Predictors of pretransplant dropout and posttransplant recurrence in patients with perihilar cholangiocarcinoma

We have previously reported excellent outcomes with liver transplantation for selected patients with early-stage perihilar cholangiocarcinoma (CCA) following neoadjuvant chemoradiotherapy. Our aim was to identify predictors of dropout before transplantation and predictors of cancer recurrence after transplantation. We reviewed all patients with unresectable perihilar CCA treated with neoadjuvant chemoradiation in anticipation for transplantation between 1993 and 2010. Predictors were identified by univariate and multivariate Cox regression analysis of clinical variables. In total, 199 patients were enrolled, of whom 62 dropped out and 131 underwent transplantation at our institution, with six undergoing transplantation elsewhere. Predictors of dropout were carbohydrate antigen 19-9 (CA 19-9) ≥ 500 U/mL (hazard ratio [HR] 2.3; P = 0.04), mass ≥ 3 cm (HR 2.1; P = 0.05), malignant brushing or biopsy (HR 3.6; P = 0.001), and Model for End-Stage Liver Disease (MELD) score ≥ 20 (HR 3.5; P = 0.02). Posttransplant, recurrence-free 5-year survival was 68%. Predictors of recurrence were elevated CA 19-9 (HR 1.8; P = 0.01), portal vein encasement (HR 3.3; P = 0.007), and residual tumor on explant (HR 9.8; P < 0.001). Primary sclerosing cholangitis (PSC), age, history of cholecystectomy, and waiting time were not independent predictors. Conclusion: Outcome following neoadjuvant chemoradiation and liver transplantation for perihilar CCA is excellent. Risk of dropout is related to patient and tumor characteristics and this can be used to guide patient counseling before enrollment. Recurrence risk is mostly associated with presence of residual cancer on explant. Patients with PSC do not have an independent survival advantage over de novo patients, but present with more favorable tumor characteristics. (HEPATOLOGY 2012;56:972-981).     

Employers' Duties for Reasonably Foreseeable Psychiatric Injuries

Psychiatric injury, or mental harm, is readily foreseeable in some circumstances for emergency services personnel who are regularly exposed to traumatic incidents. However, it is far from straightforward to identify what appellate decisions have specified is a sufficient response for such emergency services and other employers to protect themselves against civil liability. This article explores the ramifications of the Queensland Court of Appeal decision in Hegarty v Queensland Ambulance Service [2007] QCA 366 and endeavours to identify from decided authorities when employers will be exposed to liability for failure to exercise due care for their employees, or, alternatively, to provide them with a safe workplace.     

Mental Harm Claims Against Emergency Services Organisations: AnImportant Australian Development

The decision of Garling J in Benic v State of New South Wales [2010] NSWSC 1039 is a significant adverse finding for a plaintiff in the context of a police officer alleging afailure to provide him with a safe place of work. The decision was made in response to a claim for negligence arising out of alleged provision of an inadequate response to his complaints of threats to his life in the course of his employment. The fact that he was unable to prove either the requisite breach of a duty of care or causation between a breach and his psychiatric harm has the potential to be an important development in this form of psychiatric injury litigation in Australia. In particular, the court's reliance upon the National Clinical Practice Guideline No 26 – Post Traumatic Stress Disorder: The Management of PTSD in Adults and Children in Primary and Secondary Care (‘the NICE guidelines’) – in order to evaluate the likely consequence of early intervention after a traumatic experience has the potential to have important forensic ramifications for other cases.     

