Factors linked to longterm survival of patients with hepatocellular carcinoma accompanied by tumour thrombus in the major portal vein after surgical resection

Objectives

The prognosis in patients with hepatocellular carcinoma (HCC) accompanied by main portal vein tumour thrombus (MPVTT) is poor. The aim of this study was to clarify the factors linked to survival of >5 years after hepatectomy in HCC patients with MPVTT.

Methods

Twenty-nine HCC patients with MPVTT were divided into two groups comprising, respectively, patients who survived >5 years after hepatectomy (survivors, n = 5) and those who did not (non-survivors, n = 24). The two groups were compared.

Results

Overall survival rates at 1, 3 and 5 years were 62.1%, 24.1% and 17.2%, respectively. Four (80.0%) 5-year survivors had recurrences of HCC in which the number of recurrent nodules was under four. Three (21.4%) of the 14 non-survivors who underwent curative resection experienced recurrences of HCC and all of them demonstrated fewer than four recurrent nodules (P = 0.0114). Local therapy, such as radiofrequency ablation and resection of recurrence, had more often been used in survivors than in non-survivors (P = 0.0364).

Conclusions

Although surgical outcomes in patients with HCC accompanied by MPVTT are unsatisfactory, some patients do enjoy longterm survival. When the number of recurrent nodules is less than four, local therapy should be selected with the aim of achieving 5-year survival.     

Spontaneous regression of hepatocellular carcinoma is most often associated with tumour hypoxia or a systemic inflammatory response

Background

Spontaneous regression of hepatocellular carcinoma (HCC) is well documented, although the aetiology of this phenomenon remains unknown.

Methods

A review of the English literature was performed for reports of spontaneous regression of HCC. Reports were classified by mechanism based on the available information.

Results

Spontaenous regression of HCC has been identified in 75 patients. The most common mechanisms of regression identified were tumour hypoxia (n= 21, 28.0%), a systemic inflammatory response (n= 25, 33.3%) and unknown (n= 29, 38.7%). In patients where tumour hypoxia was described as the aetiology, mechanisms included spontaneous hepatic artery thrombosis and sustained systemic hypotension. In patients where a systemic inflammatory response was the aetiology, mechanisms included cholangitis, trauma and elevated cytokine levels.

Discussion

Spontaneous regression of HCC is most commonly associated with tumour hypoxia or a systemic inflammatory response. Determining the aetiology of spontaneous regression may identify potential therapeutic pathways. Tumour hypoxia is already the basis of treatment modalities such as hepatic artery embolization and the anti-angiogenic agent sorafenib. However, treatment modalities for HCC do not currently include immune-directed therapies; this may prove to be a worthy target for future research.     

Resection or transplant-listing for solitary hepatitis C-associated hepatocellular carcinoma: an intention-to-treat analysis

Objectives

The relative roles of liver resection (LR) and liver transplantation (LT) in the treatment of a solitary hepatocellular carcinoma (HCC) remain unclear. This study was conducted to provide a retrospective intention-to-treat comparison of these two curative therapies.

Methods

Records maintained at the study centre for all patients treated with LR or listed for LT for hepatitis C-associated HCC between January 2002 and December 2007 were reviewed. Inclusion criteria required: (i) an initial diagnosis of a solitary HCC lesion measuring ≤ 5 cm, and (ii) Child–Pugh class A or B cirrhosis. The primary endpoint analysed was intention-to-treat survival.

Results

A total of 75 patients were listed for transplant (LT-listed group) and 56 were resected (LR group). Of the 75 LT-listed patients, 23 (30.7%) were never transplanted because they were either removed from the waiting list (n = 13) or died (n = 10). Intention-to-treat median survival was superior in the LR group compared with the LT-listed group (61.8 months vs. 30.6 months), but the difference did not reach significance. Five-year recurrence was higher in the LR group than in the 52 LT patients (71.5% vs. 30.5%; P < 0.001).

Conclusions

In the context of limited donor organ availability, partial hepatectomy represents an efficacious primary approach in properly selected patients with hepatitis C-associated HCC.     

Bile duct thrombi in hepatocellular carcinoma: is aggressive surgery worthwhile?

