrence risk in Stage II CRC, but not Stage III disease. Methods: The next-generation sequencing based AVENIO ctDNA Surveillance Kit (Research Use Only) was used to identify single nucleotide variants (SNVs) in tumor tissue within a cohort of 145 Stage II and III CRC pts following R0 surgical resection (n = 86 and 59 respectively; median follow-up = 32.1 mo). The same assay was used to monitor ctDNA with a single post-operative blood sample (mean surgery-to-phlebotomy time: 10 days). Regions from 197 genes recurrently mutated in CRC were interrogated, and pts were classified as ctDNA positive (+) or negative (-) in plasma based on the detection of SNVs previously identified in tumor tissue. Results: Variants were identified in 99% of tumors (n = 144) with a median of 4 SNVs/sample (range 1-24) and all post-operative plasma samples were successfully profiled. Pts with detectable ctDNA (n = 12) displayed a significantly shorter 2-year relapse-free survival (RFS; 17% vs 88%; HR 10.3; 95% CI 2.3-46.9; p < 0.00001), time to recurrence (TTR; HR 20.6; 95% CI 3.1-139.0; p < 0.00001) and overall survival (OS; HR 3.4; 95% CI 0.5-25.8; p = 0.041) than ctDNA- pts (n = 132). 11 (92%) of ctDNA+ pts developed recurrence compared to 9 (7%) of ctDNA- pts. Monitoring multiple variants doubled sensitivity of MRD detection compared to tracking a single driver mutation. TTR was shorter in ctDNA+ vs ctDNA- Stage II (HR 23.1, 95% CI 0.28-1900.4; p < 0.00001) and stage III pts (HR 17.9; 95% CI 2.7-117.3, p < 0.00001). TTR of Stage II and III ctDNA- pts was similar (p = 0.7). Conclusions: Our results indicate that ctDNA analysis can detect MRD within days after complete resection of CRC and accurately identifies pts at high risk of recurrence in both Stage II and III CRC. MRD detection via ctDNA sequencing may allow personalization of adjuvant treatment strategies.

Functional Implications of LH/hCG Receptors in Pregnancy-Induced Cushing Syndrome

Context:

Elevated human choriogonadotropin (hCG) may stimulate aberrantly expressed luteinizing hormone (LH)/hCG receptor (LHCGR) in adrenal glands, resulting in pregnancy-induced bilateral macronodular adrenal hyperplasia and transient Cushing syndrome (CS).

Objective:

To determine the role of LHCGR in transient, pregnancy-induced CS.

Design, Setting, Patient, and Intervention:

We investigated the functional implications of LHCGRs in a patient presenting, at a tertiary referral center, with repeated pregnancy-induced CS with bilateral adrenal hyperplasia, resolving after parturition.

Main Outcome Measures and Results:

Acute testing for aberrant hormone receptors was negative except for arginine vasopressin (AVP)–increased cortisol secretion. Long-term hCG stimulation induced hypercortisolism, which was unsuppressed by dexamethasone. Postadrenalectomy histopathology demonstrated steroidogenically active adrenocortical hyperplasia and ectopic cortical cell clusters in the medulla. Quantitative polymerase chain reaction showed upregulated expression of LHCGR, transcription factors GATA4, ZFPM2, and proopiomelanocortin (POMC), AVP receptors (AVPRs) AVPR1A and AVPR2, and downregulated melanocortin 2 receptor (MC2R) vs control adrenals. LHCGR was localized in subcapsular, zona glomerulosa, and hyperplastic cells. Single adrenocorticotropic hormone–positive medullary cells were demonstrated in the zona reticularis. The role of adrenal adrenocorticotropic hormone was considered negligible due to downregulated MC2R. Coexpression of CYP11B1/CYP11B2 and AVPR1A/AVPR2 was observed in ectopic cortical cells in the medulla. hCG stimulation of the patient’s adrenal cell cultures significantly increased cyclic adenosine monophosphate, corticosterone, 11-deoxycortisol, cortisol, and androstenedione production. CTNNB1, PRKAR1A, ARMC5, and PRKACA gene mutational analyses were negative.

Conclusion:

Nongenetic, transient, somatic mutation-independent, pregnancy-induced CS was due to hCG-stimulated transformation of LHCGR-positive undifferentiated subcapsular cells (presumably adrenocortical progenitors) into LHCGR-positive hyperplastic cortical cells. These cells respond to hCG stimulation with cortisol secretion. Without the ligand, they persist with aberrant LHCGR expression and the ability to respond to the same stimulus.

Local recurrence in the neck and survival after thyroidectomy for metastatic renal cell carcinoma

BACKGROUND

Most investigations of thyroidectomy for metastatic renal cell carcinoma (RCC) are case studies or small series. This study was conducted to determine the contribution of clinical and histopathologic variables to local recurrence in the neck and overall survival after thyroidectomy for RCC metastases.

METHODS

The medical records of 140 patients with thyroidectomy for metastatic RCC performed between 1979 and 2012 at 25 institutions in Germany and Austria were analyzed.

RESULTS

The median interval between nephrectomy and thyroidectomy was 120 months. Concurrence of thyroid and pancreatic metastases was present in 23 % of the patients and concurrence of thyroid and adrenal metastases in 13 % of the patients. Clinical outcome data were available for 130 patients with a median follow-up period of 34 months. The 5-year overall survival rate was 46 %, and 28 % of patients developed a local neck recurrence at a median of 12 months after thyroidectomy. Multivariate analysis showed that invasion of adjacent cervical structures (hazard ratio [HR] 3.2; p = 0.001), patient age exceeding 70 years (HR 2.5; p = 0.004), and current or past evidence of metastases to nonendocrine organs (HR 2.4; p = 0.003) were independent determinants of inferior overall survival. Conversely, invasion of adjacent cervical structures (HR 12.1; p < 0.0001) and year of thyroidectomy (HR 5.7 before 2000; p < 0.0001) were shown to be independently associated with local recurrence in the neck by multivariate analysis.

