红细胞计数对原发性肝癌患者术后生存期的预测价值

目的探讨红细胞计数在原发性肝癌患者术后生存期预测中的应用价值。方法选择2007年1月至2012年12月于本院行切除手术的原发性肝癌患者120例为研究对象。应用全自动血液分析仪和生化分析仪检测血液中各项指标,并结合患者的临床资料和病历资料,采用Kaplan-Meier法进行累积生存时间曲线的绘制,采用Cox比例风险回归模型进行多因素分析,确定影响累积生存时间的因素。结果 120例原发性肝癌患者的平均年龄为(56.98±14.39)岁,以男性、伴肝硬化、无PVTT、TNM分期Ⅲ～Ⅳ期、Child-Pugh分级A期、肿瘤大小≥5 cm、RBC(3.5～5.0)×10~(12)/L患者居多。不同RBC水平患者的PVTT、肿瘤大小、Child-Pugh分级、TNM分期、TBil、ALT、AST、AST/ALT、ALP、GGT、ALB、A/G及PT的差异有统计学意义(P均0.05)。单因素Logistic回归分析结果显示PVTT、肿瘤大小、Child-Pugh分级、TNM分期、TBil、ALT、AST、AST/ALT、ALP、GGT、ALB、A/G、RBC和PT是影响原发性肝癌患者累积生存时间的危险性因素(P均0.05)。多因素Logistic回归分析结果显示Child-Pugh分级为B级和C级、TNM分期为Ⅲ～Ⅳ期、AST/ALT高于标准、GGT高于标准、RBC低于标准是影响原发性肝癌患者累积生存时间的危险性因素(P均0.05)。随访5年后,标准RBC数量的原发性肝癌患者累积生存率为33.33%(11/33),低于标准RBC数量的原发性肝癌患者累积生存率为26.44%(23/87),差异有统计学意义(χ~2=5.22,P=0.007)。结论原发性肝癌患者术前血液中RBC数量低于标准是影响其累积生存时间的危险性因素之一。RBC计数在原发性肝癌患者术后生存期预测中具有重要意义,对于患者的病情进展具有一定的提示价值。     

Stathmin蛋白在人原发性肝癌中的表达与原发性肝癌生物学行为的关系

目的 探讨Stathmin蛋白在人原发性肝癌中的表达及其与原发性肝癌生物学行为的关系.方法 分别采用免疫组化法和Western blot法检测20例正常肝组织和36例原发性肝癌组织中Stathmin蛋白的表达.结果免疫组化法检测Stathmin蛋白在正常肝组织、低级别原发性肝癌 (Ⅱ级-Ⅲ级)及高级别原发性肝癌(Ⅳ级)组织中阳性表达率分别为20%、65%、100%.Ⅱ级-Ⅲ级组、Ⅳ级组分别与正常肝组织比较,差异均有统计学意义(P<0.05);Ⅱ级-Ⅲ级组与Ⅳ级组比较,差异有统计学意义(P<0.05).Western blot法检测显示,Stathmin蛋白在正常肝组织、Ⅱ级-Ⅲ级组、Ⅳ级组表达相对值分别为0.35±0.16、0.69±0.22、0.91±0.18.Ⅱ级-Ⅲ级组、Ⅳ级组分别与正常肝组织比较,差异均有统计学意义(P<0.01),Ⅱ级-Ⅲ级组与Ⅳ级组比较,差异有统计学意义(P<0.01).结论 Stathmin在原发性肝癌中过表达,与原发性肝癌的发生及发展可能有关.     

Ⅲ期、Ⅳa期肝癌肝移植围术期辅助性化疗效果分析

目的探讨Ⅲ期、Ⅳa期肝癌肝脏移植围术期辅助性化疗的效果.方法对16例Ⅲ期、Ⅳa期肝癌患者(观察组)在肝脏移植围术期行辅助性化疗,并与前期单纯行肝移植手术的8例Ⅲ期、Ⅳa肝癌患者(对照组)进行比较.结果对照组和观察组分别随访3～12个月和3～16个月,后者肿瘤复发率(43.75% )低于前者(100%),长期存活率(36.25%)高于前者(0).结论Ⅲ期、Ⅳa期肝癌肝脏移植围术期行辅助性化疗效果确切,值得临床借鉴.     

