Value of Imaging Findings in the Prediction of Microvascular Invasion in Hepatocellular Carcinoma

BackgroundThe purpose of this study was to determine the utility of some imaging findings in predicting microvascular invasion (MVI) and hepatocellular carcinoma (HCC) recurrence risk after liver transplantation.MethodThis retrospective study included 123 patients with histopathologically proven HCC at explant. All HCCs were classified as MVI positive (group I) or negative (group II) based on histopathological findings. In each group, multifocality, largest tumor size, bulging (tumor causing liver capsule expansion), beak sign (the acute angle between the tumor and liver parenchyma), and diffusion restriction on diffusion weighted images (DWI) were evaluated. These findings were compared between the groups by Student’s t test. The relation between the parameters and MVI was analyzed by using the Spearman’s correlation test.ResultsOf the total patients, 30.1% had MVI (group I) and 69.9% (group II) did not have MVI. Presence of beak sign (P ≤ .005), bulging sign (P = .002), and diffusion restriction (P = .045) were significantly more frequent in group I than group II. The beak sign, bulging sign, and diffusion restriction were correlated with presence of MVI. Largest tumor size and multifocality were higher in group I than group II, but the differences were not statistically significant.ConclusionRadiologists and transplant surgeons should be aware of some clue imaging findings, especially beak and bulging signs because these findings may predict the presence of MVI in HCC. These patients might benefit from histologic confirmation of the tumor characteristics through biopsy and subsequent bridging treatment options before liver transplantation to reduce the risk of recurrence.     

肝移植术后肺部细菌感染的诊治

目的：总结肝移植术后肺部细菌性感染的诊治经验。方法：对33例同种异体原位肝移植后发生肺部细菌感染者的临床资料进行分析。结果：33例术后住院期间发生肺部细菌感染53例次，所有患者的痰或胸水培养均有阳性发现；较常见的病原菌为铜绿色假单胞菌、肺炎克雷伯氏菌、鲍曼倩血不动杆菌、金黄色葡萄球菌等；对革兰氏阴性杆菌敏感的抗生素有阿米卡星、亚胺培南、环丙沙星，对革兰氏阳性球菌敏感的抗生素有万古霉素；16例在感染治疗过程中发生急性排斥反应，死亡5例；治疗时根据药物敏感试验选用抗生素，必要时调整免疫抑制方案；33例中，治愈20例，死亡13例。结论：肺部细菌感染是肝移植术后常见并发症，其诊断有赖于对临床资料综合分析，治疗上除应遵循一般肺部感染的处理原则外，应注意合理选择抗生素及对受者免疫功能的调控。     

Unification Venoplasty to Cope With Recipient Portal Vein Anomaly During Living Donor Liver Transplantation

Purpose

To cope with recipient portal vein (PV) anomalies, such as early branching of the right posterior section (RPS), during living donor liver transplantation (LDLT) surgery, we performed a simulation study to standardize the surgical technique for unification portal venoplasty.

Methods

This study included an observational analysis of conventional methods utilizing RPS PV, simulation-based design of a new surgical technique, and clinical application of this new technique.

Results

In a case encountering RPS PV, a mild anastomotic PV stenosis was persistent over 6 months postsurgery, indicating the need for technical refinement. After computational simulation analysis, we found that simple suturing of the PV branch patch automatically resulted in a funnel-shaped elongation. A prospective recipient study (n = 30) indicated that usual PV reconstruction via the PV bifurcation method is feasible in the absence of unusual donor or recipient PV anomaly. Retrospective living donor PV anatomy analysis (n = 20) revealed that 20-mm-long limbs of the first-order PV branches are necessary to make a 10- to l5-mm-long funneled PV stump. This technique of unification venoplasty for an anomalous recipient PV was applied to an adult patient undergoing LDLT with a right liver graft, for which it was shown to be technically feasible and effective.

Conclusions

A simplified unification venoplasty technique was developed to cope with a recipient PV anomaly in adult LDLT.     

Umbilical portion of recipient's left portal vein: a useful vascular conduit in dual living donor liver transplantation for the thrombosed portal vein.

We considered performing living donor liver transplantation (LDLT) in a larger-size recipient. When the recipient was large-sized, or when the donor liver was severely steatotic or had a right-to-left volume discrepancy. We devised dual living donor liver transplantation (DLDLT) to make up for graft size insufficiency and to secure the donor's safety. However, portal vein thrombosis (PVT) presented a challenge for DLDLT because of the need for intact right and left portal veins for the implantation of both liver grafts. Our 52-year-old male patient with hepatitis B cirrhosis had suffered from repeated esophageal and gastric variceal bleeding and underwent 2 trials of a transjugular intrahepatic portosystemic shunt (TIPS). He developed TIPS occlusion and PVT involving the area just above the spleno-mesenteric confluence to the right and left PV. Also, the right PV orifice was destructed and difficult to isolate because of severe periportal inflammation and neointima growth in the TIPS mesh. The patient's two sons were inadequate for donation because of right-to-left volume discrepancy. Therefore, DLDLT using 2 left lobes was necessary to compensate for graft-size insufficiency and to secure donor safety, and we substituted an intact umbilical portion of recipient's left PV for the destroyed right PV. The patient recovered well, and liver function has been normal for more than a year. In conclusion, the umbilical portion of recipient's left PV can be a useful vascular substitute for the reconstruction of a thrombosed main portal branch in DLDLT.     