Introduction

Obstructive jaundice as a result of bile duct tumour thrombus (BDTT) is an unusual clinical entity and an uncommon presenting feature of hepatocellular carcinoma (HCC). This study evaluates the outcome of hepatectomy for HCC with obstructive jaundice as a result of BDTT in non-cirrhotic livers.

Methods

Between 1997 and 2012, out of 426 patients with HCC in non-cirrhotic livers, 39 patients with BDTT (Group I n = 39), who underwent a hepatectomy, were analysed and compared with the non-BDTT group (Group II n = 387).

Results

The demographic profile and biochemical parameters between Group I and Group II were compared; apart from the presence of jaundice at presentation and an elevated serum bilirubin, there were no significant differences. Post-operative morbidity and mortality were 11 (28.2%) and 2 (5.1%), respectively, in Group I. There were no differences between the groups with regards to the operative variables and short-term outcomes. The 1-, 3- and 5-year survival rates in Group I were 82%, 48% and 10%, respectively, with a median survival of 28.6 months and were significantly poorer than Group II (90%, 55% and 38%, respectively, with a median survival of 39.2 months).

Conclusion

The mere presence of BDTT in HCC does not indicate an advanced or inoperable lesion. When technically feasible, a formal hepatic resection is the preferred first-line treatment option in these patients.     

Adjuvant stereotactic body radiotherapy following transarterial chemoembolization in patients with non‐resectable hepatocellular carcinoma tumours of ≥3 cm

Objectives

The optimal locoregional treatment for non-resectable hepatocellular carcinoma (HCC) of ≥3 cm in diameter is unclear. Transarterial chemoembolization (TACE) is the initial intervention most commonly performed, but it rarely eradicates HCC. The purpose of this study was to measure survival in HCC patients treated with adjuvant stereotactic body radiotherapy (SBRT) following TACE.

Methods

A retrospective study of patients with HCC of ≥3 cm was conducted. Outcomes in patients treated with TACE alone (n = 124) were compared with outcomes in those treated with TACE + SBRT (n = 37).

Results

There were no significant baseline differences between the two groups. The pre-TACE mean number of tumours (P = 0.57), largest tumour size (P = 0.09) and total tumour diameter (P = 0.21) did not differ significantly between the groups. Necrosis of the HCC tumour, measured after the first TACE, did not differ between the groups (P = 0.69). Local recurrence was significantly decreased in the TACE + SBRT group (10.8%) in comparison with the TACE-only group (25.8%) (P = 0.04). After censoring for liver transplantation, overall survival was found to be significantly increased in the TACE + SBRT group compared with the TACE-only group (33 months and 20 months, respectively; P = 0.02).

Conclusions

This retrospective study suggests that in patients with HCC tumours of ≥3 cm, treatment with TACE + SBRT provides a survival advantage over treatment with only TACE. Confirmation of this observation requires that the concept be tested in a prospective, randomized clinical trial.     

Outcome of hepatectomy for hepatocellular carcinoma in patients with renal dysfunction

Objectives

There are few reports on the efficacy of hepatectomy for hepatocellular carcinoma (HCC) in patients with renal dysfunction (RD). This study aimed to clarify the validity of hepatectomy for treating HCC in RD patients, and to compare postoperative courses in RD and non-RD patients.

Methods

The clinical features of 722 HCC patients who underwent curative hepatectomy between 1986 and 2009 were retrospectively reviewed. Seventeen patients (2.4%) with preoperative serum creatinine levels of >2.0 mg/dl were defined as the RD group, and, of these, seven who did not receive preoperative haemodialysis were defined as borderline patients. Clinicopathological characteristics and postoperative outcomes were compared between the RD group (n = 17) and the non-RD group (n = 705). The postoperative courses of borderline patients were reviewed in detail.

Results

Overall survival (P = 0.177) and disease-free survival (P = 0.942) after hepatectomy did not differ significantly between the groups. Incidences of massive ascites (35.3% vs. 14.3%; P = 0.034) and pleural effusion (52.9% vs. 17.6%; P = 0.001), defined as massive effusion (ME), were significantly higher in the RD group than in the non-RD group. Hypoalbuminaemia (≤2.8 g/dl; P = 0.031), heavy blood loss (≥1000 ml; P = 0.012) and intraoperative blood transfusion (P = 0.007) were risk factors for ME. Among the borderline patients, serum creatinine values were not increased immediately after surgery and four patients underwent haemodialysis.

