Is the combination of superselective transcatheter autologous clot embolization and duplex sonography-guided compression therapy useful treatment option for the patients with high-flow priapism?

The aim of this study was to report feasibility, benefit and complications of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy in four patients with delayed post-traumatic high-flow priapism. Medical records of four consecutive patients diagnosed with delayed post-traumatic high-flow priapism (arterial priapism) were reviewed. High-flow priapism occurred mean 41.8 (6-92) h after the trauma developed. The patients were presented to hospital mean 8.3 (5-15) days after priapism occurred. The patients were assessed by penile color flow Doppler sonography. After the pathologically increased, arterial flow or arteriocavernosal fistula was seen, combination therapy with superselective transcatheter autologous clot embolizations and duplex sonography-guided compression was performed. If complete detumescence could not be achieved, this therapy was applied in the following day. In patients who had resistance to the second embolization, superselective embolization with microcoil was performed. Follow-up included penile color flow Doppler sonography at the following day, 1 month and 3 months after the procedure. International Impotence Symptoms Score (IIEF) was obtained during the follow-up. The treatment was successful in one, partially successful in one and not successful in two of the four patients. This therapy was reperformed to the latter three patients. After the treatment, high-flow priapism disappeared in one of the three patients and embolization with methalic microcoil was needed to perform to the other two patients. At 1 day after the treatment, color flow Doppler sonography and physical examinations were normal in all four patients. In the 1st and 3rd months of the follow-up, color flow Doppler sonography and the NPT tests were normal in three of the four patients. Slight erectile dysfunction was detected in one patient. Combination of superselective transcatheter autologous clot embolizations and duplex sonography-guided compression therapy may be considered as one of the first-line treatment options in adult patients with delayed post-traumatic high-flow priapism.     

Can we expand the indications for liver transplantation among hepatocellular carcinoma patients with increased tumor size?

INTRODUCTION: Due to the scarcity of donors and the fact that size is the main prognostic factor, Milan criteria have been used since 1996 to select hepatocellular carcinoma (HCC) patients for liver transplantation. In 2001 UCSF criteria showed that including layer tumors did not reduce the survival results. The objective of this paper was to evaluate whether HCC tumor sizes exceeding the Milan criteria adversely influence survival rates. PATIENTS AND METHODS: Between May 1988 and July 2001, 53 patients were transplanted due to HCC and cirrhosis. The etiology of cirrhosis was HCV in 23 cases and HBV in 6. In 11 cases the HCC were incidental by discovered namely, a mean/ diameter of 1.8 cm (versus 2.6 cm in nonincidental HCC). Sixty-two percent of tumors met the Milan criteria, and 68% the USCF criteria. RESULTS: The actuarial survival was 79% at 1 year and 62% at 5 years. The survival of patients with incidental HCC was 82% at 1 year and 82% at 5 years, which is better than the survival of those with nonincidental HCC (78% at 1 year and 57% at 5 years, P<.05). According to Milan criteria, the survival patients with early tumors was 82% at 1 year and 68% at 5 years, and for advanced tumors (NS), 75% and 54%, respectively. Comparison of early versus advanced tumors according to UCSF criteria showed survivals of 84% versus 64% at 1 year (P<.05) and 67% versus 48% at 5 years (P<.05), respectively. CONCLUSION: Increasing the HCC size among LT according to the California criteria did not reduce survival rates compared with the Milan criteria.     

Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?

OBJECTIVE: To evaluate the perioperative outcomes and long-term survival of extended hepatic resection for hepatocellular carcinoma (HCC) in patients with cirrhosis. SUMMARY BACKGROUND DATA: Hepatic resection is a well-established treatment for HCC in cirrhotic patients with preserved liver function and limited disease. However, the role of extended hepatic resection (more than four segments) for HCC in cirrhotic patients has not been elucidated. METHODS: Between 1993 and 2000, 45 consecutive patients with histologically confirmed cirrhosis underwent right or left extended hepatectomy for HCC (group A). Perioperative outcomes and long-term survival of these patients were compared with 161 patients with HCC and cirrhosis who underwent hepatic resection of a lesser extent in the same period (group B). All clinicopathologic and follow-up data were collected prospectively. RESULTS: Group A patients had significantly higher intraoperative blood loss, longer operation time, and longer hospital stay than group B. However, the two groups were similar in overall morbidity and hospital mortality. There were no significant differences in the incidence of liver failure or other complications. The resection margin width was similar between the two groups. Despite significantly larger tumor size in group A compared with group B, long-term survival was comparable between the two groups. CONCLUSIONS: Extended hepatic resection for HCC can be performed in selected cirrhotic patients with acceptable morbidity, mortality, and long-term survival that are comparable to those of lesser hepatic resection. Extended hepatectomy for large HCC extending from one lobe to the other or central HCC critically related to the hepatic veins is justifiable in cirrhotic patients with preserved liver function and adequate liver remnant.     