CONCLUSIONS

Although significant improvement of local disease control in patients with thyroid metastases of RCC has been achieved during the last decade, overall outcome continues to be poor for patients with locally invasive thyroid metastases.

Early experience with a novel gelatine-based sponge for local haemostasis in thyroid surgery

AIM

The aim of the present investigation was to assess the feasibility, efficacy and safety of a novel gelatine-based sponge as a haemostat in thyroid surgery.

PATIENTS AND METHODS

A questionnaire was completed by surgeons after having used the sponge in thyroid surgery. The product in general, its effectiveness as a haemostat, its absorption capacity and handling issues were rated. Moreover unexpected complications or side-effects were documented.

RESULTS

Whenever thyroid resections were performed by the members of our study group (11 consultant surgeons in 8 hospitals specialized in thyroid surgery) the new haemostat was used during the period of surveillance. It was mainly rated as "excellent" or "good" by the study group members who used the product in 87 thyroid resections. Its effectiveness as a haemostat, its absorption capacity and handling issues were also rated as excellent. No poor results were reported. Complications occurred in only 2% of cases and were related to inappropriate application.

CONCLUSION

The evaluated data demonstrated that the sponge has an excellent safety and haemostatic efficacy in surgical application. The product is user-friendly and demonstrated its effectiveness as a haemostat and its excellent absorption capacity.

German Association of Endocrine Surgeons practice guideline for the surgical management of malignant thyroid tumors

INTRODUCTION

Over the past years, the incidence of thyroid cancer has surged not only in Germany but also in other countries of the Western hemisphere. This surge was first and foremost due to an increase of prognostically favorable ("low risk") papillary thyroid microcarcinomas, for which limited surgical procedures are often sufficient without loss of oncological benefit. These developments called for an update of the previous practice guideline to detail the surgical treatment options that are available for the various disease entities and tumor stages.

METHODS

The present German Association of Endocrine Surgeons practice guideline was developed on the basis of clinical evidence considering current national and international treatment recommendations through a formal expert consensus process in collaboration with the German Societies of General and Visceral Surgery, Endocrinology, Nuclear Medicine, Pathology, Radiooncology, Oncological Hematology, and a German thyroid cancer patient support organization.

RESULTS

The practice guideline for the surgical management of malignant thyroid tumors includes recommendations regarding preoperative workup; classification of locoregional nodes and terminology of surgical procedures; frequency, clinical, and histopathological features of occult and clinically apparent papillary, follicular, poorly differentiated, undifferentiated, and sporadic and hereditary medullary thyroid cancers, thyroid lymphoma and thyroid metastases from primaries outside the thyroid gland; extent of thyroidectomy; extent of lymph node dissection; aerodigestive tract resection; postoperative follow-up and surgery for recurrence and distant metastases.

CONCLUSION

These evidence-based recommendations for surgical therapy reflect various "treatment corridors" that are best discussed within multidisciplinary teams and the patient considering tumor type, stage, progression, and inherent surgical risk.

Major influence of liver function itself but not of immunosuppression determines glucose tolerance after living-donor liver transplantation

Controversial data exists concerning the impact of immunosuppressive therapy on the development of post-transplantation diabetes mellitus (PTDM). Therefore, we investigated glucose metabolism in healthy donors and in recipients of living-donor liver transplants (LD-LTX, n=18) without pre-existing diabetes mellitus before, on day 10, month 6, and month 12 after intervention. The computer-assisted analysis of glucose, insulin, and C-peptide profiles obtained from frequently sampled intravenous glucose tolerance tests allows to achieve an integrated view of factors controlling glucose tolerance, i.e., insulin sensitivity (SI), first and second phase insulin secretion (phi1 and phi2). SI of donors declined by day 10 after operation (SI 2.65 +/- 0.41 vs. 4.90 +/- 0.50 10(-4) minute(-1) microU ml(-1), P < 0.01) but returned to values as before after 6 months. Phi1 did not change. Phi(2), however, significantly increased by day 10 (8.57 +/- 0.82 10(9) minute(-1) to 13.77 +/- 1.53 10(9) minute(-1), P < 0.01) but was in the same range as before after 6 months. In parallel to donors SI of recipients progressively increased after LD-LTX. Phi1 did not alter in recipients. Phi2 continuously decreased and was not different from donors by month 12. The extent of liver injury assessed by liver enzyme concentrations and liver function represented by cholinesterase activity, albumin, and INR were closely related with changes of SI in donors and recipients during the first year after intervention. In conclusion, the extent of liver damage plays a predominant role in regulating glucose tolerance. No impact of immunosuppressive therapy on SI, phi1 and phi2 was detected.

Prevalence of Thyroid Nodules and Carcinomas in Patients Operated on for Renal Hyperparathyroidism: Experience with 339 Consecutive Patients and Review of the Literature

