Incidencia y supervivencia de los tumores de novo en el trasplante hepático

Introduction

The greater survival of transplanted patients is accompanied by an increase in the rate of de novo malignancies (NM), which are the most frequent late-onset complication. We can distinguish between non-melanoma skin cancers (NMSC), post-transplant lymphoproliferative disorders (PTLD) and solid organ cancers (SOC). Our objective is to determine the incidence of the different types of NM, the time elapsed until diagnosis and survival rates in our setting.

Aplicabilidad y resultados del trasplante hepático combinado con quimiorradioterapia neoadyuvante en el tratamiento del colangiocarcinoma perihiliar irresecable

BackgroundIn 2007, a multicenter protocol was developed in Catalonia, Spain, combining neoadjuvant chemoradiotherapy and liver transplantation (LT) for those patients with unresectable hilar cholangiocarcinoma (hCCA).AimTo analyse the effectiveness of the neoadjuvant chemoradiotherapy and LT for those patients enrolled in the protocol based on intention-to-treat.MethodsObservational multicenter study which includes patients ≤ 68 years-old diagnosed with unresectable, solitary tumors ≤ 3 cm in radial diameter, without evidence of lymph node metastases. The protocol was based on a strategy of neoadjuvant therapy with high-dose radiation (45 Gy in total) plus intravenous fluorouracil (5-FU) given as a daily bolus for the first 3 days of radiation follow by oral capecitabine until transplantation. The patient was included in waiting list for LT if no evidence of disseminated disease was found.ResultsBetween 2007 and 2018, 13 patients were enrolled in the transplant protocol. Of those, 61% (8/13) of the patients were transplanted. The average time spent on the waiting list was 122 days (range 5-192). Intent-to-treat survival was 69% and 39% at one and 5 years. Post-transplantation overall survival was 87% and 62% and 29% recurrence rate at 5 years.ConclusionThe suitability of the neoadjuvant chemoradiotherapy and LT protocol was 61% in our series with long-term overall survival and should be considered as an alternative to resection for patients with localized node-negative hCCA.     

Encuesta a los jefes de Unidad y residentes de Cirugía sobre la accesibilidad y el trabajo en los equipos de trasplante hepático en España

IntroductionThe access of surgeons to liver transplant teams in Spain is heterogeneous. This study aims to portray the current human resources of Spanish transplant teams, distribution of transplant duties among team members, how transplant team members acquire their skills, their leaders’ view of their future, as well the motivations of Spanish General Surgery residents to choose transplantation as their future career choice.MethodsTwo different surveys were created, one for head surgeons and one for residents, about the number of team members and their training, recruitment, organization of tasks and motivation to work in transplantation. The questionnaires were e-mailed to both the transplant program directors and the surgical residents.ResultsThere are on average 8 surgeons in each transplant unit. More than four surgeons perform the hepatectomy in 54.2% of the groups, while the graft implantation is performed by more than 4 surgeons at just 25% of the centers. Forty-two percent of the transplant chiefs advocated a fellowship training system, and 87.5% believe that generational turnover is guaranteed.Out of 525 residents, 101 responded. Regarding training, 12.8% had no interest in transplantation. Concerning their work preferences, 37.6% were not interested in transplantation because it is excessively demanding, and 52.5% would not like to be part of a liver transplant team in the future.ConclusionsThe generational turnover seems to be guaranteed according to liver transplant program directors. The new generations of surgeons generally opt for other areas of surgery other than transplantation. Studies with a greater number of responses are necessary to validate these results     

Impacto de la anemia sobre la supervivencia de los pacientes intervenidos de cistectomía radical por tumor vesical