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

BackgroundHepatocellular carcinoma (HCC) with portal vein tumour thrombus (PVTT) signifies advanced disease, whether LT confers any survival superiority over resection remains uncertain.MethodsA propensity score matched (PSM) analysis of liver transplantation (LT) and liver resection (LR) for HCC with PVTT was performed.ResultsA consecutive series of 88 patients who received either LT (10 DDLTs and 3 LDLTs) or LR (n=75) respectively were recruited. Before PSM, the LT group has a higher MELD score (17.3 vs. 7.8, P<0.001), lower serum AFP levels (96 vs. 2,164 ng/mL, P=0.017) and smaller tumour size (4 vs. 10 cm, P<0.001). The 5-year overall survival for LT and LR were 55.4% and 15.9% respectively (P=0.007). After matching for serum AFP levels and tumour size, 1-, 3- and 5-year overall survival for LT were 81 ng/mL, 3.9 cm, 80%, 70% and 70% and the corresponding rates for LR were 1,417 ng/mL, 5.3 cm, 51.8%, 19,6% and 9.8% (P value =0.12, 0.27 and 0.009 respectively).ConclusionsLT is associated with significantly better oncological outcomes in HCC patients with PVTT involving the lobar or segmental level. A modest expansion of selection criteria to include small HCC with segmental PVTT should be considered.     

Are HLA antigens a risk factor for acute GVHD in thalassemic patients receiving HLA-identical stem cell transplantation?

We retrospectively evaluated the association between risk factors and acute graft-versus-host disease (aGVHD) among 182 beta thalassemia patients who received 73 peripheral blood stem cell (PBSC) or 109 bone marrow transplants from HLA-identical siblings between 1991 and 2003. The relationship between the severity of aGVHD was examined for the following factors: HLA antigens, age, sex, ABO mismatch, sex mismatch (between recipient and donor), thalassemia class, graft source, transplant cell dose, CD3+ cell dose, conditioning regimen, GVHD prophylaxis, neutrophil engraftment duration, and blood product transfusions using univariate and multivariate analyses. Overall 61 (34%) patients developed clinical grade III or grade IV aGVHD. Univariate analysis confirmed an increased risk of severe aGVHD, which was associated with HLA-A11, HLA-A26, and PBSCT (P=.04, .03, and .03, respectively). The risk of aGVHD was reduced in the presence of HLA-A3 (P=.03). Multivariate analysis confirmed the increased risk of aGVHD associated with HLA-A11 (P=.04), HLA-A26 (P=.01), and a short-period neutrophil recovery (P=.009). In this study HLA-A11, HLA-A26, PBSCT, and a short neutrophil engraftment period were probable risk factors and HLA-A3 a probable protective factor associated with severe aGVHD. These data may provide useful guidelines to choose strategies for treatment and prevention.     

What possible treatments for liver cirrhosis patients with a small hepatocellular carcinoma?

UNDERLYING LIVER DISEASE: Most cases of hepatocellular carcinoma (HCC) develop in subjects with an underlying chronic liver disease, primarily hepatitis C infection. The underlying liver disease greatly limits treatment possibilities due to the restrictions on surgery or the risk of recurrence even when surgical resection, chemoembolization or alcoholization appears to be successful. IN CASE OF NORMAL LIVER FUNCTION: Percutaneous destruction of the tumor with alcoholization or radiofrequency techniques can be effective against HCC tumors measuring less than 3 cm. Access is however sometimes limited, leading to partial destruction and risk of local recurrence. When the patient's liver functions are compatible with surgery, resection of the tumor and its adjacent portal segment has been found to be effective against tumors measuring 3 to 5 cm. TRANSPLANTATION: Liver transplantation is by far the most effective treatment for HCC, treating both the carcinoma and the underlying liver disease. Indications are however limited to patients with at most 3 tumors measuring less than 3 cm with no portal involvement and who can be expected to tolerate the major surgery. In addition, the absence of tumoral extension while waiting for transplantation is an important factor.     