34例肝移植患者术后生存影响因素分析

目的总结肝移植患者术后生存情况,分析影响肝移植术后长期生存的因素。方法回顾分析2002年9月-2014年8月新疆医科大学第一附属医院完成的34例肝移植病例,统计生存率,分析并发症、死亡原因。生存率估计采用Kaplan-Meier法。结果本组1、3、5年实际生存率达到82.8%、64.4%和50.9%。Child-Pugh A级与B/C级患者1、3和5年生存率比较差异均无统计学意义(P值分别为0.756、0.486、0.261)。尸体肝移植患者与活体肝移植患者术后1、3、5年生存率比较差异均有统计学意义(P值分别为0.01、0.006、0.006)。结论有选择地实施肝移植可以取得良好疗效。肝癌复发、胆道吻合口狭窄、免疫抑制剂副作用是影响本组肝移植患者术后长期生存的因素。     

可脱卸弹簧圈早期栓塞治疗颅内破裂动脉瘤的临床研究

目的 探讨可脱卸弹簧圈早期栓塞治疗颅内破裂动脉瘤的治疗效果.方法 208例颅内破裂动脉瘤,其中首次破裂198例,2次破裂10例;动脉瘤的位置:大脑前动脉瘤3例,大脑中动脉瘤45例,前交通动脉瘤56例,后交通动脉瘤78例,眼动脉瘤2例,脉络膜前动脉瘤1例,基底动脉瘤3例,小脑后下动脉瘤1例,颈内动脉瘤14例,颅内多发动脉瘤5例.病人分级:Hunt-Hess Ⅰ级12例,Ⅱ级114例,Ⅲ级76例,Ⅳ级5例,Ⅴ级1例.Fisher CT分级Ⅰ级2例,Ⅱ级17例,Ⅲ级164例,Ⅳ级25例.采用可脱卸弹簧圈(GDC、EDC、DCS、NXT、MicroPlex、HydroCoil)早期栓塞治疗,185例于3 d内治疗,23例于6 d内治疗.结果 208例中213个动脉瘤,100% 栓塞113个,95%栓塞89个,90% 栓塞11个.疗效按GOS分级:恢复良好者(Ⅴ级)196例(94.23%).中残(Ⅳ级)4例(1.92%);重残(Ⅲ级)3例(0.96%);植物状态生存(Ⅱ级)2例(0.96%),死亡(Ⅰ级)3例(1.44%).结论 采用可脱卸弹簧圈早期栓塞是治疗颅内破裂动脉瘤较理想的方法,具有微创、安全可靠、效果确切的特点.     

非小细胞肺癌的双重放疗效果

为进一步提高放疗效果和缩短放疗时间,作者在1990年1月～1992年9月间应用双重照射法(F-f法)对18例原发性非小细胞肺癌进行治疗探讨。18例中,男13例,女5例,年龄58～80岁,平均61岁。PS1、215例。占83%.临床分期Ⅰ期2例,Ⅱ期1例,ⅢA期5例,ⅢB期6例,Ⅳ期4例,Ⅲ、Ⅳ期占83%。其中鳞癌7例,腺癌7例,大细胞癌2例。病理诊断不明者2例。放疗前化疗6例,其中4例行支气管动脉灌注法(BAI)2例行BAI+全身化疗,余12例未经治疗。放疗同时化     