The association between renal hyperparathyroidism (HPT) and differentiated thyroid carcinoma is discussed. To determine the prevalence and potential risk factors, we performed a retrospective analysis of our patients (1998-2004) and compared the data with the data from other surgical and autopsy studies. At our hospital, a total of 347 parathyroidectomies in 339 patients with renal HPT were performed. Most patients underwent preoperative ultrasound investigation of the thyroid gland and, if indicate, thyroid scintigraphy. Intraoperatively, both thyroid lobes were mobilized and palpated. Detected thyroid nodules were adequately resected and investigated histologically. A systematic analysis of the international literature was performed using the PubMed/MEDLINE system to identify publications on the prevalence of papillary thyroid carcinoma (PTC) in patients with renal HPT and in the overall population. Altogether, 133 patients (39.2%) underwent simultaneous thyroid surgery. The initial operation was hemithyroidectomy in 55 (16.2%), Dunhill operation in 36 (10.6%), unilateral subtotal resection in 17 (5.0%), bilateral subtotal resection in 5 (1.5%), and enucleation of a thyroid nodule in 18 (5.3%). A PTC was found in 8 of 339 patients (2.4%) and a follicular thyroid carcinoma in 1. Among 311 patients with primary cervical operation, 6 (1.9%) had a papillary thyroid carcinoma. All papillary tumors were classified as pT1 with a diameter of 1 to 12 mm; three were bifocal, and only one patient had positive lymph nodes. None of the analyzed factors showed a significant correlation with the occurrence of thyroid carcinoma. Depending on the screening method, the prevalence of occult PTC in European autopsy studies ranged from 5% to 9% and was markedly higher in almost all studies than in the present one. The prevalence of PTC in the present study makes an etiologic association between renal HPT and PTC unlikely. The clinical significance of these tumors remains unclear because all incidental tumors were small. However, if easily and safely feasible, relevant thyroid nodules should be removed during parathyroid surgery.

No influence of immunosuppression on insulin sensitivity and beta-cell function in living donor liver transplantation

In liver transplantation alterations of glucose metabolism are common but not well understood. Influence of immunosuppression is widely presumed but has not proven until now. Using a frequently sampled intravenous glucose tolerance test with a minimal modeling technique of glucose disappearance we analyzed insulin sensitivity (SI) and beta-cell function (first and second phase of pancreatic beta-cell secretion, Phi 1 and Phi 2) in living donor liver transplantation of the right lobe. Initial immunosuppression in recipients was done with tacrolimus, prednisolone, and basiliximab induction. Donors and recipients were investigated before and 10 days, 6 months, and 1 year after operation. Normal SI of controls (donors before operation) decreased markedly 10 days after right lobectomy to SI 2.22 +/- 0.35 x 10(-4) min(-1) x microU/mL (P < .001); Phi 2 was compensatory increased. All parameters normalized within 1 year. Recipients were insulin-resistant with hyperinsulinemia before transplantation. After transplantation no parameter was significantly different from donors; all normalized equally to donors over 1-year follow-up. Thus, immunosuppression in recipients has no influence on glucose metabolism because liver function itself seems to play a more pronounced role than known until now.

Predictive value of intact parathyroid hormone measurement during surgery for renal hyperparathyroidism

BACKGROUND AND AIMS

In contrast to that in patients with primary hyperparathyroidism, the value of intraoperative intact parathyroid hormone (iPTH) measurement is still unclear in patients with renal hyperparathyroidism and was, therefore, evaluated in a large cohort of patients.

PATIENTS

Intraoperative iPTH measurement was performed in 153 patients with renal hyperparathyroidism (129 with terminal renal failure and 24 with functioning kidney graft). Subtotal and total parathyroidectomy were performed in 123 and 13 patients, respectively, during initial surgery. In patients with recurrent disease (17), the respective hyperfunctioning tissue was removed. Intraoperative blood samples were obtained by puncture of the internal jugular vein before preparation of the parathyroids (PTH0) and 15 min after parathyroidectomy (PTH15). iPTH was measured with the Elecsys 2010 system. Postoperative iPTH levels (PTH(post)) were determined at postoperative days 1 to 3 and at week 2. Patients were arbitrarily divided in four groups according to the postoperative iPTH values: 0-25 pg/ml (group 1), 26-65 pg/ml (group 2), 66-150 pg/ml (group 3) and more than 150 pg/ml (group 4).

RESULTS

The mean PTH0 value was 869+/-57 pg/ml, which decreased to 167+/-15 pg/ml at PTH15. The mean relative PTH15 value was 21.6+/-1.7%. Postoperatively, iPTH decreased to 42+/-9 pg/ml. The postoperative iPTH value of the 129 patients with terminal renal failure was 25 pg/ml or less in 99 patients, 26-65 pg/ml in 11 patients, 66-150 pg/ml in eight patients and higher than 150 pg/ml in 11 patients. Two successive criteria of iPTH decrease were used: first, a PTH15 of < or =150 pg/ml or, second, a relative PTH15 of < or =30% less was used. Fifteen patients did not fulfil both criteria. In 13 of them (86.7%) iPTH(post) was higher than 65 pg (true failure to decline). Of 114 patients who fulfilled the criteria, 108 (94.7%) had normal postoperative iPTH values (true decline). Absolute PTH15 values of less than 150 pg/ml predicted normal postoperative iPTH levels in 77 of 78 patients.

CONCLUSION

A PTH15 value of 150 pg/ml or less predicts operative success in patients with renal failure in 98.7% of cases, independently of the relative decay. In contrast, if the relative PTH15 is higher than 30%, high postoperative PTH values are predicted with a probability of 86.7%. Although there remain some borderline cases, intraoperative iPTH measurement is accurate and also can be useful in patients with renal hyperparathyroidism.

Parathyroid Hormone Venous Sampling Before Reoperative Surgery in Renal Hyperparathyroidism

OBJECTIVES

To analyze the predictive values of selective venous sampling (SVS) in our own experience and in a systematic meta-analysis of the international literature and to compare them with the results of noninvasive localization studies before reoperative parathyroid surgery.

DATA SOURCES

Twenty-one consecutive patients with persistent or recurrent renal hyperparathyroidism underwent preoperative SVS and noninvasive imaging. These data were added to a systematic review of the literature on localization studies before reoperative surgery. The literature search included localization studies, recurrent hyperparathyroidism, and reoperation. STUDY SELECTION Prospective and retrospective studies that provided at least the true-positive rate of 1 procedure were included. Data from initial surgery, hyperfunctioning autografts, and case reports were excluded.

DATA EXTRACTION

Thirty-one publications reported on SVS (n = 22), technetium Tc 99m sestamibi scintigraphy (n = 17), thallium-technetium scintigraphy (n = 11), ultrasonography (n = 18), magnetic resonance imaging (n = 12), and computed tomography (n = 13). The overall analysis was performed by dividing the overall number of true- and false-positive results by the total number of patients.