ObjectiveTo evaluate the prevalence of preoperative anemia and its effect on oncological outcomes in patients undergoing radical cystectomy (RC) due to bladder cancer.Material and methodsRetrospective single-center study with 176 RCs between May 2008 and July 2018. Anemia was defined according to the WHO classification (male < 130 mg/dL, female < 120 mg/dL). Kaplan-Meier test was used to estimate recurrence-free, cancer-specific and overall survival rates. Multivariate logistic regression was used to identify factors associated with overall mortality rates.ResultsOverall, 89 (50.6%) patients had preoperative anemia, and 44 of them (49.4%) received neoadjuvant chemotherapy. Anemic patients resulted in higher rates of ASA (ASA > 2: 54.6 vs. 27.5%; P = .003), ectasia rate previous to RC (41.6 vs. 19.5%; P = .002), treatment with neoadjuvant chemotherapy (49.4 vs. 19.5%; P < .001), blood transfusion rate (25.8 vs. 11.5%; P = .015) and pathological stage (pT > 2: 49.4 vs. 33.3%; P = .03) compared to non-anemic patients. Median follow-up was 27.2 months (IQR 11.12-72.28). Median overall survival (105 vs. 34 months, log-rank; P = .001), cancer-specific survival (89 vs. 61 months; P = .004) and recurrence-free survival (85 vs. 57 months; P = .002) were significantly lower in anemic patients compared to the non-anemic group. In multivariable Cox analysis, preoperative anemia, pT > 2 and N ≥ 1 were independently associated with overall mortality.ConclusionPreoperative anemia was common in patients undergoing RC for bladder cancer, and it is related with a worse cancer prognosis. Anemia is a preoperative modifiable factor; we believe that the implementation of Patient Blood Management programs during prehabilitation may have a relevant role in improving the oncological outcomes in these patients.     

VI documento de consenso de la sociedad española de trasplante hepático (SETH)

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6 th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.     

Análisis de supervivencia de los pacientes con cáncer de próstata con factores patológicos desfavorables tratados con prostatectomía radical y radioterapia de rescate tras la recidiva y persistencia bioquímica

ObjectiveSurvival analysis of patients with prostate cancer (PCa) with adverse prognostic factors (APF) treated with radical prostatectomy (RP) and salvage radiotherapy (SRT) after biochemical recurrence (BR) or biochemical persistence (BP).Materials and methodsRetrospective analysis of 446 patients with at least one of the following APF: Gleason score ≥ 8, pathologic stage ≥ pT3 and/or positive surgical margins. BR criteria used was PSA level over 0.4 ng/ml.A survival analysis using Kaplan-Meier was performed to compare the different variable categories with log-rank test. In order to identify risk factors for SRT response and cancer specific survival (CSS) we performed univariate and multivariate analyses using Cox regression.ResultsMean follow up: 72 (IQR 27-122) months, mean time to BR: 42 (IQR 20-112) months, mean PSA level at BR: 0.56 (IQR 0.42-0.96). BR was present in 36.3% of the patients. Biochemical response to SRT was observed in 121 (75.7%) patients.Recurrence-free survival (RFS) rates after SRT at 3, 5, 8 and 10 years were 95.7%, 92.3%, 87.9%, and 85%; overall survival (OS) rates after 5, 10 and 15 years was 95.6%, 86.5% and 73.5%, respectively. CSS rates at 5, 10 and 15 years were 99.1%, 98.1% and 96.6%.Only time to BR < 24 months (HR = 2.55, P = .01) was identified as an independent risk factor for RFS after SRT.ConclusionsIn these patients, RP only controls the disease in approximately half of the cases. Multimodal sequential treatment (RP + SRT when needed) increases this control, achieving high CSS rates and biochemical control in over 87% of the patients. Patients with time to recurrence > 24 months responded better to rescue treatment.     

Resultados obtenidos tras el tratamiento quirúrgico de los pacientes con metástasis hepáticas de sarcomas

IntroductionThe presence of liver metastases in sarcomatous tumors is associated with poor prognosis. However, in selected patients, surgical resection has been suggested as a tool to improve survival rates. The aim of our study is to describe postoperative and oncological outcomes after liver resection.MethodsA retrospective unicentric study was conducted including patients diagnosed with hepatic metastases from soft tissue sarcoma who underwent hepatic resection between 2003 and 2019. The inclusion criteria were the presence of resectable disease, including synchronic and metachronic lesions. The presence of extra-hepatic controlled disease was not considered unresectable.ResultsNineteen patients underwent liver resection for liver metastasis of 7 different sarcomatous subtypes. Median age was 58-yo. Liver metastases were diagnosed a median 25 months after primary tumor diagnosis. Six patients (32%) suffered of synchronic metastases and 12 (63%) were affected of extrahepatic disease. Major hepatectomy was done in 5 (26%) patients, 8 (42%) minor complications were described. Median follow-up was 33 months. Survival analysis was performed independently for, GIST tumors and non-GIST sarcomas. One, three and five-year survival rate was 100%, 85.7% and 42.9% in non-GIST sarcomas, while five and ten-year survival rate was 100% and 40% in GIST, respectively.ConclusionsSurgical approach of liver metastases of sarcomatous tumors seems to be useful in order to improve survival in selected patients, while associated to be of low complications rate. In our cohort, extrahepatic disease rate is high in comparison with series published before, nevertheless survival is comparable. These results support performing surgical resection in selected patients with stable extrahepatic disease.     