慢性阻塞性肺疾病合并肺癌临床分析

目的 探讨慢性阻塞性肺病(COPD)合并肺癌的临床特点.方法 对35例COPD合并肺癌的病例进行分析.结果 COPD分级:Ⅰ级8例,Ⅱ级17例,Ⅲ级7例,Ⅳ级3例.CT表现:肿块影28例;阻塞性肺炎9例;胸腔积液6例;肺不张5例.细胞类型:鳞癌16例,腺癌9例,小细胞癌7例,大细胞癌1例,未定型2例.肺癌TNM分期:Ⅰa期2例,Ⅰb期4例,Ⅱa期2例,Ⅱb期5例,Ⅲa期7例,Ⅲb期8例,Ⅳ期7例.转归:死亡29例,生存期1～28个月.结论 COPD合并肺癌时,早期常不易被发现,确诊时多为晚期.故COPD合并吸烟的患者,如出现可疑肺癌征象,应高度引起重视,及早完善检查及明确诊断,以降低死亡率,延长生存期.     

血清PIVKA-Ⅱ在原发性肝癌诊断中的应用

目的探究血清PIVKA-Ⅱ对原发性肝癌的诊断价值。方法 2016年2月至11月就诊于徐州医科大学附属医院肝癌患者330例,采用LUMI-PULSE G1200全自动免疫分析仪检测患者血清PIVKA-Ⅱ和AFP水平,比较二者在原发性肝癌的诊断和预后监测中的作用。结果血清PIVKA-Ⅱ检测原发性肝癌的敏感度(83.19%)高于血清AFP(66.37%,校正χ2=7.60,P=0.006),且两者联合检测的敏感度(89.38%)也高于血清AFP(校正χ2=16.05,P=0.00);血清PIVKA-Ⅱ与肿瘤体积呈正相关(r=0.63,P=0.00),且随着肿瘤直径增大而检测敏感度提高;血清PIVKA-Ⅱ在肝癌Ⅲ期和Ⅳ期分别高于Ⅰ期和Ⅱ期(Ⅲ期:U=151.00、173.00,P=0.00、0.04;Ⅳ期:U=238.50、292.50,P=0.00、0.02);原发性肝癌患者经手术或介入治疗后,血清PIVKA-Ⅱ下降幅度(80.13%)高于血清AFP(57.87%,χ2=4.226,P=0.04)。结论血清PIVKA-Ⅱ检测原发性肝癌的敏感度和特异度均高于AFP,并且在原发性肝癌的预后亦具有较大意义,可作为临床上检测和评价原发性肝癌预后的肿瘤标志物。     

肝硬化CT分级评估肝癌介入治疗肝储备功能及预后的临床价值

目的探讨肝硬化CT分级在肝癌(HCC)介入治疗肝储备功能(LRF)及预后评估中的临床价值。方法行肝动脉化疗栓塞术(TACE)治疗的HCC患者52例,在TACE术前及术后1个月均行肝脏CT平扫加三期增强扫描。术前所有患者行肝硬化CT分级,并于术前和术后行肝脏血清学指标谷丙转氨酶(ALT)、谷草转氨酶(AST)检测,进行肝功能Child-Turcotte-Pugh分级比较,评价所有患者术后1年的中位生存时间和生存率。结果肝硬化CT分级中,Ⅰ、Ⅱ、Ⅲ、Ⅳ级患者术后AST、ALT水平均较术前降低,以Ⅱ级以上降低明显(P<0.05),肝硬化CT分级越高,AST、ALT水平增高越明显(P<0.05);术前患者肝硬化CT分级中,Ⅰ级、Ⅱ级患者术后肝功能Child-Turcotte-Pugh分级以A、B级例数较多,Ⅲ级、Ⅳ级患者以C级例数较多;Ⅰ、Ⅱ、Ⅲ、Ⅳ级患者的中位生存时间分别为52.14、13.42、5.27、2.13个月,1年生存率分别为58.33%、41.18%、35.71%、22.22%,不同CT分级患者之间生存率比较差异有统计学意义(P<0.05)。结论肝硬化CT分级越高,其术前及术后肝功能损伤越明显,LRF越差,其生存时间越短,生存率越低,对于评价肝癌介入治疗LRF及预后有重要价值。     

经胼胝体-侧脑室手术入路治疗重型原发性脑室出血

目的探讨经胼胝体-侧脑室手术入路治疗重型原发性脑室出血的临床价值.方法回顾分析显微镜下经胼胝体-侧脑室手术入路治疗14例重型原发性脑室出血的临床资料.结果14例患者存活11例;其中恢复正常生活6例,轻偏瘫1例,记忆力下降2例,植物生存2例;死亡3例.随访3个月GOS预后分级:Ⅰ级3例,Ⅱ级2例,无Ⅲ级病例,Ⅳ级3例,Ⅴ级6例.结论早期显微镜下经胼胝体-侧脑室手术入路治疗重型原发性脑室出血可明显改善患者的预后、降低病死率,具有较好的临床价值.     