DATA SYNTHESIS

Localization by SVS was correct in 20 of 21 patients. In 1 patient with 2 localizations, only 1 was predicted correctly. Therefore, the sensitivity of SVS was at least 90%, with no false-positive results. Overall true- and false-positive rates, respectively, in 31 studies were 71% and 9% for SVS, 69% and 7% for technetium Tc 99m sestamibi scintigraphy, 54% and 16% for magnetic resonance imaging, 55% and 15% for thallium-technetium scintigraphy, 50% and 18% for ultrasonography, and 45% and 14% for computed tomography.

CONCLUSIONS

With its high sensitivity, SVS is the gold standard in patients with persistent or recurrent renal hyperparathyroidism and negative results of noninvasive localization procedures. The noninvasive procedure of choice is now technetium Tc 99m sestamibi scintigraphy, with high sensitivity and a low rate of false-positive results.

Charakterisierung von Lebertumoren durch kontrastverstärkte Sonographie und digitale Graustufenbestimmung

PURPOSE

The characterization of different liver tumors is of therapeutic and prognostic relevance and has been the purpose of several studies. Although ultrasound offers the opportunity to detect hepatic tumors without ionizing radiation, its previous techniques did not lead toward a definitive differentiation of different tumor entities. The purpose of this study was the clinical evaluation of contrast enhanced ultrasound followed by quantitative digital analysis in patients with focal hepatic tumors.

MATERIALS AND METHODS

In a prospective study, 50 patients (18 females, 32 males, age 28 to 83 years, mean age 59.4 years) with liver tumors previously detected by CT (n = 47) or MRI (n = 3) were examined by ultrasound of the upper abdomen using conventional technique and phase inversion technique after intravenous application of sulfur-based contrast enhancer SonoVue. At scheduled intervals after application of the contrast enhancer, a digital image was stored and the characteristic signal course of each lesion determined semiquantitatively. The gold standard was either resection (n = 17), percutaneous needle biopsy (n = 19) or the clinical course (n = 14).

RESULTS

While the percentage of tumors correctly characterized by CT/MRI amounted to 78 %, the percentage increased from 60 % using conventional ultrasound to 86 % using contrast enhanced ultrasound including grey-scale analysis. Typical graphs were achieved for different tumor entities on digital grey-scale analysis. The optimal intervals for the differentiation of particular entities were 20 and 100 seconds after injection.

CONCLUSION

Quantification of contrast enhanced ultrasound is an addition to the previous diagnostic procedure in hepatic tumors. It offers the possibility of an investigator-independent characterization of lesions and should be evaluated in further studies.

Postural hand tremor before and following liver transplantation and immunosuppression with cyclosporine or tacrolimus in patients without clinical signs of hepatic encephalopathy

OBJECTIVE

To assess tremor characteristics and severity in patients with severe liver disease without hepatic encephalopathy and following orthotopic liver transplantation (LTX) and immunosuppression (IS) with cyclosporin A (CsA) or tacrolimus (FK 506).

METHODS

A total of 35 consecutive patients were included into the prospective study and serum levels of CsA (n = 29) or FK 506 (n = 6) were monitored following LTX. Tremor characteristics and severity were assessed by two-blinded raters before and following LTX. In addition, accelerometric recordings were taken before and after LTX, and compared with 16 normal controls without tremor and without clinical signs of hepatic encephalopathy or liver disease. Accelerometry was performed while sitting in a comfortable chair with the forearms supported and included rest and postural condition with and without weight load (500 g) on each hand. Kolmogorov-Smirnov test, paired t-test and t-test for independent samples were used for statistical analysis.

RESULTS

The clinical rating revealed no rest but a mild postural hand tremor before LTX with a significant increase following LTX (p < 0.001). After LTX the mean score of postural tremor was significantly (p < 0.05) higher in patients with plasma levels of >850 ng CsA/ml compared with patients with lower levels. Patients and normal controls showed comparable mean peak frequencies of rest and postural hand tremor. The mean amplitude of postural hand tremor was significantly higher in patients before and after LTX compared with controls. In the majority of patients (89%) and controls (88%), the dominant tremor frequency decreased significantly (>1.5 Hz) when applying a weight load on each hand.

CONCLUSION

The present study is the first to describe hand tremor characteristics in patients with severe liver disease without clinical signs of hepatic encephalopathy and in patients following LTX and IS. Compared with normal controls the patients showed a significant postural hand tremor prior and post-LTX and an increase of mean tremor amplitude following LTX and CsA/FK 506 treatment. The decrease of the dominant tremor frequency with weight load and an increase of tremor amplitude with higher plasma levels of CsA are both indicative of an enhanced physiological or toxic tremor.

Role of F18-FDG PET for Monitoring of Radiochemotherapy – Estimation of Detectable Number of Tumour Cells

BACKGROUND

FDG-PET has been proven to be useful for the diagnosis of pancreatic cancer. However, no quantitative data exist concerning its sensitivity for treatment monitoring or early diagnosis.

CASE REPORT

We report on a 61-year-old patient with locally advanced cancer of the pancreas head who received sequential radiochemotherapy including gemcitabine and 5-FU/FA. Under this regimen, MR and CT showed a partial remission with a residual mass which seemed to allow surgical treatment for this patient. A pre-operative FDG-PETScan displayed a count rate close to the detection limit of vital residual tumour. An R0 resection was performed successfully. However, histopathology revealed residual tumour at the core of the resected mass that had gone undetected by all imaging modalities.

CONCLUSION

The number of vital tumour cells within this specimen was estimated to be 10(6)-10(7). The detection threshold for FDG-PET in pancreatic carcinoma appears to be within this range.

Diagnosis of neuroendocrine tumours by retrospective image fusion: is there a benefit?