Conclusions

Preoperative hypoalbuminaemia, heavy blood loss and blood transfusion are independent risk factors for ME in RD patients. Preoperative improvement of anaemia and reduction of blood loss by meticulous surgical techniques may prevent ME in RD patients who require hepatectomy for HCC.     

Good longterm survival after primary living donor liver transplantation for solitary hepatocellular carcinomas up to 8 cm in diameter

Objectives

There is controversy over whether hepatocellular carcinoma (HCC) should be primarily treated with living donor liver transplantation (LDLT) if liver resection (LR) can be effective. This retrospective study was conducted to compare survival outcomes in patients treated with either modality for solitary HCC measuring ≤8 cm in diameter.

Methods

Outcomes in patients with solitary HCC primarily treated by LDLT were analysed. Patients with solitary HCC of similar sizes with or without microvascular invasion primarily treated with LR were selected at a ratio of 6 : 1 for comparison.

Results

In-hospital mortality amounted to 0% and 1.3% in the LDLT (n = 50) and LR (n = 300) groups, respectively (P = 0.918). Complication rates were 34% and 20% in the LDLT and LR groups, respectively (P = 0.027). Rates of 1-, 3-, 5- and 10-year overall survival were 98%, 94%, 89% and 83%, respectively, in the LDLT group and 95%, 85%, 76% and 56%, respectively, in the LR group (P = 0.013). Rates of 1-, 3-, 5- and 10-year disease-free survival were 96%, 90%, 87% and 81%, respectively, in the LDLT group and 81%, 64%, 57% and 40%, respectively, in the LR group (P < 0.0001).

Conclusions

Living donor liver transplantation surpassed LR in survival outcomes, achieving a 10-year overall survival rate 1.5 times as high and a 10-year disease-free survival rate twice as high as those facilitated by LR. However, it entailed more complications, in addition to the inevitable risks to the donor.     

Outcomes of hepatectomy for hepatocellular carcinoma with bile duct tumour thrombus

Background

Hepatocellular carcinoma (HCC) with bile duct tumour thrombus (BDTT) is rare. The aim of the present study was to determine the prognosis of HCC with BDTT after a hepatectomy.

Methods

A retrospective analysis was performed on all HCC patients with BDTT having a hepatectomy from 1989 to 2012. The outcomes in these patients were compared with those in the control patients matched on a 1:6 ratio.

Results

Thirty-seven HCC patients with BDTT having a hepatectomy (the BDTT group) were compared with 222 control patients. Patients in the BDTT group had poorer liver function (43.2% had Child–Pugh B disease). More patients in this group had a major hepatectomy (91.9% versus 27.5%, P = 0.001), portal vein resection (10.8% versus 1.4%, P = 0.006), en-bloc resection with adjacent structures (16.2% versus 5.4%, P = 0.041), hepaticojejunostomy (75.7% versus 1.6%, P < 0.001) and complications (51.4% versus 31.1%, P = 0.016). The two groups had similar hospital mortality (2.7% versus 5.0%, P = 0.856), 5-year overall survival (38.5% versus 34.6%, P = 0.59) and 5-year disease-free survival (21.1% versus 20.8%, P = 0.81). Multivariate analysis showed that lymphovascular permeation, tumour size and post-operative complication were significant predictors for worse survival whereas BDTT was not.

Discussion

A major hepatectomy, extrahepatic biliary resection and hepaticojejunostomy should be the standard for HCC with BDTT, and long-term survival is possible after radical surgery.     

Computed tomography predictors of hepatocellular carcinoma tumour necrosis after chemoembolization

Background

Radiographical features associated with a favourable response to trans-arterial chemoembolization (TACE) are poorly defined for patients with hepatocellular carcinoma (HCC).