Los sistemas de clasificación de la OMS de 1973 y 2004 difieren en la predicción de supervivencia entre los pacientes con cáncer de vejiga en estadio T1

Introduction and objectivesThe aim of this study was to analyse prognostic impact of tumour histological grade on survival differences between primary G2 and G3 WHO1973 stage T1 tumours which were graded as HG according to WHO2004 grading system.Materials and methodsData from 481 patients with primary T1HG bladder cancer who were treated between 1986 and 2016 in 2 university centres were retrospectively reviewed. Log-rank test and Cox regression analysis was performed to compare the groups.Results95 (19,8%) tumours were classified as G2 and 386 (80,2%) were G3. Median follow-up was 68 months. The recurrence was observed in 228 (47,5%), and progression in 109 patients (22,7%). Radical cystectomy was performed in 114 pts (23,7%) and there were 64 (13,3%) cancer specific deaths. Recurrence-free rates at 5-years follow-up for G2, G3 and all patients were 68,7%, 51,2% and 56,3% and progression-free rates were 89,3%, 73,2% and 78,1% respectively. For total observation period patients with G3 tumours presented also worse recurrence-free, and progression-free survival levels than patients with G2 tumours. In multivariate analysis, after adjustment for clinical features, the risk of recurrence and progression for G3 tumours was 1,65 and 2,42 fold higher than for G2 tumours.ConclusionsIt was shown that G3 T1 tumours are characterized by worse recurrence free and progression free survivals when compared to G2 cancers.     

Utilidad de la diferencia venoarterial de PCO2 como predictor de complicaciones en el postoperatorio inmediato del trasplante hepático

ObjectiveTest whether the development of abnormal venous-to arterial CO₂ difference (ΔPCO₂) during the early phases of postoperative care after a liver transplantation is related to multi-organ dysfunction and outcomes.Materials and methodsProspective cohort study accomplished in a mixed intensive care unit at a university hospital. We included 150 eligible patients after a liver transplantation between 2015 and 2018.Patients were classified in 4 predefined groups according to the ΔPCO₂ evolution during the first 6 h of resuscitation: 1) persistently normal ΔPCO₂ (normal at T0 and T6); 2) decreasing ΔPCO₂ (high at T0, normal at T6); 3) increasing ΔPCO₂ (normal at T0, high at T6); and 4) persistently high ΔPCO₂ (high at T0 and T6). Multiorgan dysfunction at day-3 was compared for predefined groups and a Kaplan Meier curve was constructed to show the survival probabilities using a log-rank test to evaluate differences between groups. A Spearman-rho was used to test the agreement between cardiac output and ΔPCO₂.ResultsThere were no significant differences between the study groups regarding higher SOFA scores at day-3 (P = 0.86), Δ-SOFA (P = 0.088), as well as global mortality rates (χ² = 5.72; P = 0.126) and mortality rates at day-30 (χ² = 2.23; P = 0.5252).A significantly poor inverse agreement between cardiac output and ΔPCO₂ was observed (rho de Spearman ?0,17; P = 0,002) at different points of resuscitation.ConclusionsAfter a liver transplantation, central venous-to-arterial CO₂ difference was not associated with survival or postoperative adverse outcomes in a critical care patients population.     

La incidencia acumulada y los factores predictivos de la cistitis rádica en pacientes con cáncer de próstata localizado

Purpose

To determine the cumulative incidence of overall and severe radiation cystitis in a high volume cohort of patients and to investigate its potential predictive factors.

