Association between surgical margins and long-term outcome in advanced hepatoblastoma

Background

Many patients with hepatoblastoma present with unresectable disease. Neoadjuvant therapy has improved resectability rates to as high as 70% to 90%. Despite this improvement, many patients will be left with tumors that are of borderline resectability. The authors hypothesize that favorable outcomes may be achieved even with resection margins less than 1 cm thus sparing the need for liver transplantation.

Methods

Between January 1981 and March 2003, 23 patients age less than 16 years with a diagnosis of hepatoblastoma undergoing surgical resection were identified. The clinical characteristics, pathologic resection margins, and survival status were reviewed.

Results

Eighteen (78%) of the patients were alive with no evidence of recurrence at last follow-up. Thirteen (56.5%) had ≥1 cm resection margins, whereas 10 (43.5%) had resection margins less than 1 cm. Eleven (47.8%) presented with PRETEXT III tumors. There was no significant difference in survival rate between resection margins less than 1 cm and ≥1 cm (P = .13; 95% CI 0.91 to 2.61). Thirteen patients (56.5%) presented with synchronous pulmonary metastatic disease, where survival was significantly worse (P = .04; 95% CI 1.10 to 2.50). Subgroup analysis confirmed that margins less than 1 cm did not significantly affect survival after controlling for pulmonary metastatic disease (P = .56; 95% CI 0.71 to 3.61).

Conclusions

Surgical resection with margins less than 1 cm are associated with survival that is equivalent to resection with margins ≥1 cm. Our findings suggest it is preferable to preserve key structures with a small resection margin and therefore spare the need for liver transplantation in patients with advanced hepatoblastoma.     

Effect of postoperative chemotherapy on the serum alpha-fetoprotein level in hepatoblastoma

Purpose

It is generally accepted that postoperative chemotherapy does not affect the serum alpha-fetoprotein (AFP) level. The authors report on 3 patients who supposedly showed chemotherapy-related changes in their AFP levels after operation.

Methods

This study included 3 patients with hepatoblastoma (1 case of PRETEXT III and 2 cases of PRETEXT IV).

Results

One patient with PRETEXT III underwent a complete tumor resection, and the postoperative AFP level decreased until it reached the normal range. However, he consistently exhibited a transient, 2- to 3-fold increase in the AFP after each course of chemotherapy for 3 courses. The chemotherapy regimen had to be stopped because of drug-induced encephalopathy, but he has been followed up for 5 years without any evidence of recurrence, and his AFP level has also remained stable and in the normal range. Two patients with PRETEXT IV, who underwent a curative tumor resection, also showed similar chemotherapy-related changes in AFP levels. Both of these cases were observed only after the administration of routine postoperative chemotherapy instead of administering further high-dose chemotherapy. The AFP level remained stable for 17 months and 7 months after the cessation of chemotherapy in 2 cases, respectively.

Conclusions

Regarding the postoperative chemotherapy of hepatoblastoma, we have to pay close attention to both the AFP status during chemotherapy as well as the absolute AFP level.     

Sirolimus in Kidney Transplant Donors and Clinical and Histologic Improvement in Recipients: Rat Model

Background

Ischemia-reperfusion (I/R) injury is one of the risk factors for delayed graft function, acute rejection episodes, and impaired long-term allograft survival after kidney transplantation. This antigen-independent inflammatory process produces tissue damage. Isogeneic transplantation in a rat model is a useful method for study of nonimmunologic risk factors for kidney damage.

Objective

To study the effect of sirolimus on I/R injury using only 1 dose of the drug in the donor.

Materials and Methods

Eighteen rats were allocated to 3 groups of 6 rats each: sham group, control group, and rapamycin group.

Results

Improved renal function and systemic inflammatory response were observed in the rapamycin group compared with the control group (Δurea, Δcreatinine, and ΔC3, all P < .01). The number of apoptotic nuclei in the renal medulla in the control group was higher than in the rapamycin group (P < .01). Tubular damage was less severe in the rapamycin group compared with the control group (P < .01). Complement 3 and tumor necrosis factor-α expression in the kidney samples were significantly decreased when rapamycin was given to the donor rats (P > .01). Bcl-2 protein was upregulated in the rapamycin group compared with the control group (P < .01).

Conclusion

Administration of rapamycin in donors attenuates the I/R injury process after kidney transplantation in a rat model.     