Methods

From 2008 to 2012, all first TACE interventions for HCC performed at the University of Alabama at Birmingham (UAB) were retrospectively reviewed. Only patients with a pre-TACE and a post-TACE computed tomography (CT) scan were included in the analyses (n = 115). HCC tumour response to TACE was quantified via the the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Univariate and multivariable analyses were constructed.

Results

The index HCC tumours experienced a > 90% or complete tumour necrosis in 59/115 (51%) of patients after the first TACE intervention. On univariate analysis, smaller tumour size, peripheral tumour location and arterial enhancement were associated with a > 90% or complete tumour necrosis, whereas, only smaller tumour size [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.48, 0.81] and peripheral location (OR 6.91; 95% CI 1.75, 27.29) were significant on multivariable analysis. There was a trend towards improved survival in the patients that experienced a > 90% or complete tumour necrosis (P = 0.08).

Conclusions

Peripherally located smaller HCC tumours are most likely to experience a > 90% or complete tumour necrosis after TACE. Surprisingly, arterial-phase enhancement and portal venous-phase washout were not significantly predictive of TACE-induced tumour necrosis. The TACE response was not statistically associated with improved survival.     

Radiofrequency ablation of hepatocellular carcinoma as a bridge to liver transplantation

Background

Radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) is widely utilized as a bridge to liver transplant with limited evidence to support efficacy. The purpose of the present study was to measure the effect of RFA on time to drop-off in HCC-listed patients.

Methods

Patients with Milan criteria tumours listed between January 1999 and June 2007 were stratified into RFA (n = 77) and No Treatment groups (n = 93).

Results

The primary effectiveness of RFA was 83% (complete radiographic response). RFA was associated with a longer median wait time to transplant (9.5 vs. 5 months). Tumour-specific drop-off events were equivalent between RFA (21%) and No Treatment (12%) groups (P = 0.11). Controlling for wait time, there was no difference in overall (P = 0.56) or tumour-specific drop-off (P = 0.94). Furthermore, there were no differences in 5-year overall or tumour-free survivals from list date or transplant. Using multivariate analysis, the likelihood of receiving a transplant and patient survivals were associated with tumour characteristics (AFP, tumour number and size) and not with bridge therapy or waiting time.

Discussion

RFA allows patients to be maintained longer on the waiting list without negative consequences on drop-off or survival compared with no treatment. Post-transplant outcomes are affected more by tumour characteristics than RFA or wait time.     

Sequential intra-arterial therapy and portal vein embolization is feasible and safe in patients with advanced hepatic malignancies

Background

A major hepatic resection for malignancies requires an adequate post-operative liver reserve. Portal vein embolization (PVE) with intra-arterial therapy (IAT) may increase future liver remnant (FLR) hypertrophy. As such, the feasibility, safety and efficacy of IAT+PVE were investigated.

Methods

Between 2000 to 2011, 86 patients with malignancy of the liver were identified from a multi-institutional database. Twenty-nine patients underwent sequential IAT+PVE, 25 had PVE alone and 32 had IAT alone. Clinicopathological data were evaluated.

Results

Most patients had hepatocellular carcinoma (HCC) (65.1%) and 31.4% had secondary metastatic disease. A complete or partial response using European Association for the Study of the Liver (EASLD) criteria was seen in 48.3% of patients undergoing IAT+PVE vs. 56.6% among patients undergoing IAT (P = 0.601). The median increase in percentage FLR volume was comparable in IAT+PVE (7.4%) vs. PVE only (7.9%) (P = 0.203). There were no IAT+PVE-associated deaths and only one complication. Among patients treated with IAT+PVE (n = 29), 27 underwent a subsequent hepatic resection. Peri-operative morbidity and mortality was 29.6% and 7.4%, respectively. Among the patients with HCC who underwent curative intent surgery after IAT+PVE, the median survival was 59.0 months.

Conclusions

Sequential IAT and PVE are feasible and safe. Utilization of IAT+PVE before a resection can lead to long-term survival and should be considered in the treatment of patients with advanced hepatic malignancies.     

Predicting Non-Adherence with Outpatient Colonoscopy Using a Novel Electronic Tool that Measures Prior Non-Adherence

BACKGROUND

Accurately predicting the risk of no-show for a scheduled colonoscopy can help target interventions to improve compliance with colonoscopy, and thereby reduce the disease burden of colorectal cancer and enhance the utilization of resources within endoscopy units.