Indicaciones y resultados de retrasplante hepático: experiencia del hospital universitario La Fe (1.181 pacientes)

Liver retransplantation (LrT) is the only therapeutic option for irreversible failure of a hepatic graft and accounts for 2.9%–24.0% of all liver transplantations (LT). It is technically difficult and has a high level of immediate morbidity and a lower survival than primary LT. Our aim was to determine the rate of LrT and its indications, morbidity, post-operative mortality and actuarial survival in the retransplanted patient.Patients and methodA historical cohort study of 1181 patients transplanted between 1991 and 2006.ResultsOf the 1260 LT performed, 79 were LrT. At the time of the first LT there were no differences between those patients and those that did not require an LrT. The LrT rate was 6.3% and the most frequent causes were: hepatic artery thrombosis (31.6%), recurrence of cirrhosis due the HVC (30.4%) and primary graft (21.5%). The ischemia times, perfusion syndrome and hepatic congestion were no different between the primary LT and the LrT. On the other hand, red cell transfusions were higher in LrT (6.3±4.9 vs. 3.5±3.0 units, P<0.001). The post-operative morbidity and morbidity (up to 30 days after the LT) was higher in retransplanted patients (68.4% vs. 57.0%, P=0.04 and 25.3% vs. 10.9%, P<0.001; respectively). The actuarial survival at 1 and 5 years was 83% and 69% in those without LrT, 71% and 61% in early LrT and 64% and 34% in delayed LrT (P<0.001).ConclusionsDespite the increased morbidity and mortality of LrT, it appears that this treatment alternative is still valid in those patients with an early loss of the liver graft. On the other hand, when the graft loss is delayed, it needs to be defined, what would be the minimum acceptable results to indicate LrT and which patients could benefit from this treatment.     

Impacto de la prostatectomía radical en los resultados urodinámicos de pacientes con cáncer de próstata tratados con radioterapia de intensidad modulada

Introduction and objectivesTo evaluate the effect of radical prostatectomy and age on urodynamics before and after intensity-modulated radiation therapy administered to prostate cancer patients.Materials and methodsThe sample consisted of 40 prostate cancer patients, 22 of whom had undergone a radical prostatectomy. Urodynamic parameters before and after an average of 4.2 months of radiotherapy were measured and compared. External radiotherapy was administered via Volumetric Modulated Arc Therapy (VMAT), Intensity Modulated Radiation Therapy (IMRT) techniques.ResultsUroflowmetry presented no significant parameters. In the case of Cystomanometry, the data did not show an increase in secondary stress urinary incontinence, although there is 7 percent increase in urge urinary incontinence. There were statistically significant changes in reduced bladder capacity with a strong desire to void, with an urge to void and also in the detrusor pressure with a normal desire to void. Furthermore, pressure/flow analysis revealed a statistically significant reduction of residual urine volume.ConclusionsThe effect of prostatectomy and age varies according to the evolution of urodynamics. There was a significant reduction in terms of residual urine volume and detrusor pressure with a normal desire to void in patients without a prostatectomy and in those under 75 years old. In addition to an increase in urge incontinence, there was also a significant worsening of the bladder filling urodynamics and a decrease in the cystomanometric bladder capacity with a strong desire and an urge to void. None of these were modified by age or prostatectomy.     

Influencia del acceso laparoscópico en la mortalidad cáncer-específica de los pacientes con cáncer de vejiga en un estadio pTa-2pN0R0 tratados con cistectomía radical

Introduction and objectiveMinimally invasive surgery represents an attractive surgical approach in radical cystectomy. However, its effect on the oncological results is still controversial due to the lack of definite analyses. The objective of this study is to evaluate the effect of the laparoscopic approach on cancer-specific mortality.Material and methodA retrospective cohort study of two groups of patients in a pT0-2pN0R0 stage, undergoing open radical cystectomy (ORC) (n = 191) and laparoscopic radical cystectomy (LRC) (n = 74). Using Cox regression, an analysis has been carried out to identify the predictor variables in the first place, and consequently, the independent predictor variables related to survival.Results90.9% were males with a median age of 65 years and a median follow-up period of 65.5 (IQR 27.75-122) months. Patients with laparoscopic access presented a significantly higher ASA index (P = .0001), a longer time between TUR and cystectomy (P = .04), a lower rate of intraoperative transfusion (P = .0001), a lower pT stage (P = .002) and a lower incidence of infection associated with surgical wounds (P = .04). When analyzing the different risk factors associated with cancer-specific mortality, we only found the ORC approach (versus LRC) as an independent predictor of cancer-specific mortality (P = .007). Open approach to cystectomy multiplied the risk of mortality by 3.27.ConclusionsIn our series, the laparoscopic approach does not represent a risk factor compared to the open approach in pT0-2N0R0 patients.