Post-transplant infection improves outcome of hepatocellular carcinoma patients after orthotopic liver transplantation

BACKGROUND Tumor recurrence after orthotopic liver transplantation(OLT) remains a serious threat for long-term survival of the recipients with hepatocellular carcinoma(HCC), since very few factors or measures have shown impact on overcoming HCC recurrence after OLT. Postoperative infection suppresses tumor recurrence and improves patient survival in lung cancer and malignant glioma probably via stimulating the immune system. Post-transplant infection(PTI), a common complication, is deemed to be harmful for the liver transplant recipients from a short-term perspective. Nevertheless, whether PTI inhibits HCC recurrence after OLT and prolongs the long-term survival of HCC patients needs to be clarified.AIM To investigate the potential influence of PTI on the survival and tumor recurrence of patients with HCC after OLT.METHODSA total of 238 patients with HCC who underwent OLT between August 2002 and July 2016 at our center were retrospectively included and accordingly subdivided into a PTI group(53 patients) and a non-PTI group(185 patients). Univariate analyses, including the differences of overall survival(OS), recurrence-free survival(RFS), and post-recurrence survival(PRS), between the PTI and non-PTI subgroups as well as survival curve analysis were performed by the KaplanMeier method, and the differences were compared using the log rank test. The variables with a P-value 0.1 in univariate analyses were included in the multivariate survival analysis by using a Cox proportional-hazards model.RESULTS The 1-, 3-, and 5-year OS and RFS rates of the whole cohort were 86.6%, 69.0%,and 63.6%, and 75.7%, 60.0%, and 57.3%, respectively. The 1-, 3-, and 5-year OS rates for the PTI patient group(96.0%, 89.3%, and 74.0%) were significantly higher than those for the non-PTI group(84.0%, 63.4%, and 60.2%)(P = 0.033).The absence of PTI was an independent risk factor for dismal OS(relative risk[RR] = 2.584, 95%CI: 1.226-5.449) and unfavorable RFS(RR = 2.683, 95%CI: 1.335-5.390). Subgroup analyses revealed that PTI remarkably improved OS(P = 0.003)and RFS(P = 0.003) rates of HCC patients with vascular invasion(IV), but did not impact on OS(P = 0.404) and RFS(P = 0.304) of patients without VI. Among the patients who suffered post-transplant tumor recurrence, patients with PTI showed significantly better OS(P = 0.026) and PRS(P = 0.042) rates than those without PTI.CONCLUSION PTI improves OS and RFS of the transplant HCC patients at a high risk for posttransplant death and tumor recurrence, which is attributed to suppressive effect of PTI on HCC recurrence.     

Liver transplantation for hepatocellular carcinoma: expansion of the tumor size limits does not adversely impact survival