The effect of vitamin A deficiency in maternal rats on tumor formation in filial rats

Purpose

We established a vitamin A-deficient (VAD) model of pregnant rats to evaluate the effect of vitamin A deficiency in maternal rats on tumor formation in filial rats.

Methods

Ten pregnant Wistar rats were divided into 2 groups: (1) VAD group, 6 rats were given nonvitamin A diet from 2 weeks before mating till delivery and (2) normal diet (ND) group, 4 rats were given normal diet. Twenty random neonatal rats from each group were killed on the next day of delivery. The rest neonates were given normal diet for 1 year until killed. Serum levels of vitamin A, morphology of the kidney, incidence of tumor formation, and retinoid X receptor (RXR) α messenger RNA (mRNA) expression in renal tissue were assessed for the filial rats.

Results

Fifty-six and 49 neonatal rats were born for VAD group and ND group, respectively. The detection rate of nephrogenic rests (NRs) from neonates in VAD group (50%) was significantly higher than that in ND group (20%; P < .05). The incidence of nephroblastoma was 13.9% in filial rats of VAD group and 0% for ND group. The detection rate of NRs for filial rats of VAD group (30.6%) was significantly higher than that of ND group (6.9%; P < .01). The expression of RXRα mRNA in tumor tissue of the filial rats of VAD group (3.17 ± 0.15) was significantly lower than that in kidney tissue of ND group (3.58 ± 0.20; P < .01).

Conclusion

Deficiency in vitamin A for pregnant rats resulted in renal dysplasia, increased NRs, and higher incidence of nephroblastoma.     

Surgical challenges associated with intensive treatment protocols for high-risk neuroblastoma

Background

High-risk neuroblastoma (NB; age, >1 year; INSS stage 4) is associated with a poor outcome. At our institution, the current dose-intensive high-risk Children's Oncology Group protocol for advanced NB appears to have a higher surgical complication rate as compared with previous protocols.

Methods

All stage 4 patients (n = 51) entered in high-risk protocols between 1995 and 2005 were analyzed. Patients in the current high-risk protocol, Children's Oncology Group A3973 (n = 22), were compared with those in the 2 previous protocols, CCG 3891 and POG 9341 (n = 29).

Results

Patients were comparable in their mean age and tumor markers, including Shimada histology, MYCN amplification, 1p deletion, tumor origin, and extent of metastasis. However, transfusion requirement (86% vs 45%; P = .0019), postoperative infection rate (32% vs 3%; P = .02), and other postoperative issues including nutritional support (45% vs 3%; P = .0001) were significantly higher with the current protocol. No perioperative mortality was noted in either group, and the extent of resectability and margins were similar. Importantly, with the current protocol, the survival rate was higher (P = .0022) and the recurrence rate was significantly lower (P = .0003).

Conclusions

Despite higher surgical morbidity associated with the current high-risk protocol (2.59 vs 0.86 complications/person; P < .01), the recurrence rate is lower and interim survival rate is improved for patients with high-risk NB. Therefore, the higher surgical complication rates associated with the current high-risk protocol are acceptable.     

Extracellular pressure stimulates adhesion of sarcoma cells via activation of focal adhesion kinase and Akt

Background

The effect of extracellular pressure on adhesion and adhesiogenic focal adhesion kinase (FAK) and Akt signaling in sarcomas was investigated.

Methods

Human sarcoma cells (HT-1080 fibrosarcoma, KHOS-240S osteosarcoma, and A-673 rhabdomyosarcoma) were subjected to increased pressure followed by adhesion assay. Two cell lines were pretreated with the FAK inhibitor 1,2,4,5-benzenetetraamine tetrahydrochloride (Y15) or Akt IV inhibitor, followed by Western analysis for activated FAK and Akt. Parallel studies were conducted in cells from a resected human fibrous histiosarcoma.

Results

Pressure increased adhesion in all 3 sarcoma lines and primary histosarcoma cells by 7% to 18% (n = 6; P < .01 each). Pressure activated FAK and Akt (n = 5; P < .01). Inhibiting FAK or Akt inhibited FAK or Akt phosphorylation and the stimulation of adhesion by increased pressure (n = 5 each; P < .01 each).

Conclusions

Pressure increases sarcoma cell adhesiveness via Akt and FAK. Perioperative manipulation or forces in lymphatic or circulatory systems may potentiate local recurrence or distant metastasis.     