Are bisphosphonates an indispensable tool in the era of targeted therapy for renal cell carcinoma and bone metastases?

One third of patients with metastatic renal cell carcinoma (RCC) suffer from bone metastases. Skeletal involvement in RCC is associated with the occurrence of skeletal-related events, and may negatively impact on the outcome of patients treated with systemic therapies. In patients with RCC and bone metastases, therapies that inhibit osteoclasts, as bisphosphonates and denosumab, are used as adjunct to systemic targeted therapies to prevent skeletal-related events. Data suggest that they may also improve the outcome of systemic targeted therapies. Herein we review the preclinical and clinical data on their use, as well as remaining open questions.     

Liver transplantation and incidentally found hepatocellular carcinoma in liver explants: need for a new definition?

BACKGROUND: "Incidentally" identified hepatocellular carcinoma (iHCC) in liver explants after liver transplantation (LTx) is a frequently reported finding, which is characterized with a good prognosis. The purpose of this study was to evaluate the outcome of patients with these tumors in our series and in literature reports, and to compare their prognosis to that of HCC diagnosed preoperatively. METHODS: From April 1998 to December 2003, 432 patients underwent deceased-donor LTx at our center for nonmalignant indications. An additional 31 patients with a preoperative known HCC (pkHCC) received deceased-donor grafts. A literature search was performed intending to estimate the incidence of iHCC in liver explants and the outcome after LTx. RESULTS: iHCC was found in 5 of the 432 patients. All five patients are currently alive without evidence of tumor recurrence after a median follow-up of 43 months. On the other hand, in the group of the 31 patients with pkHCC, 22 of them are at the moment alive in a median follow-up of 28 months. When comparing the two groups, no difference in survival could be found (P=0.1419 in log-rank test). Literature reports of 705 instances with iHCC over the past 20 years showed a statistical "better survival" in only 24 cases. CONCLUSION: Literature reports showed a remarkable "deviation" of the expected tumor characteristics for the iHCC. Obviously, this is because of a widely characterization of iHCC, including also tumors which are rather undetected HCC during the waiting time to LTx. A more precise definition for the iHCC is needed.     

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

Background  Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection. Methods  A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2–6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound. Results  From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50–79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 ± 69 min (median, 220; range, 80–300). Perioperative blood loss was 183 ± 72 ml (median, 160; range, 80–400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 ± 4.3 days (median, 5; range, 4–25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 ± 1 (median, 5; range, 4–8). Conclusion  Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.     

Is there a role for partial nephrectomy in patients with metastatic renal cell carcinoma?

ObjectivesThe incidence of metastatic disease in patients with renal cell carcinoma (RCC) correlates with tumor size. We sought to determine the incidence of metastatic disease by tumor size, and the utilization and impact of nephron-sparing surgery on survival in those with metastatic disease.Materials and methodsUtilizing the Surveillance, Epidemiology, and End Results (SEER) database, we identified 56,011 patients between 1988 and 2005 diagnosed with RCC. Patients were initially separated into two groups—those with and without metastatic disease—and stratified by tumor size. Cox proportional hazard modeling and Kaplan-Meier analyses were then utilized to evaluate the role of gender, age, grade, histology, tumor size, and type of surgery (radical vs. partial nephrectomy) on overall- and cancer-specific survival in patients with metastatic disease.ResultsEight thousand four hundred ninety-eight patients (15%) had metastatic disease. Four percent of patients with tumors less than 2 cm and 5% of patients with tumors between 2 and 3 cm presented with metastatic disease. Two thousand nine hundred fifty patients (35%) with metastatic disease underwent surgery (radical or partial nephrectomy). Seventy patients (2% of those undergoing surgery) had a partial nephrectomy. Those who underwent partial nephrectomy were 0.49 times less likely to die of RCC than those who underwent radical nephrectomy (95% CI 0.35–0.69, P < 0.001).ConclusionsAlbeit small, the risk of metastases in patients with small kidney tumors is distinct and should be considered in management discussions. Partial nephrectomy, when able to be done, should be utilized in the setting of metastatic disease.