The precise staging of hepatocellular carcinoma (HCC) based on the size and number of lesions that predict recurrence after orthotopic liver transplantation (OLT) has not been clearly established. We therefore analyzed the outcome of 70 consecutive patients with cirrhosis and HCC who underwent OLT over a 12-year period at our institution. Pathologic tumor staging of the explanted liver was based on the American Tumor Study Group modified Tumor-Node-Metastases (TNM) Staging Classification. Tumor recurrence occurred in 11.4% of patients after OLT. The Kaplan-Meier survival rates at 1 and 5 years were 91.3% and 72.4%, respectively, for patients with pT1 or pT2 HCC; and 82.4% and 74.1%, respectively, for pT3 tumors (P =.87). Patients with pT4 tumors, however, had a significantly worse 1-year survival of 33.3% (P =.0001). An alpha-fetoprotein (AFP) level > 1,000 ng/mL, total tumor diameter > 8 cm, age > or = 55 years and poorly differentiated histologic grade were also significant predictors for reduced survival in univariate analysis. Only pT4 stage and total tumor diameter remained statistically significant in multivariate analysis. Patients with HCC meeting the following criteria: solitary tumor < or = 6.5 cm, or < or = 3 nodules with the largest lesion < or = 4.5 cm and total tumor diameter < or = 8 cm, had survival rates of 90% and 75.2%, at 1 and 5 years, respectively, after OLT versus a 50% 1-year survival for patients with tumors exceeding these limits (P =.0005). We conclude that the current criteria for OLT based on tumor size may be modestly expanded while still preserving excellent survival after OLT.     

Multimodal therapy before liver transplantation for hepatocellular carcinoma.

BACKGROUND:: The use of orthotopic liver transplantation (OLT) for the treatment of patients with hepatocellular carcinoma (HCC) remains controversial because of the risk of both exclusion from the waiting list due to tumor progression and post OLT HCC recurrence. The aim of the present study was to evaluate the effect of an aggressive HCC treatment during the waiting list time on overall and recurrence-free survival of HCC transplanted patients in a single institutional study. METHODS:: Since 1991, 40 HCC patients joined the OLT-waiting list. Poorly differentiated HCC cases were excluded, while size and number of nodules were not considered as absolute selection criteria. In all, 90% of the study group had HCC treatment while on the waiting list (transarterial chemoembolization, percutaneous therapies, chemotherapy). RESULTS:: Only one patient (2.5%) was removed from the waiting list after developing neoplastic portal thrombosis 3 months after listing, while 33 (82.5%) underwent to OLT after a median waiting list time of 11 months (range 3-16 months). On histological examination, 42% of the group did not meet the "Milan criteria" and 42% were pTNM stages III and IV. The median follow-up was 42 months. The 5-year actuarial survival rate was 64% and recurrence-free survival was 91%. HCC recurred in only two patients (6%). CONCLUSIONS:: The use of routine pre-OLT tumor grading and of an aggressive HCC treatment during the waiting list, in our experience, resulted in a very low risk of pre OLT tumor progression leading to exclusion and of post OLT HCC recurrence.     

Predictors of long-term survival after liver transplantation for hepatocellular carcinoma

AIMS: The aim of this study was to identify predictors of both survival and tumor-free survival of a cohort of 155 patients, with hepatocellular carcinoma (HCC) and cirrhosis, who were treated by orthotopic liver transplantation (OLT). METHODS: From January 1989 to December 2002, 603 OLTs were performed in 549 patients. HCC was diagnosed in 116 patients before OLT and in 39 at histological examination of the explanted livers. Eighty-four percent of the patients met "Milan" criteria at histology. Ninety-four patients received anticancer therapies preoperatively. RESULTS: The median follow-up was 49 months (range, 0-178). Overall, 1-, 3-, 5-, and 10-yr survival were 84%, 75%, 72%, and 62%, respectively. Survival was not affected by the patient's age or sex, etiology of liver disease, Child score at transplantation, rejection episodes, tumor number, total tumor burden, bilobar tumor, and pathologic Tumor, Nodes, Metastasis (pTNM) stages. There was no statistically significant difference in survival when patients were grouped according to the recently proposed simplified pTNM staging (5-yr survival, 80% in stage I, 69% in stage II, 50% in stage III, p= 0.3) or the United Network for Organ Sharing (UNOS) staging system for HCC. Encapsulation of the tumor and alpha-fetoprotein levels significantly affect patient survival. Five-year survival of patients with poorly differentiated (G3) HCC was significantly worse than that of patients with moderately (G2) or well-differentiated (G1) HCC (respectively, G3 44%, G2 67%, and G1 97%, p= 0.0015). Patients with micro- or macro-vascular invasion had a worse 5-yr survival than patients without vascular invasion (49%vs 77%, p= 0.04). Multivariate analysis showed that histological grade of differentiation and macroscopic vascular invasion are independent predictors of survival (HR 2.4, 95% CI 1.4-4.1, p= 0.0009 and HR 2.8, 95% CI 1.2-6.8, p= 0.022). CONCLUSION: Histological grade of differentiation and macroscopic vascular invasion, as assessed on the explanted livers, are strong predictors of both survival and tumor recurrence in patients with cirrhosis who received transplants for HCC.     