Hepatoblastoma--evolution of management and outcome and significance of histology of the resected tumor. A 31-year experience with 40 cases

Background/purpose

The aim of this study was to retrospectively evaluate and compare the clinical features, treatment strategy, pathology, and outcome of all patients with hepatoblastoma treated at an African hospital over a 31-year period (1970 to 2001).

Methods

Forty patients with hepatoblastoma were divided into 3 groups according to the treatment given. Group I (1970 to 1983, 14 patients) had no protocol therapy; group II (1984 to 1988, 6 patients) received protocol treatment according to Children’s Study Group (CCSG) guidelines; group III (1989 to 2001, 20 patients) received SIOPEL protocol therapy. All available clinical, surgical, radiologic, and pathologic data were reviewed and analyzed.

Results

Overall patient survival was as follows: group I, 14%; group II, 50%, and group III, 80%. Deaths in group II were caused by chemotherapy-induced immunosuppression only. Prognostic data for group III showed that all tumor-related deaths could be predicted by identifying multifocal disseminated growth patterns (P = .001) or vascular invasion (P = .001) in resected tumors. Of the 40 diagnostic tumor biopsies performed, 2 significant complications (1 death, 1 intraperitoneal tumor seeding) occurred. Histologic criteria evaluating these biopsies were not predictive of overall survival.

Conclusions

The introduction of protocol therapy has resulted in a marked improvement in survival. Immunosuppression-related sepsis in our setting resulted in unacceptable mortality in patients treated according to CCSG guidelines. A diagnostic biopsy in hepatoblastoma is of value but not without complications. Preoperative chemotherapy followed by complete surgical excision according to International Society of Paediatric Oncology guidelines yields excellent results with a current survival rate of 80%.     

Anesthetic Risk Factors Associated With Early Mortality in Pediatric Liver Transplantation

Introduction

Early mortality in pediatric patients after liver transplantation (30 days) may be due to surgical and anesthetic perioperative factors.

Objective

To identify anesthetic risk factors associated with early mortality in pediatric patients who undergo liver transplantation (OLT).

Materials and Methods

This retrospective study of all patients who underwent a deceased or living donor liver transplantation evaluated demographic variables of age, weight, gender, degree of malnutrition, and etiology, as well as qualitative variables of anesthesia time, bleeding, massive transfusion, acid-base balance, electrolyte and metabolic disorders, as well as graft prereperfusion postreperfusion characteristics. Chi-square tests with corresponding odds ratio (OR) and 95% confidence intervals as well as Interactions were tested among significant variables using multivariate logistic regression models. P ≤.05 was considered significant.

Results

We performed 64 OLT among whom early death occurred in 20.3% (n = 13). There were deaths associated with malnutrition (84.6% vs 43.6%) in the control group (P < .01); massive bleeding, 76.9% (n = 10) versus 25.8% in the control group (P < .05) including transfusions in 84.6% (n = 11) versus 43.6% in the control group (P < .03); preperfusion metabolic acidosis in 84.6% (n = 11) versus 72.5% (n = 37; P < .05); posttransplant hyperglycemia in 69.2% (n = 9) versus 23.5% (n = 12; P < .01); and postreperfusion hyperlactatemia in 92.3% (n = 12) versus 68.6% (n = 35; P < .045).

Conclusion

Prereperfusion metabolic acidosis, postreperfusion hyperlactatemia, and hyperglycemia were significantly more prevalent among patients who died early. However, these factors were exacerbated by malnutrition, bleeding, and massive transfusions. Postreperfusion hypokalemia and hypernatremia showed high but not significant frequencies in both groups.     

Survival after liver transplantation for hepatoblastoma: a 2-center experience

Purpose

Complete resection with adjuvant chemotherapy is the accepted treatment for hepatoblastoma. The aim of this study is to evaluate our results of liver transplantation (LT) for tumors still unresectable after adequate chemotherapy.

Methods

All patients transplanted for hepatoblastoma from 2 institutions between 1990 and 2004 were included. Variables reviewed to determine impact on survival included the following: previous tumor resection, metastatic disease at diagnosis, microscopic vascular invasion, α-fetoprotein (AFP) levels at diagnosis and at transplant, tumor histology, and administration of posttransplantation chemotherapy. Effectiveness of pretransplantation chemotherapy was defined as a drop of more than 99% in peak AFP levels.