OBJECTIVES

We aimed to utilize information available in an electronic medical record (EMR) and endoscopy scheduling system to create a predictive model for no-show risk, and to simultaneously evaluate the role for natural language processing (NLP) in developing such a model.

DESIGN

This was a retrospective observational study using discovery and validation phases to design a colonoscopy non-adherence prediction model. An NLP-derived variable called the Non-Adherence Ratio (“NAR”) was developed, validated, and included in the model.

PARTICIPANTS

Patients scheduled for outpatient colonoscopy at an Academic Medical Center (AMC) that is part of a multi-hospital health system, 2009 to 2011, were included in the study.

MAIN MEASURES

Odds ratios for non-adherence were calculated for all variables in the discovery cohort, and an Area Under the Receiver Operating Curve (AUC) was calculated for the final non-adherence prediction model.

KEY RESULTS

The non-adherence model included six variables: 1) gender; 2) history of psychiatric illness, 3) NAR; 4) wait time in months; 5) number of prior missed endoscopies; and 6) education level. The model achieved discrimination in the validation cohort (AUC= =70.2 %). At a threshold non-adherence score of 0.46, the model’s sensitivity and specificity were 33 % and 92 %, respectively. Removing the NAR from the model significantly reduced its predictive power (AUC = 64.3 %, difference = 5.9 %, p < 0.001).

CONCLUSIONS

A six-variable model using readily available clinical and demographic information demonstrated accuracy for predicting colonoscopy non-adherence. The NAR, a novel variable developed using NLP technology, significantly strengthened this model’s predictive power.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-3165-6) contains supplementary material, which is available to authorized users.KEY WORDS: adherence, cancer screening, colorectal cancer, quality improvement, prediction rules     

Impact of peri-operative bevacizumab on survival in patients with resected colorectal liver metastases: an analysis of the LiverMetSurvey

Background

Peri-operative chemotherapy is recommended for the management of colorectal liver metastases (CRLM). The aim of this study was to examine the impact of peri-operative bevacizumab on survival in patients with resected CRLM.

Methods

A multicentre retrospective cohort of patients with resected CRLM was analysed from the LiverMetSurvey Registry. Patients who received peri-operative FOLFOX (group A) were compared with those who received peri-operative FOLFOX and bevacizumab (group B).

Results

In total, 501 patients were compared (A, n = 384; B, n = 117). Group A was older (68.3 versus 62.5 years, P < 0.01), had more rectal cancers (30.7 versus 18.8%, P < 0.01) and higher carcinoembryonic antigen (CEA) levels at diagnosis (17.0 versus 9.7 ng/ml, P = 0.043). No difference was observed regarding primary tumour stage, synchronicity and the number or size of metastases. Post-operative infections were more frequent in group B (4.7% versus 12.8%, P < 0.01). Peri-operative bevacizumab had no effect on 3-year overall survival (OS) (76.4% versus 79.8%, P = 0.334), or disease-free survival (DFS) (7.4% versus 7.9%, P = 0.082). DFS was negatively associated with primary tumour node positivity (P = 0.011) and synchronicity (P = 0.041).

Conclusions

The addition of bevacizumab to standard peri-operative chemotherapy does not appear to be associated with improved OS or DFS in patients with resected CRLM.     

Loco-regional therapy in patients with Milan Criteria-compliant hepatocellular carcinoma and short waitlist time to transplant: an outcome analysis

Objectives

Liver transplantation (LT) in Milan Criteria (MC) hepatocellular carcinoma (HCC) has excellent outcomes. Pre-transplant loco-regional therapy (LRT) has been used to downstage HCC to meet the MC. However, its benefit in patients with a brief waiting time to transplant remains unclear. This study evaluated outcomes in patients with short waitlist times to LT for MC-compliant HCC.

Methods

Patients undergoing LT for MC HCC at either of two transplant centres between 2002 and 2009 were retrospectively evaluated for outcome. Patients for whom post-transplant follow-up amounted to <12 months were excluded.