Hepatocellular carcinoma: surgical treatment and prognostic variables in 56 patients

BACKGROUND/AIMS: Partial hepatectomy (PH) or total hepatectomy and orthotopic liver transplantation (OLT) may be curative in selected patients treated for hepatocellular carcinoma (HCC). The analysis of clinical series may help in the choice of the more appropriate treatment. METHODOLOGY: During the past 11 years, 40 patients with HCC were treated by PH and 16 patients underwent total hepatectomy and OLT. Selection criteria for transplantation were the liver function and the tumor resectability. RESULTS: The actuarial 1-, 3- and 5-year survival rates were 67%, 34% and 18%, respectively, after PH and 62%, 54% and 54% after OLT. The only prognostic factor after PH was the tumor extension to a single or both lobes. Patients with associated cirrhosis had significantly more post-operative complications, but a comparable long-term survival. The proliferative cell nuclear antigen labeling index (PCNA-LI), evaluated on tumoral tissue in 16 patients, showed that an index <30% indicates a better prognosis for HCC developing in non-cirrhotic liver. CONCLUSIONS: For patients carefully pre-operatively evaluated, the presence of an associated cirrhosis does not seem to modify the long-term survival after PH, and OLT may offer more than 50% 5-year survival. A PCNA-LI <30% appears to be a good prognostic factor in patients without cirrhosis.     

Surgical dilemma: liver resection or liver transplantation for hepatocellular carcinoma and cirrhosis. Intention-to-treat analysis in patients within and outwith Milan criteria

Background:

The optimal role of surgery in the management of hepatocellular carcinoma (HCC) is in continuous evolution.

Objective:

The objective of this study was to analyse survival rates after liver resection (LR) and orthotopic liver transplantation (OLT) for HCC within and outwith Milan criteria in an intention-to-treat analysis.

Methods:

During 1997–2007, 179 patients with cirrhosis and HCC either underwent LR (n= 60) or were listed for OLT (n= 119). Patients with incidental HCC after OLT, preoperative macrovascular invasion before LR, non-cirrhosis and Child–Pugh class C cirrhosis prior to OLT were eliminated, leaving 51 patients primarily treated with LR and 106 patients listed for primary OLT (84 of whom were transplanted) to be included in this analysis. A total of 66 patients fell outwith Milan criteria (26 LR, 40 OLT) and 91 continued to meet Milan criteria (25 LR, 66 OLT).

Results:

The median length of follow-up was 26 months. The mean waiting time for OLT was 7 months. During that time, 21 patients were removed from the waiting list as a result of tumour progression. Probabilities of dropout were 2% and 13% at 6 and 12 months, respectively, for patients within Milan criteria, and 34% and 57% at 6 and 12 months, respectively, for patients outwith Milan criteria (P < 0.01). Tumour size >3 cm was found to be the independent factor associated with dropout (hazard ratio [HR] 6.0). Postoperative survival was slightly higher after OLT, but this was not statistically significant (64% for OLT vs. 57% for LR). Overall survival from time of listing for OLT or LR did not differ between the two groups (P= 0.9); for patients within Milan criteria, 1- and 4-year survival rates after LR were 88% and 61%, respectively, compared with 92% and 62%, respectively, after OLT (P= 0.54). For patients outwith Milan criteria, 1- and 4-year survival rates after LR were 69% and 54%, respectively, compared with 65% and 40%, respectively, after OLT (P= 0.42). Tumour size >3 cm was again found to be an independent factor for poor outcome (HR 2.4) in the intention-to-treat analysis.