Results

Fourteen patients were transplanted: 9 boys and 5 girls (age range, 18 months-13 years; mean age, 57 ± 48 months). Patients were transplanted a mean of 4 ± 1 months after diagnosis. Overall survival was 71% (10/14) with a mean follow-up of 46 months. All deaths were secondary to recurrent tumor. Of 10 patients who underwent a primary LT, 9 survived compared to only 1 of 4 transplanted for unresectable tumor recurrence after primary resection (90% vs 25%; P = .02). Decline in peak AFP of more than 99% was also associated with better survival (100% vs 56%; P = .08). Similarly, patients who received posttransplantation chemotherapy had 100% survival compared with 56% without chemotherapy (P = .08). Other variables had little effect on survival.

Conclusions

Liver transplantation is a successful treatment option for children with unresectable hepatoblastoma with a 90% survival rate for primary transplantation. Rescue LT for recurrent hepatoblastoma after previous resection has a poor survival outcome and should be considered a relative contraindication. Posttransplantation chemotherapy improves survival. A prospective multicenter collaboration to validate these findings with a larger patient population is necessary. Until that time, patients who receive rescue transplants should receive posttransplantation chemotherapy.     

Liver transplantation for childhood hepatic malignancy: a review of the United Network for Organ Sharing (UNOS) database

Background

Orthotopic liver transplantation (OLT) is the only treatment option for unresectable hepatoblastoma (HB) and hepatocellular carcinoma (HCC) in children. Aggregated outcomes of OLT for these hepatic malignancies have not been evaluated in the United Network for Organ Sharing national database.

Purpose

The purpose of this study was to evaluate graft and patient survival in pediatric OLT recipients with HB and HCC.

Methods

Data from the United Network for Organ Sharing Standard Transplant and Research Files were analyzed and included pediatric (<18 years) OLT recipients with HB or HCC from 1987 to 2004. The effects of diagnosis on pretransplant variables were evaluated using analysis of variance methods or χ² tests, as appropriate. Actuarial survival and effect of diagnosis on survival were determined using Kaplan-Meier methods and log-rank tests.

Results

Since 1987, 152 OLTs have been performed in 135 pediatric patients for HB and 43 OLTs in 41 pediatric patients for HCC. Respective 1-, 5-, and 10-year patient survival after OLT was 79%, 69%, and 66% for HB and 86%, 63%, and 58% for HCC (P = .73). The primary cause of death for both groups was metastatic or recurrent disease, accounting for 54% of deaths in the HB group and 86% in the HCC group (P = .338). Patients with hepatoblastoma were younger (mean age, 2.9 ± 2.5 vs 10.4 ± 4.8 years for the HCC group; P < .001) and more likely to receive a living donor organ (16% vs 4%, P = .03). A greater proportion of the patients with HB had previous abdominal surgery than patients with HCC (63% HB vs 37% HCC, P = .04). Pretransplant medical condition and transplant era were associated with graft and patient survival on univariate and multivariate analysis (all P < .05).

Conclusions

Orthotopic liver transplantation remains a viable option for pediatric patients with unresectable primary hepatic malignancies and results in good long-term survival. Pretransplant medical condition is an important predictor of outcome. Thus, in conjunction with better chemotherapy regimens, earlier evaluation for OLT in patients with unresectable HB and HCC may result in yet further improved long-term survival.     

Growth factor modulation of hepatic inflammation: a novel approach to the management of total parenteral nutrition-associated liver disease

Purpose

Dependence on total parenteral nutrition in intestinal failure or short bowel syndrome patients can lead to many complications. The most significant complication is progressive liver injury leading to liver failure. This study assesses the potential of hepatocyte growth factor (HGF) in modulating the hepatic response in a rat cholestatic liver injury model.

Methods

Female Sprague-Dawley rats were divided into 3 groups: control (n = 5), chronic liver injury (α-naphtylisocyocyanate [ANIT] every 3.5 days at 75 mg/kg; n = 5), and chronic liver injury plus HGF (ANIT + HGF at 250 μg kg⁻¹ d⁻¹; n = 5). The rats initially underwent massive (80%) small bowel resections. Seven days later, they were given intraperitoneal injections of saline (control) or ANIT and implantation of an osmotic minipump for continuous intravenous saline or HGF. Intraperitoneal saline or ANIT injections were subsequently administered every 3.5 days to create a chronic cholestatic model. After 14 days, the animals were euthanized, and liver biopsies were obtained. The liver biopsies were evaluated by histology, immunofluorescence staining for interleukin-6 and tumor necrosis factor α, and assessment of apoptosis by terminal dUTP-transferase-mediated nick end labeling (TUNEL) technique.