Results

A total of 225 patients were included, 93 (41.3%) of whom received neoadjuvant LRT. The median waiting time to transplant was 48 days. Mean post-transplant follow-up was 32.2 months. Overall and disease-free survival at 1 year, 3 years and 5 years were 93.1%, 82.4% and 72.6%, and 91.3%, 79.3% and 70.6%, respectively. There was no difference in overall (P = 0.94) and disease-free survival (P = 0.94) between groups who received and did not receive pre-LT LRT. There were also no disparities in survival or tumour recurrence among categories of patients (with single tumours measuring <3 cm, with single tumours measuring 3–5 cm, with multiple tumours).

Conclusions

Loco-regional therapy followed by rapid transplantation in MC HCC appears not to have an impact on post-transplant outcome.     

Hepatic epithelioid haemangioendothelioma: is transplantation the only treatment option?

Background

Hepatic epithelioid haemangioendothelioma (HEH) is a rare vascular neoplasm with unpredictable clinical behaviour.

Aim

To compare overall survival (OS) and disease-free survival (DFS) between liver resection (LR) and orthotopic liver transplantation (OLT) for the treatment of HEH.

Methods

Retrospective review of 30 patients with HEH treated at Mayo Clinic during 1984 and 2007.

Results

Median age was 46 years with a female predominance of 2 : 1. Treatment included LR (n = 11), OLT (n = 11), chemotherapy (n = 5) and no treatment (n = 3). LR was associated with a 1-, 3- and 5-year OS of 100%, 86% and 86% and a DFS of 78%, 62% and 62%, respectively. OLT was associated with a 1-, 3- and 5-year OS of 91%, 73% and 73% and a DFS 64%, 46% and 46%, respectively. Metastases were present in 37% of patients but did not significantly affect OS. Important predictors of a favourable OS and DFS were largest tumour ≤ 10 cm and multifocal disease with ≤10 nodules.

Conclusion

LR and OLT achieve comparable results in the treatment of HEH. LR is appropriate for patients with resectable disease and favourable prognostic factors. OLT is appropriate for patients with unresectable disease and possibly those with unfavourable prognostic factors. Metastases may not be a contraindication to surgical treatment.     

The appropriateness of surveillance colonoscopy intervals after polypectomy

BACKGROUND:

Adherence to surveillance colonoscopy guidelines is important to prevent colorectal cancer (CRC) and unnecessary workload.

OBJECTIVE:

To evaluate how well Canadian gastroenterologists adhere to colonoscopy surveillance guidelines after adenoma removal or treatment for CRC.

METHODS:

Patients with a history of adenomas or CRC who had surveillance performed between October 2008 and October 2010 were retrospectively included. Time intervals between index colonoscopy and surveillance were compared with the 2008 guideline recommendations of the American Gastroenterological Association and regarded as appropriate when the surveillance interval was within six months of the recommended time interval.

RESULTS:

A total of 265 patients were included (52% men; mean age 58 years). Among patients with a normal index colonoscopy (n=110), 42% received surveillance on time, 38% too early (median difference = 1.2 years too early) and 20% too late (median difference = 1.0 year too late). Among patients with nonadvanced adenomas at index (n=96), 25% underwent surveillance on time, 61% too early (median difference = 1.85) and 14% too late (median difference = 1.1). Among patients with advanced neoplasia at index (n=59), 29% underwent surveillance on time, 34% too early (median difference = 1.86) and 37% later than recommended (median difference = 1.61). No significant difference in adenoma detection rates was observed when too early surveillance versus appropriate surveillance (34% versus 33%; P=0.92) and too late surveillance versus appropriate surveillance (21% versus 33%; P=0.11) were compared.

CONCLUSION:

Only a minority of surveillance colonoscopies were performed according to guideline recommendations. Deviation from the guidelines did not improve the adenoma detection rate. Interventions aimed at improving adherence to surveillance guidelines are needed.     

Chemoembolization outcomes for hepatocellular carcinoma in cirrhotic patients with compromised liver function

Background

Transarterial chemoembolization (TACE) is recommended as a treatment for unresectable hepatocellular carcinoma (HCC) in patients with normal underlying liver function. The efficacy of TACE in cirrhotic patients with compromised liver function is unknown.