This study evaluated the use of image fusion in the preoperative staging of neuroendocrine tumors (NET) of the pancreas and the gastrointestinal tract (GIT). Thirty-eight patients suffering from a metastasized NET with location of the primary in the pancreas ( n=15) or the GIT ( n=23) were examined by somatostatin receptor scintigraphy (SRS) and computed tomography (CT). Consecutive image registration and fusion were performed using custom-built software integrated in AVS/Express (Advanced Visual Systems, Waltham, MA, USA). Registration was performed by a voxel-based algorithm based on normalized mutual information. Image fusion was feasible in 36/38 patients. A total of 87 foci were assigned to anatomical regions (e.g. gut, pancreas, liver, lymph node or others) by two independent observers in both SRS and SRS/CT fusion images. The assignments used a binary ranking system (1="definite", 0="not definite"). These results were then retrospectively compared to the classification of the foci, based on postoperative histology or clinical follow-up. Imaging by SRS allowed a definite anatomical assignment in 57% (50/87) and 61% (53/87) of all lesions in the case of observers A and B, respectively. Image fusion improved the topographic assignment to 91% (79/87) and to 93% (81/87). The number classified as "definite" by both observers increased from 54% (47/87) to 86% (77/87). The increase in definite assignments was highly significant for both observers ( P<0.0001 for each). In the case of foci classified as liver metastases, image fusion allowed improved assignment to the corresponding liver segment from 45% (18/40) to 98% (39/40) and from 58% (23/40) to 100% (40/40) by observers A and B, respectively. Furthermore, the improved assignment of foci classified as lesions by image fusion was relevant for therapy in 7/36 patients (19%). Therefore, the image fusion technique presented herein appears to be a very useful method for clinical routine.

Complex vascular reconstructions in living donor liver transplantation

We describe here the indications for and our experience with complex vascular reconstructions in living donor liver transplantation. From December 1999 to June 2002, 59 patients underwent liver transplantation, 51 receiving the right lobe, and 8 the left lateral lobe, as a graft from a living donor. The indication for interpositional grafts on the arterial side (6/59, 10%) were stenoses of the celiac trunk and after resection of the hepatic artery for oncological reasons in adults. In children, arterial interpositional grafts were performed in situations of long distances between the donor and recipient artery, or in cases of inflow release from the aorta in patients with small hepatic arteries. On the portal-venous side, one interpositional graft was performed after an oncological resection. Once the portal vein was partially arterialized because of insufficient inflow. We used veins from the recipient, and native or cryopreserved arterial homografts for these grafts. All patients were treated during the first 6 months after transplantation with aspirin only. During the follow-up we did not observe vascular complications. If required, vascular interpositional grafts in the arterial and portal-venous position can be performed without adding postoperative complications.

[Accuracy of the CT-estimated weight of the right hepatic lobe prior to living related liver donation (LRLD) for predicting the intraoperatively measured weight of the graft]

PURPOSE

Due to the shortage of cadaver donors, living related liver donation (LRLD) has emerged as an alternative to cadaver donation. The expected graft weight is one of the main determinants for donor selection. This study investigates the accuracy of preoperatively performed CT-volumetry to predict the actual weight of the right liver lobe graft.

MATERIALS AND METHODS

In a prospective study the weight of the right hepatic lobe was calculated by volumetric analysis based on CT in 33 patients (21 females, 12 males, mean age 42.1 years, median age 41 years) prior to living related liver donation. Graft weight was calculated as the product of CT-based graft volume and 1.00 g/ml (the approximated density of healthy liver parenchyma). The calculated weight was compared with the intraoperatively measured weight of the harvested right hepatic lobe. The difference was used to determine a correction factor for estimating the actual graft weight.

RESULTS

Based on the assumption of a parenchymal density of 1.00 g/ml, the preoperatively estimated graft weight (mean 980 g +/- 168 g) deviated +33 % from the intraoperatively measured right hepatic lobe weight (mean 749 g +/- 170 g). By reducing the preoperatively predicted weight of the right hepatic lobe with a correction factor of 0.75, the actual graft weight can be calculated.

CONCLUSION

Preoperative estimation of the weight of the right hepatic lobe based on CT of living related liver donors predicts the weight of the right lobe graft with sufficient accuracy by applying a single correction factor. Intraoperative fluid loss (i.e., blood, bile) from the harvested liver as well as variations in parenchymal density may contribute to the observed preoperative overestimation of the actual graft volume by CT-based volumetry.

Clinical extracorporeal hybrid liver support--phase I study with primary porcine liver cells

The objective of this study was to evaluate the feasibility and safety of a hybrid liver support system with extracorporeal plasma separation and bioreactor perfusion in patients with acute liver failure (ALF) who had already fulfilled the criteria for high urgency liver transplantation (LTx). Eight patients (one male, seven female) were treated in terms of bridging to transplantation. The mean age was 36.5 yr (range 20 to 58). Etiology of liver failure was drug-related in two patients, hepatitis B infection in three patients, and unknown for three patients. The bioreactors were charged with primary liver cells from specific pathogen-free pigs. Cell viability varied between 91 and 98%. Continuous liver support treatment over a period of 8 to 46 h (mean 27.3 h) was safely performed and well-tolerated by all patients. No complications associated with the therapy were observed during the follow-up period. Thrombocytopenia was considered to be an effect of the plasma separation. Subsequently, all patients were transplanted successfully and were observed over at least 3 yr with an organ and patient survival rate of 100%. Screening of patient's sera for antibodies specific for porcine endogenous retroviruses (PERVs) showed no reactivity--either prior to application of the system, or after extracorporeal treatment. The results encourage us to continue the development of the technology, and further studies appear to be justified. The bioreactor technology has been integrated into a modular extracorporeal liver support (MELS) system, combining biologic liver support with artificial detoxification technology.