Results

In this chronic liver injury model, HGF did not effect the grade of inflammation. However, HGF did induce retention of the ductal structures and avoided ductal proliferation, damage, and evidence of primary sclerosing cholangitis (P < .05). Hepatocyte growth factor induced less interleukin-6 (P < .011) and tumor necrosis factor α (P < .01) expression. Apoptotic activity was also significantly less in the HGF group (P < .01).

Conclusion

Hepatocyte growth factor preserved the hepatic ductal system, modulated the hepatic inflammatory response, and reduced the apoptotic index in this chronic cholestatic liver injury model. It may diminish or prevent liver damage in patients with total parenteral nutrition-induced liver injury.     

Outcomes of intestinal failure—a comparison between children with short bowel and dysmotile intestine

Background

We investigated whether mortality, intestinal adaptation, and liver function differ between intestinal failure (IF) patients with either short bowel (SB) or bowel dysmotility (DM).

Patients and methods

Twenty-six consecutive patients with SB (n = 20) or DM (n = 6) treated between 2000 and 2007 were retrospectively assessed. Intestinal failure was defined as less than 25% of age-adjusted small intestinal length or dependence on parenteral nutrition (PN) more than 6 months.

Results

Median age-adjusted small intestinal length (17% vs 45%) and gestational age (35 vs 40 weeks) were (P < .05) shorter, whereas proportion of the remaining colon (86% vs 0%) was (P < .05) higher in the SB group relative to the DM group. Overall survival was 92%. Median peak serum bilirubin (80 vs 25 μmol/L) and rate of cholestasis (11/20 vs 0/6) were higher (P < .05) in the SB group. Short bowel rather than DM as an etiology of IF predicted weaning off PN (RR, 39.3; 95% confidence interval [CI], 1.43-526; P < .01) and development of cholestasis (risk ration [RR], 18.3; 95% CI, 0.658-127; P < .05). Three SB children developed liver failure and two died, whereas neither of these occurred in the DM group.

Conclusions

Children with SB are more likely to wean off PN but more prone to cholestatic liver disease than those with DM as an etiology of IF.     

The impact of gross total resection on local control and survival in high-risk neuroblastoma

Background/purpose

Gross total resection of the primary tumor in treatment of high-risk neuroblastoma remains controversial. Furthermore, there are few reports of the effect of primary tumor resection on local control as opposed to overall survival. The authors reviewed their institutional experience to assess the effect of primary tumor resection on local control and overall survival.

Methods

A total of 141 patients were treated on protocol between November 1, 1979 and June 25, 2002 and are the subject of this report. Gross total resection was assessed by review of operative notes, postoperative computerized axial tomograms, and postoperative meta-iodobenzyl guanidine (MIBG)¹ scans when available.

Results

The median age was 3.3 years, and all patients were International Neuroblastoma Staging System (INSS) stage 4 with 79% having metastases to cortical bone. The primary site was the adrenal gland in 74%, the central abdominal compartment in 13%, the posterior mediastinum in 7%, and other sites in 6%. Gross total resection was accomplished in 103 (73%) but was more than 90% for the last 3 protocols. Five kidneys were lost overall. The probability of local progression was 50% in unresected patients compared with 10% in patients undergoing gross total resection (P < .01). Overall survival rate in resected patients was 50% compared with 11% in unresected patients (P < .01).

Conclusions

Our data indicate that local control and overall survival rate are correlated with gross total resection of the primary tumor in high-risk neuroblastoma. Gross total resection should be part of the management of stage 4 neuroblastoma in patients greater than 1 year of age.     

Outcomes of liver transplantation from hepatitis B core antibody-positive donors in viral cirrhosis patients: the prevailing negative effect of recipient hepatitis C virus infection

Background

Liver transplantation (LT) with grafts from hepatitis B core antibody (HBcAb)-positive donors has been the object of recent studies, suggesting different outcomes depending on the etiology of viral cirrhosis in the recipient.