Conclusions:

Survival rates for patients with HCC are similar in LR and OLT. Liver resection can potentially decrease the dropout rate and serve as a bridge for future salvage LT, particularly in patients with tumours >3 cm.     

Excellent outcome following down-staging of hepatocellular carcinoma prior to liver transplantation: an intention-to-treat analysis

We previously reported encouraging results of down-staging of hepatocellular carcinoma (HCC) to meet conventional T2 criteria (one lesion 2-5 cm or two to three lesions <3 cm) for orthotopic liver transplantation (OLT) in 30 patients as a test of concept. In this ongoing prospective study, we analyzed longer-term outcome data on HCC down-staging in a larger cohort of 61 patients with tumor stage exceeding T2 criteria who were enrolled between June 2002 and January 2007. Eligibility criteria for down-staging included: (1) one lesion >5 cm and up to 8 cm; (2) two to three lesions with at least one lesion >3 cm and not exceeding 5 cm, with total tumor diameter up to 8 cm; or (3) four to five lesions with none >3 cm, with total tumor diameter up to 8 cm. A minimum observation period of 3 months after down-staging was required before OLT. Tumor down-staging was successful in 43 patients (70.5%). Thirty-five patients (57.4%) had received OLT, including two who had undergone live-donor liver transplantation. Treatment failure was observed in 18 patients (29.5%), primarily due to tumor progression. In the explant of 35 patients who underwent OLT, 13 had complete tumor necrosis, 17 met T2 criteria, and five exceeded T2 criteria. The Kaplan-Meier intention-to-treat survival at 1 and 4 years after down-staging were 87.5% and 69.3%, respectively. The 1-year and 4-year posttransplantation survival rates were 96.2% and 92.1%, respectively. No patient had HCC recurrence after a median posttransplantation follow-up of 25 months. The only factor predicting treatment failure was pretreatment alpha-fetoprotein >1,000 ng/mL. CONCLUSION: Successful down-staging of HCC can be achieved in the majority of carefully selected patients and is associated with excellent posttransplantation outcome.     

Survival after liver transplantation: Is racial disparity inevitable?

Previous analyses have reported that minority patients undergoing orthotopic liver transplantation (OLT) have poorer survival than Caucasian recipients. The reason for this disparity is unclear. We examined whether racial differences in survival exist at select academic OLT centers. OLT recipients from 4 academic centers were prospectively enrolled in 2 multicenter databases. Data including demographics, liver disease diagnosis, and post-OLT follow-up were obtained for 2823 (135 African, 2448 Caucasian, and 240 other race) adult patients undergoing primary OLT between 1985 and 2000. The survival of patients and grafts after OLT was compared across race. The Kaplan-Meier estimates for 1-year recipient survival were 90.8% [95% confidence interval (CI): 86.0-95.9] for African Americans, 86.5% (95% CI: 85.1-87.9) for Caucasians, and 84.4% (95% CI: 79.8-89.2) for other races. The 5-year recipient survival probability was 69.2% (95% CI: 60.1-79.7) for African Americans, 72.2% (95% CI: 70.1-74.4) for Caucasians, and 67.5% (95% CI: 60.5-75.3) for other races. The 10-year recipient survival probability for African Americans was 54.4% (95% CI: 41.1-72.1), for Caucasians 50.7% (95% CI: 46.4-55.3), and for other races 55.7% (95% CI: 41.5-74.8). There was no difference in patient survival (P = 0.162) or graft survival (P = 0.582) among racial groups. A multivariable proportional hazards model confirmed the absence of an association between race and post-OLT survival after adjustments for age, gender, total bilirubin, creatinine, prothrombin time, and diagnosis. CONCLUSION: These data demonstrate that as a proof of principle, minority OLT recipients should not necessarily expect an OLT outcome inferior to that of Caucasians.     