Clinical implications of hepatic preservation injury after adult liver transplantation

Several advances in organ preservation have allowed for improved results after liver transplantation; however, little information is available regarding the clinical impact of preservation injury on the postoperative course. The medical records of 889 liver transplants were retrospectively reviewed. Preservation injury was classified according to postoperative aspartate aminotransferase values as minor (<1000 U/L), moderate (1000-5000 U/L), or severe (>5000 U/L). The following criteria were analyzed and compared according to the extent of preservation injury: patient and graft survival, retransplantation rate, duration of hospitalization and postoperative ventilation, as well as incidence of rejection, infection, and hemodialysis. The majority of patients received a liver with minor preservation injury (75.9%), whereas 22.7% and 1.3% of grafts showed moderate or severe injury. Graft survival was significantly lower in patients with severe preservation injury, when compared to minor or moderate injury. The relative risk for initial nonfunction was 39.36-fold increased (95% confidence interval (ci): 10.3-150.2), as it was increased for duration of postoperative ventilation (6.92-fold; 95%ci: 2.1-22.3) and hemodialysis (6.13-fold; 95%ci: 1.9-19.3). Since the incidence of retransplantation was significantly increased (50%), patient survival remained comparable between all groups. Severe preservation injury had a tremendous impact on the postoperative clinical course, requiring the maximum medical effort to achieve adequate patient survival.

Mycophenolatemofetil for immunosuppression after liver transplantation: a follow-up study of 191 patients

BACKGROUND

Mycophenolatemofetil (MMF) combined with calcineurin inhibitors (CNIs) as immunosuppression after orthotopic liver transplantation (OLT) is still under discussion. We retrospectively investigated the immunosuppressive potency of MMF for treatment of steroid-resistant acute rejection (AR) or chronic rejection (CR), chronic graft dysfunction, and CNI-induced toxicity in patients after OLT.

METHODS

Between 1988 and 2001 we performed 1386 OLTs in 1258 patients. Since 1995, 191 patients have received MMF after OLT for steroid-resistant AR or CR, chronic graft dysfunction (115 patients), and CNI-induced toxicity (76 patients). The mean follow-up time was 56 months.

RESULTS

Of 47 patients with steroid-resistant AR, 12 had been treated with OKT3, without resolving the rejection. Overall, bilirubin and transaminases decreased significantly within 2 weeks after the addition of MMF, and liver function normalized in 38 patients. Five of eight patients with CR demonstrated stable liver function after a follow-up of 55+/-8 months; 52 of 60 patients with chronic graft dysfunction improved within 3 months; and 46 of 59 patients with CNI-induced nephrotoxicity improved after MMF treatment and a reduction of CNIs (with a significant decrease in serum creatinine within 2 weeks and an increase of creatinine clearance within 3 months). Clinical symptoms improved in 10 of 12 patients with neurotoxicity and four of five patients with hepatotoxicity. Side effects of MMF, such as gastrointestinal disorders or bone marrow toxicity, occurred in 60 patients (31.4%). The incidence of infections did not increase. Patient survival was 93%, and graft survival was 88.2%.

CONCLUSIONS

MMF is a potent and safe immunosuppressive agent in OLT recipients for rescue therapy in AR, CR, or chronic graft dysfunction and helps to reduce the serious toxic side effects of CNIs.

Multicenter evaluation of a new immunoassay for intact PTH measurement on the Elecsys System 2010 and 1010

BACKGROUND AND OBJECTIVE

The determination of parathyroid hormone (PTH) is of great clinical relevance in the assessment of calcium metabolic disorders. Although PTH was one of the first hormones measured by immunoassays, there are still many difficulties in its determination due to the low concentration of the hormone in blood and due to the heterogeneity of PTH resulting from different circulating hormone fragments. The aim of our multicenter-study was to evaluate the technical performance and the clinical validity of a new immunoassay for intact PTH measurement on the Elecsys Systems 2010 and 1010.

METHODS AND RESULTS

The multicenter evaluation was performed in 11 clinical laboratories. The Elecsys PTH assay is a one step sandwich electrochemiluminescence immunoassay based upon the streptavidin-biotin technology. Two monoclonal antibodies are used in the assay providing detection of intact PTH. The imprecision study yielded within-run and between-days coefficients of variation of 3.1% - 6.6% and 3.4% - 15.6%, respectively using a three level control (PreciControl Bone, Roche Diagnostics) and human pool sera at two different concentrations (HS-low: 20 - 60 pg/ml, HS-high > 65 pg/ml). The analytical sensitivity calculated as the mean value plus 2 standard deviations of a within-run imprecision was below 2.70 pg/ml using zero calibrator matrix. Dilution linearity was observed up to 4890 pg/ml using zero calibrator matrix or human pool sera. Recoveries ranged between 85% - 115%. Serum, EDTA- and heparin plasma were evaluated for PTH measurement. Due to a better analyte stability (48h at 21 degrees C; 3d at 4 degrees C) EDTA plasma was recommended for PTH measurement. Results of the Elec sys PTH immunoassay correlated well (r = 0.926 - 0.994) with three different immunoradiometric assays (N-tact PTH SP, DiaSorin; Nichols Allegro Intact PTH, Nichols Institute Diagnostics; ELSA-PTH, CISBio International) and two different immunochemiluminometric assays (PTH-Intact-Immulite, DPC Biermann; Nichols Advantage Intact PTH, Nichols Institute Diagnostics) in technical and clinical method comparisons. The Passing/Bablok regression analysis yielded slopes of 0.692 - 1.729 and intercepts of -13.982 - +15.763 pg/ml. Deviations from slope 1.0 and intercept 0.0 were not unexpected due to differences in immunoassay standardization and probably due to the presence of different PTH fragments and a variable affinity of the used antibodies to these PTH fragments. Highly similar PTH concentration pattern of the Elecsys immunoassay and the Quick-Intraoperative Intact PTH immunoassay (Nichols Institute Diagnostics) obtained from specimens taken intraoperatively support the applicability of the Elecsys immunoassay to monitor the success of parathyroid resection. A reference range of 12.3 - 56.0 pg/ml calculated from PTH values of 43 apparently healthy individuals confirms reference limits published in the literature. The partition of collectives according to age showed, that individuals > 50 years have slightly higher PTH concentrations, independently of gender. This shift could be due to age itself or to an increased prevalence of individuals without obvious calcium metabolic disorders in this collective.