Methods

From November 2002 to December 2009, we transplanted 124 livers from hepatitis B surface antigen (HBsAg)-negative HBcAb-positive deceased heart-beating donors to adult recipients with viral cirrhosis, classified as: HBsAg positive (group 1; n = 63); hepatitis C virus (HCV) RNA positive (group 2; n = 52); and simultaneously HBsAg and HCV-RNA positive (group 3; n = 9). Immunosuppression included a calcineurin inhibitor, mycophenolate, and steroids (tapered to suspension in 6 months). In all groups, anti-HBV prophylaxis was performed with anti-HBs immunoglobulins and nucleos(t)idic analogues.

Results

The groups were similar regarding donor, recipient, donor-recipient match, transplant procedure, variables, and treatment of acute rejection, except for younger recipient age in group 1 (P = .009), lower recipient body mass index in group 3 (P = .03), and longer cold ischemia time in group 2 (P = .003). Median follow-up for surviving grafts was 63 (range, 16-102) months. No case of recurrent or de novo hepatitis B occurred. The prevalence of histologically proven recurrent HCV hepatitis was similar in groups 2 and 3 (65% vs 78%). Graft survival at 5 years was 86% in group 1, 35% in group 2, and 31% in group 3 (P < .0001 for group 1 vs 2; P < .01 for group 1 vs 3). On multivariate analysis, independent predictors of worse graft survival were HCV infection in the recipient (HR 8.08, 95% CI 3.36-17.97; P < .0001) and MELD at LT ≥25 (HR 3.72, 95% CI 1.12-12.37; P = .032).

Conclusions

The presence of HCV infection in the recipient is the factor which most negatively influenced the outcome of LT using grafts from HBcAb-positive donors. Allocation of such grafts should consider the type of viral cirrhosis among LT candidates.     

Outcomes of treatment of childhood achalasia

Purpose

The optimal management of achalasia in children and adolescents remains unclear. The aim of this study was to review a single institution's experience with endoscopic and surgical interventions in children with achalasia.

Methods

A retrospective review was conducted of the medical records of children treated for achalasia from 1978 to 2008. Patient demographics and interventions were reviewed. Outcomes after procedural intervention were evaluated.

Results

Thirty-five patients with achalasia were identified, and data were available for 34 (age, 13 ± 6 years; male, 62%). Eighteen patients underwent esophageal dilation (ED), and 16 patients underwent Heller myotomy (HM). Follow-up was available for 30 patients (ED, 15; HM, 15). There was symptom recurrence in 15 of 15 ED cases and 8 (53%) of 15 HM cases (P < .01). Additional interventions were performed in 14 (93%) of 15 ED cases and 6 (40%) of 15 HM cases (P < .01).

Conclusions

Heller myotomy may provide more durable long-term outcomes, as defined by symptom recurrence and need for subsequent intervention, and may be considered the procedure of choice.     

Early and late indications for implantation of cardiac pacemakers in patients after heart transplantation: a single-center experience

Background

Data regarding the incidence and predictors of permanent pacemaker (PPM) implantation following cardiac transplantation are still limited and inconsistent. The aim of our study was to assess the incidence and indications for PPM implantation in cardiac transplant recipients in a single center.

Methods

We retrospectively analyzed the records of 508 consecutive patients including 425 men and an overall mean age of 45 y who underwent heart transplantation from 1988 to 2011 at our institution, using the biatrial surgical technique.

Results

Twenty-three (4.5%) subjects developed intermittent third-degree atrioventricular block (AVB) or sinus node dysfunction (SND) requiring PPM: 7 early (<3 months) and 16, late (>3 months) after transplantation. The incidence of AVB was higher than SND early (0.98% vs 0.4%; P < .05) and late (2.4% vs 0.8%; P < .01). The time from transplantation to PPM implantation was shorter among the SND group compared with the AVB group early (mean, 4.5 vs 6.5 weeks; P < .05) and late (mean, 4 vs 7 years; P < .05).

Conclusion

The incidence of PPM after heart transplantation was 4.5%. AVB was the main indication for PPM early and late after transplantation. The time interval from transplantation to PPM implantation was shorter among SND compared with AVB patients.     

Loss of carcinoembryonic antigen-related cell adhesion molecule 1 expression predicts metachronous pulmonary metastasis and poor survival in patients with hepatoblastoma

Purpose

Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1) is a member of the carcinoembryonic antigen family of immunoglobulin-like adhesion molecules. The aim of this study was to test the hypothesis that loss of CEACAM1 expression in hepatoblastoma cells may promote hematogeneous metastasis and function as an adverse prognostic factor.