Management of the single liver nodule in a cirrhotic patient: a decision analysis model

The widespread use of liver imaging in patients with cirrhosis results in the discovery of small (<3 cm) nodules. Although the subsequent management of these patients is variable, it is generally focused on the diagnosis and treatment of hepatocellular carcinoma (HCC). We aimed to compare the 3-year survival associated with several competing strategies used in the management of patients with compensated liver cirrhosis in whom a single small liver lesion is detected during surveillance. We constructed a decision analysis model using a decision tree and Markov model. We assumed that all patients undergo an initial "diagnostic phase" consisting of an imaging study and serum alpha-fetoprotein (AFP). Patients with a "positive initial diagnostic phase" for HCC are referred for either imaging-guided biopsy (IGB) or surgical resection or orthotopic liver transplantation (OLT) without preceding IGB. IGB, if positive for HCC, was followed by OLT, surgical resection, or local therapy. Patients with a "negative initial diagnostic phase" undergo either repeat diagnostic testing (imaging, AFP) every 4 months or are referred for either OLT, surgical resection, or IGB followed by interventions. Probability assumptions were estimated from the published literature. The outcomes compared were 3-year overall survival and recurrence-free survival. When the initial diagnostic phase is positive for HCC, OLT it is associated with the longest survival. In the sensitivity analysis, when the 3-year overall survival for patients referred to OLT is <54%, surgical resection or IGB preceding therapy become more favorable strategies. This 3-year overall survival (<54%) associated with OLT is reached after a waiting time of 4 months on the transplant list, if a 4% monthly dropout rate is assumed. When the initial diagnostic phase is negative for HCC, then performing IGB, before proceeding to therapeutic intervention, is associated with the longest 3-year overall survival. If the IGB is positive, subsequent OLT is associated with the longest survival. The higher the predictive value of the initial diagnostic phase for HCC, the more favorable is OLT (for the "positive results" arm), and follow-up testing (for the "negative results" arm). In conclusion, given a high pretest likelihood of HCC in a single liver nodule detected during surveillance in patients with cirrhosis, IGB may not be required in the presence of a positive noninvasive diagnostic testing. The long waiting time prior to OLT limits its advantage over surgical resection in the treatment of patients with early HCC.     

Conversion to sirolimus immunosuppression in liver transplantation recipients with hepatocellular carcinoma： Report of an initial experience

AIM: To report a retrospective analysis of preliminary results of 36 patients who received sirolimus (SRL, Rapa-mune, rapamycin) in a consecutive cohort of 248 liver allograft recipients. METHODS: Thirty-six liver transplant patients with he-patocellular carcinoma (HCC) who were switched to SRL-based immunosuppression therapy from tacrolimus were enrolled in this study. The patients who were diagnosed as advanced HCC before orthotopic liver transplantation (OLT) were divided into group A (n = 11), those who were found to have HCC recurrence and/or metastasis after OLT were assigned to group B (n=18), and those who developed renal insufficiency caused by calcineurin inhibitor (CNI) were assigned to group C (n = 7) after OLT. RESULTS: The patients were followed up for a median of 10.4 mo (range, 3.8-19.1 mo) after conversion to SRL therapy and 12.3 mo (range, 5.1-34.4 mo) after OLT. Three patients developed mild acute cellular rejection 2 wk after initiating SRL therapy, which was fully reversed after prednisolone pulse therapy. In group A, only 1 patient was found to have HCC recurrence and metastasis 12 mo after OLT. In group B, 66.7% (12/18) patients (2 with progressive tumor, 7 with stable tumor and 3 without tumor) were still alive due to conversing to SRL and/ or resection for HCC recurrence at the end of a median follow-up of 6.8 mo post conversion and 10.7 mo post-transplant. In group C, no HCC recurrence was demonstrated in 7 patients, and renal function became normal after SRL therapy. Thrombocytopenia (n = 2), anemia (n = 8), and oral aphthous ulcers (n = 7) found in our cohort were easily manageable. CONCLUSION: The conversion to SRL-based immuno-suppression may inhibit the recurrence and metastasis of HCC and improve CNI-induced renal insufficiency in OLT patients with HCC.