CONCLUSION

The Elecsys PTH assay is a useful and reliable tool for determination of intact PTH. Our data support the intended use of the assay in clinical applications related to disorders of calcium metabolism.

Complete bile duct sequestration after liver transplantation, caused by ischemic-type biliary lesions

Ischemic-type biliary lesions (ITBLs) are the most frequent cause of nonanastomotic biliary strictures in liver grafts, affecting about 2-19 % of patients after liver transplantation. ITBL is characterized by bile duct destruction, subsequent stricture formation, and sequestration. We report here the case of a patient affected by extremely severe ITBL, with sequestration and disintegration of the entire bile duct system, in which it was possible to extract the complete biliary tree endoscopically in a single piece. Histological examination revealed that all cells of the bile duct wall had been destroyed within 3 months after liver transplantation and replaced by connective tissue. Subsequently, biliary stricture formation occurred at the hepatic hilum, as well as the adjacent large bile ducts. It may be hypothesized that cellular rejection of small bile ducts leads to the vanishing bile duct syndrome, whereas cellular rejection of large bile ducts results in ITBL. The strictures were repeatedly dilated by endoscopic means, allowing successful control of stricture formation, as well as maintenance of liver function. At the time of writing, the grafted organ and the patient had survived for more than 3 years in good health. This is the first detailed report on a sequestration of the entire bile duct system caused by ITBL, successfully treated for several years by endoscopic means.

Primary permanent arterialization of the portal vein in liver transplantation

Permanent total arterialization of the portal vein in liver transplantation has been described as a method of providing portal inflow after insufficient thrombectomy due to chronic occlusion of the portal-vein system. A specific problem is the restriction of the arterial inflow and its long-term adaptation after transplantation. We describe here the surgical techniques and clinical course of three patients who underwent portal-vein arterialization for liver transplantation. Two patients had an uneventful course. In one patient, a flow reduction by means of coil embolization of one arterial inflow branch was performed; thereafter, the patient recuperated well. Analysing the microcirculation of an arterialized graft in comparison with liver grafts with normal non-arterialized portal-vein inflow, we observed an increase in inter-sinusoidal distance and a decrease in sinusoidal red blood cell velocity. From a technical point of view, we recommend permanent portal-vein arterialization by an iliac artery graft interposition from the subdiaphragmatic aorta. The inflow to the portal vein can easily be reduced by the banding of the arterial graft interposition.

Review article: liver transplantation for hepatocellular carcinoma

Despite recent advances in techniques of in situ tumour ablation, surgical therapy remains at present the mainstay treatment for primary hepatic malignancies. After an initial endeavour in the establishment of liver transplantation as a treatment option, in particular for unresectable liver tumours, only a few indications, for example early hepatocellular carcinoma in cirrhosis, are currently agreed upon. Other indications, such as peripheral cholangiocarcinoma and hepatocellular carcinoma in noncirrhotics have largely been abandoned or are still under debate, as is the case with fibrolamellar carcinoma. The selection of patients suffering from hepatocellular carcinoma in cirrhosis for liver transplantation is still based on tumour size and node number, because the current state of diagnostic imaging fails to reliably predict the most important prognostic parameter: vascular infiltration. Other selection criteria are under investigation. Studies on multimodal therapy are also underway but have not yet demonstrated a clear benefit.

Hepatic artery thrombosis after adult liver transplantation

The incidence, clinical presentation, therapeutic options, and outcome of hepatic artery thrombosis (HAT) were analyzed in a series of 1,192 consecutive adult orthotopic liver transplantations (OLTs). HAT after OLT was observed in 30 cases, resulting in an incidence of 2.5%. The incidence of HAT increased 5.76-fold when the donor hepatic artery was reconstructed with an interposition graft to the supraceliac aorta (P <.05). Early HAT (within the first 30 days after OLT) occurred in 14 of these patients (46.7%), whereas in 16 patients (53.3%), HAT occurred beyond 30 days post-OLT. Clinical presentation of HAT ranged from an increase in serum transaminase levels with or without cholestasis to liver abscess and biliary complications, including cholangitis, bile duct stenosis or necrosis, to liver dysfunction and failure. Impairment of graft function was observed in patients with early HAT, whereas biliary tract destruction was seen more often in patients with late HAT. In only 1 patient was HAT clinically asymptomatic. Therapy consisted of recombinant plasminogen lysis with hepaticojejunostomy, liver abscess drainage, endoscopy or surveillance, and surgical thrombectomy. In 14 of 30 patients (46.7%), the occurrence of HAT required re-OLT. Nine patients with HAT died during follow-up; however, only 4 of these deaths were related to HAT, resulting in a mortality rate of 13.3%. Our results indicate that HAT is a rare but serious complication after OLT, requiring re-OLT in almost 50% of patients. In particular, conservative treatment modalities may significantly prolong graft survival, thus postponing re-OLT.