Methods

Immunohistochemical expression of CEACAM1 in surgically resected specimens from 19 patients with hepatoblastoma was examined retrospectively. The CEACAM1 expression in the epithelial area of the tumor was classified into 2 categories as follows: diffuse expression, characterized by positive staining throughout the tumor specimen, or loss of expression, in which there were distinct areas of negative staining within the tumor specimen.

Results

Of the 19 patients, 12 were classified as having tumors with diffuse expression, and 7 had loss-of-expression tumors. Survival after treatment was significantly worse in patients with tumors with loss of CEACAM1 expression (cumulative 5-year survival rate, 29%) than in patients with diffuse CEACAM1 expression (cumulative 5-year survival rate, 92%; P = .0062). Loss of CEACAM1 expression was a significant risk factor for metachronous pulmonary metastases (P = .0105).

Conclusions

Loss of CEACAM1 expression may reflect a high metastatic potential and thus indicate a poor prognosis for patients with hepatoblastoma.     

Cure of multifocal panhepatic hepatoblastoma: is liver transplantation always necessary?

Purpose

Multifocal panhepatic hepatoblastoma (HB) without extrahepatic disease is generally considered as an indication for total hepatectomy and liver transplantation. However, after initial chemotherapy, downstaging of the tumor sometimes allows complete macroscopic resection by partial hepatectomy. This procedure is no longer recommended because of the risk of persistent viable tumor cells in the hepatic remnant. We report our experience with conservative surgery in such cases.

Method

Between 2000 and 2005, 4 children were consecutively referred to our unit with multinodular pan-hepatic HBs (classification PRETEXT IV of the International Society of Pediatric Oncology Liver Tumor Study Group SIOPEL). Three of them had extrahepatic disease at diagnosis. All patients were treated according to SIOPEL 3 and 4 protocols.

Results

Extrahepatic metastases were still viable in 2 of 3 patients after initial chemotherapy. These patients eventually died of tumor recurrence. In the 2 patients without residual extrahepatic disease, liver tumors had regressed, and complete macroscopic excision of hepatic tumor remnants could be achieved by conservative surgery. These 2 children are alive and well and free of tumor 7 years after diagnosis.

Conclusions

Conservative surgery may be curative in some multinodular PRETEXT IV HB patients, with a good response to preoperative chemotherapy and complete excision of all macroscopic tumor remnants. However, because of the lack of reliable predictors of sterilization of the microscopic disease in the residual liver, with subsequent poor prognosis, total hepatectomy and liver transplantation remain currently recommended in patients with multinodular PRETEXT IV HB without extrahepatic disease, even though some of these children are probably overtreated.     

Elective laparoscopic sigmoid resection for diverticular disease has fewer complications than conventional surgery: a meta-analysis

Background

We performed a meta-analysis of published literature comparing the complications after open and laparoscopic elective sigmoidectomy for diverticular disease.

Methods

Electronic databases were searched from January 1991 to March 2009. A systematic review was performed to obtain a summative outcome.

Results

Nineteen comparative studies involving 2,383 patients were analyzed. There were 1,014 patients in the laparoscopic group and 1,369 patients in the open group. There was no significant heterogeneity among any of the complications analyzed. Patients in the laparoscopic sigmoid resection group had fewer wound infections (fixed effects model: risk ratio [RR], .54; 95% confidence interval [CI], .36-.80; z, −3.05; P < .01; random effects model: RR, .59; 95% CI, .39-.89; z, −2.54; P < .05), blood transfusions (fixed effects model: RR, .25; 95% CI, .10-.60; z, −3.10; P < .01; random effects model: RR, .28; 95% CI, .11-.68; z, −2.81; P < .01), and ileus rates (fixed effects model: RR, .37; 95% CI, .20-.66; z, −3.34; P = .001; random effects model: RR, .37; 95% CI, .20-.68; z, −3.21; P = .001) compared with open sigmoid resections. No difference was seen for medical complications, need for rehospitalization, and reoperation.

Conclusions

Laparoscopic sigmoid resection is safe and has fewer postoperative surgical complications. This approach should be considered for elective cases, however, more randomized controlled trials are required to strengthen the evidence.