Methods

All ‘first’ TACE interventions for HCC performed at a single institution from 2008 to 2012 were retrospectively reviewed (n = 190). Liver function was quantified via the Child''s score. Tumour necrosis after TACE was quantified via the mRECIST criteria.

Results

The ‘first’ TACE procedures of 100 Child''s A and 90 Child''s B/C cirrhotic patients were evaluated. As expected, the lab-model for end-stage liver disease (MELD) score was significantly higher in the Child''s B/C group. Although the number of tumours were similar between the groups, both the size of the largest tumour and the total tumour diameter were greater in the Child''s A group. There were no significant differences in post-TACE tumour necrosis between groups. The median survival after TACE was significantly longer in the Child''s A compared with Child''s B/C patients (21.9 versus 13.7 months, P = 0.03).

Conclusions

TACE appears to be equally efficacious in cirrhotic patients regardless of their Child''s classification based upon equivalent mRECIST measures of tumour necrosis. However, inferior survival after TACE was observed in the Child''s B/C group.     

Simultaneous pancreatectomy and liver transplantation: a single-institution experience

Background:

There is wide debate among transplant centres regarding the indications for liver transplantation (LT) in malignancy. We report a single-centre experience with simultaneous LT and total pancreatectomy or pancreaticoduodenectomy.

Methods:

We performed a retrospective review of a prospectively established database of patients who underwent simultaneous LT and total pancreatectomy or pancreaticoduodenectomy. We analysed demographics, indications, approach and outcomes.

Results:

Between 1991 and 2006, 11 patients (four male; median age 51 years) underwent simultaneous LT and total pancreatectomy (n = 4) or pancreaticoduodenectomy (n = 7). Indications included metastatic neuroendocrine tumour (n = 5), hepatocellular carcinoma (n = 2), metastatic periampullary adenocarcinoma (n = 1), periampullary adenocarcinoma with end-stage liver disease (ESLD) (n = 2) and intraductal papillary mucinous neoplasm with ESLD (n = 1). The three patients with ESLD had non-alcoholic steatohepatitis, primary sclerosing cholangitis or cryptogenic cirrhosis. Median postoperative length of stay was 31 days (21–110 days). Overall median survival was 101 months (95% confidence interval 70.6–131.4). One-year survival was 91%, 2-year 90%, 5-year 67% and 10-year 33%. Postoperative complications included: re-operation (n = 4); anastamotic leak (n = 2); abdominal abscess (n = 3), and organ rejection (n = 1).

Conclusions:

We report a series of pancreatectomy or pancreaticoduodenectomy and simultaneous LT in patients with extensive malignancy or impending liver failure that prevented pancreatectomy. This series provides evidence that combined pancreatic resection and LT can be a strategy in both radical resections and cases with ESLD that would otherwise preclude operative intervention.     

Usefulness of the epicardial fat tissue thickness as a diagnostic criterion for geriatric patients with metabolic syndrome

Objective To evaluate the epicardial fat tissue thickness (EFTT) as a diagnostic criterion for geriatric patients with metabolic syndrome (MetS). Methods Sixty geriatric patients over 65 years of age were recruited for the study. Patients were divided into two groups: Group 1 (n = 30) consisted of patients with MetS; Group 2 (n = 30) consisted of patients without MetS. Echocardiography was used to measure EFTT in all patients, and blood samples were analyzed for biochemical parameters. Results Compared to Group 2, EFTT levels of Group 1 were statistically higher (P < 0.05). In a binary logistic regression analysis, EFTT levels served as the independent factor for metabolic syndrome (B = 17.35, SE = 4.93, Wald = 12.36, P < 0.001). Receivers operating characteristic Curve (ROC-curve) analysis revealed that EFTT predicted MetS with 96.7% sensitivity and 86.7% specificity above the level of 7.3 mm [area under the curve = 0.969; 95% confidence interval (CI): 0.928–1.00]. Conclusions The present study demonstrated that serum EFTT levels were higher in geriatric patients with MetS and can therefore be used as a diagnostic criterion for MetS.