Civil Liability of Health Practitioners for their Forensic Work: Further Erosion of the Witness Immunity Rule Jones v Kaney [2011] UKSC 13; [2011] 2 All ER 671, [2011] 2 WLR 823

There is a clear evolution in the law toward allowing experts to be made more accountable for the discharge of their forensic functions. A particular manifestation of this has been decisions such as General Medical Council v Meadow [2006] EWCA Civ 1390; [2007] 1 QB 462 holding experts amenable to disciplinary hearings for their forensic reports and also for the testimony that they give in court. However, until recently the witness immunity rule has wholly protected experts from being sued in negligence or defamation for their forensic work. The decision of the United Kingdom Supreme Court in Jones v Kaney [2011] UKSC 13 has commenced to erode the rule, possibly laying the ground work for further erosion. However, such developments are unlikely to occur in Australia in the short to medium term, largely because of the High Court's retention of immunity for barristers, an advantage being that Australia will be able to assess the repercussions of the disincentives that may accrue in the United Kingdom to experts undertaking forensic functions.     

Anaplastic large‐cell lymphoma associated with breast implants: A unique entity within the spectrum of peri‐implant effusions

Anaplastic large‐cell lymphoma (ALCL) is a rare and newly described complication associated with breast implants. Patients often present with a peri‐implant effusion, which is amenable to fine‐needle aspiration. The laboratory handling of peri‐implant effusions for cytology and ancillary studies is as crucial as recognizing the characteristic cytology of ALCL. All cases of peri‐implant effusions were retrieved from the PathWest database between January 2003 and May 2013, yielding four cases of breast implant‐associated ALCL and six benign samples. The cytological features were evaluated and information from ancillary studies collated. Clinical and follow‐up histology was available in all cases. All ALCL cases contained highly atypical lymphoid cells including ‘hallmark' cells. In contrast, benign peri‐implant effusions showed a mixture of inflammatory cells, being either neutrophil‐rich (three cases) or lymphocyte‐rich (three cases). A CD30 positive, ALK1 negative immunophenotype was demonstrated in all cases on cell block immunohistochemistry. Flow cytometry and T‐cell receptor clonality studies confirmed aberrant T‐cell immunophenotype in four of four and clonally rearranged T‐cell receptor antigens in three of three cases. ALCL was identified in three of four subsequent capsulectomies. Staging confirmed disease limited to the capsular tissue or peri‐implant effusion in all cases. None of the six patients with benign peri‐implant effusions developed lymphoma during follow‐up. Cases of ALCL accounted for 40% of peri‐implant effusions received over a 10‐year period, indicating the rarity of these samples and the high likelihood of malignancy. Awareness of this entity and its presentation should allow for appropriate triage of these specimens and definitive diagnosis on effusion specimens. Diagn. Cytopathol. 2014;42:929–938. © 2014 Wiley Periodicals, Inc.     

Vegetable cells in urinary samples of patients with bricker ileal conduit

During routine cytopathological evaluation of urines for malignant cells we have occasionally noticed vegetable cells that were only present in patients with Bricker ileal conduit. We wanted to identify the means and sources of contamination of urinary samples from these patients. During the period between May and November 2010, 637 urinary samples were routinely evaluated for malignant cells. Among them were 13 urinary samples from Bricker ileal conduit which we rescreened. We prepared all urinary samples by membrane filtration and stained them according to Papanicolaou. Subsequently, we prepared samples from ostomy adhesives made by Coloplast and by ConvaTec which are used to secure the ostomy bag onto urostomy. We also took samples from different constituents (hydrocolloids) of ostomy adhesives. On the cytopathological review, we found vegetable cells along with intestinal mucosa cells in urinary samples of seven patients with Bricker ileal conduit. With the light microscopic examination of the samples prepared from different ostomy adhesives, we found vegetable cells only in Coloplast adhesives. In preparations of hydrocolloids, we found vegetable cells only in guar gum. They were morphologically identical to those found in urine samples of patients with Bricker ileal conduit and in Sensura and Sensura Xpro (Coloplast) ostomy adhesives. We determined that the origin of vegetable cells in urines from Bricker ileal conduit is the ostomy adhesive. The vegetable cells differ from human intestinal epithelial cells regarding size, shape, and color so it is difficult to misinterpret them as dysplastic cells. Diagn. Cytopathol. 2014;42: 120–124. © 2013 Wiley Periodicals, Inc.