Increased mortality after liver transplantation for hepatocellular carcinoma in hepatitis B-associated cirrhosis

Transplant patients suffering from hepatocellular carcinoma in cirrhosis are selected according to tumor nodule number and diameter. Vascular invasion and histopathological grading are predictive of outcome. The prognostic influence of hepatitis B-cirrhosis has been investigated after resection and after local tumor treatment, but not after transplantation. Of the 1,188 transplantations performed between 1989 and 2000, 120 were on patients with hepatocellular carcinoma in cirrhosis (HCC) (follow-up: 57 months; 1-140 months). Within this group, 25 patients (21%) suffered from hepatitis B. Pre-transplant selection criteria were a maximum diameter of 5 degrees cm in uni-nodular tumors, or 3 degrees cm for two to three tumor nodules. The rate of tumors with 2-3 tumor nodules was increased in the hepatitis-B group (52% vs. 29%; P<0.05). Other tumor characteristics did not differ. In the hepatitis-B group, more patients died post-transplantation (44% vs.22%; P<0.05). This difference was due to unspecific causes, not to tumor recurrence or re-infection. These findings may be indicative of a more complicated course in patients suffering from hepatitis B in general.

Increased mortality after liver transplantation for hepatocellular carcinoma in hepatitis B-associated cirrhosis

Transplant patients suffering from hepatocellular carcinoma in cirrhosis are selected according to tumor nodule number and diameter. Vascular invasion and histopathological grading are predictive of outcome. The prognostic influence of hepatitis B-cirrhosis has been investigated after resection and after local tumor treatment, but not after transplantation. Of the 1,188 transplantations performed between 1989 and 2000, 120 were on patients with hepatocellular carcinoma in cirrhosis (HCC) (follow-up: 57 months; 1-140 months). Within this group, 25 patients (21%) suffered from hepatitis B. Pre-transplant selection criteria were a maximum diameter of 5 degrees cm in uni-nodular tumors, or 3 degrees cm for two to three tumor nodules. The rate of tumors with 2-3 tumor nodules was increased in the hepatitis-B group (52% vs. 29%; P<0.05). Other tumor characteristics did not differ. In the hepatitis-B group, more patients died post-transplantation (44% vs.22%; P<0.05). This difference was due to unspecific causes, not to tumor recurrence or re-infection. These findings may be indicative of a more complicated course in patients suffering from hepatitis B in general.

CMV hepatitis after liver transplantation: incidence, clinical course, and long-term follow-up

Cytomegalovirus (CMV) hepatitis is described as the most frequent manifestation of CMV tissue invasive disease after liver transplantation. Its correlation with HLA-matching, hepatic artery thrombosis, and chronic rejection is still controversial. Risk factors, incidence, clinical course, and complications of CMV hepatitis were retrospectively analyzed in a 12-year series of 1,146 consecutive liver transplantations in 1,054 patients. All patients received only low-dose acyclovir but no gancyclovir prophylaxis. CMV infection was diagnosed by viral culture, pp65 antigenemia, or by polymerase chain reaction (PCR). CMV hepatitis was proven by liver biopsy. Treatment of CMV disease consisted of intravenous ganciclovir for a minimum of 14 days. Long-term follow-up of patients included monthly routine laboratory values and routine liver biopsies 1, 3 and 5 years after transplantation. CMV hepatitis was a rare event after liver transplantation, with a total incidence of 2.1% (24 cases). It was significantly more frequent in CMV seronegative (5.2%) than in seropositive recipients (0.7%). The leading indication in patients with CMV hepatitis was HCV cirrhosis (n = 8). The maximum number of pp65 positive white blood cells was 82 +/- 23 per 10,000 cells. Most courses manifested as isolated hepatitis; only 2 patients had disseminated disease. Nine of 24 patients had received OKT3 monoclonal antibodies because of steroid-resistant rejection before CMV hepatitis. In seronegative patients with CMV hepatitis, 71% revealed 1 or 2 HLA DR matches, in contrast to 32% in patients without CMV hepatitis. One-, 3-, and 5-year graft survival was 78%, 65%, and 59% in patients with CMV hepatitis compared with 88%, 81%, and 79% in patients without. Chronic rejection was observed in one patient, but already before onset of CMV hepatitis. Beneath D+R-constellation and OKT3 treatment as risk factors, HLA DR-matched grafts and HCV seem to favor manifestation of CMV hepatitis after liver transplantation. Long-term complications of CMV hepatitis were not observed, and especially no correlation with chronic rejection was found.

[Orthotopic liver transplantation in case of TIPS stent dislocation]

Transjugular intrahepatic portosystemic shunts (TIPS) are indicated in patients with liver cirrhosis and portal hypertension for treatment of variceal bleeding or refractory ascites. Additionally implantation of stents may lead to stent dislocation or thrombosis in up to 20 % of cases. Detailed information about stent dislocation and its impact on subsequent orthotopic liver transplantation (OLT) is rare regarding the literature. We report on a patient suffering from ethyltoxic liver cirrhosis in which OLT was technically complicated by a thrombosed TIPS stent, dislocated in the portal vein. This stent was implanted prior to OLT due to refractory ascites and partial portal vein thrombosis. We conclude that TIPS stent insertion, especially in liver transplant candidates, should only be performed by radiologists in centers with expertise and experience.

Psychosocial outcome of living donors after living donor liver transplantation: a pilot study

In view of the scarcity of organ resources available for transplantation, living donor liver transplantation (LDLT) is gaining growing importance in the treatment of chronically terminal liver diseases. In the period between December 1999 and October 2000, 47 potential living liver donors were evaluated and 24 right hepatic lobes and two left lateral segments were transplanted at the Virchow-Klinikum of the Charité Hospital in Berlin. The present study looks into biomedical and psychosocial parameters of 23 donors before and 6 months after LDLT. Our aims were to investigate the development of psychosocial parameters after donation and the relationship between psychosocial findings and post-operative complications. Most donors showed an improved quality of life (QoL) after LDLT when compared with pre-operative results. Twenty-six percent of donors show high values for 'tiredness', 'fatigue' and 'limb pain' following donation. The post-operative complications had no influence on the psychosocial outcome. In this pilot study the resection of the right hepatic lobe amounts to a safe operation for donors and holds promise of a good psychosocial outcome for most donors, irrespective of donation-related complications. The pronounced complaints appears to indicate psychological tension and distress in some donors following donation.