Use of percutaneous drainage to treat hepatic abscess after radiofrequency ablation of metastatic pancreatic adenocarcinoma

Radiofrequency ablation (RFA) is well described in the treatment of primary hepatic malignancies and colorectal carcinoma hepatic metastases. A known complication of RFA is the development of hepatic abscess. The management of hepatic abscesses subsequent to RFA for metastatic disease is not well described. A 49-year-old female with pancreatic adenocarcinoma underwent pancreaticoduodenectomy followed by adjuvant chemoradiation. Following 6 months' treatment, a new liver metastasis was identified. It remained stable for 6 months during additional chemotherapy and thereafter was treated with RFA. Three weeks after RFA, the patient presented with malaise and leukocytosis, and a CT scan demonstrated a large hepatic abscess at the site of the RFA. She remained febrile despite needle aspiration and intravenous antibiotics. A percutaneous drain was placed and the symptoms resolved. Contrast injection of the drain 4 weeks later demonstrated resolution of the abscess cavity but communication with the biliary tree. The drain was removed and the tract embolized with Gel-foam to prevent complications of biliary-cutaneous fistula. She remains well without evidence of abscess or disease recurrence. Thus, RFA can be used in treatment of limited isolated hepatic metastases from previously treated pancreatic adenocarcinoma. However, the incidence of hepatic abscess is increased due to bilioenteric anastomosis; extended antibiotic prophylaxis should be considered.     

The challenge of finding donors for living donor liver transplantation in Saudi Arabia

INTRODUCTION: Organ shortage remains the main limiting factor for expanding liver transplantation (LT) in Saudi Arabia. Therefore, living donor liver transplantation (LDLT) was recently undertaken by our team at King Faisal Specialist Hospital and Research Center (KFSH&RC), in an effort to meet the increasing demand for LT in Saudi Arabia. OBJECTIVE: Analysis of donors assessed for LDLT at KFSH&RC. METHODS: Between September 2002 and May 2003, 39 potential donors were assessed for LDLT. First- or second-degree relationship to the recipient was an essential precondition. Assessment included biochemical testing, radiological studies (computed tomography: magnetic resonance angiography, magnetic resonance cholangiography), and thorough psychosocial analysis. Liver biopsy and hepatic angiogram was performed in some but not all donors. RESULTS: Male:female ratio was 28:11. Median age was 27 (18 to 34). Of 39 potential donors, only three underwent LDLT. The remaining 36 were rejected for different reasons including: psychosocial in 8 (20.5%), fatty liver in 7 (17.9%), recipient issues in 6 (15.4%), refusal after initial approval in 3 (7.7%), unfavorable anatomy in 2 (5.1%), inadequate liver volume in 2 (5.1%), abnormal liver functions in 2 (5.1%), hepatitis C virus in 2 (5.1%), liver pathology in 1 (2.6%), and other medical concerns in remaining 3 donors (7.7%). CONCLUSION: In Saudi Arabia, donor availability as well as recipient characteristics may limit the value of LDLT in overcoming organ shortage. Therefore, efforts should be directed to improve the number and quality of available cadaveric organs. Until then, LDLT may be the only way forward to save patients from dying on the waiting list.     

Phase 0 Study of Vandetanib-Eluting Radiopaque Embolics as a Preoperative Embolization Treatment in Patients with Resectable Liver Malignancies

PurposeTo assess the safety and tolerability of a vandetanib-eluting radiopaque embolic (BTG-002814) for transarterial chemoembolization (TACE) in patients with resectable liver malignancies.Materials and MethodsThe VEROnA clinical trial was a first-in-human, phase 0, single-arm, window-of-opportunity study. Eligible patients were aged ≥18 years and had resectable hepatocellular carcinoma (HCC) (Child-Pugh A) or metastatic colorectal cancer (mCRC). Patients received 1 mL of BTG-002814 transarterially (containing 100 mg of vandetanib) 7–21 days prior to surgery. The primary objectives were to establish the safety and tolerability of BTG-002814 and determine the concentrations of vandetanib and the N-desmethyl vandetanib metabolite in the plasma and resected liver after treatment. Biomarker studies included circulating proangiogenic factors, perfusion computed tomography, and dynamic contrast-enhanced magnetic resonance imaging.ResultsEight patients were enrolled: 2 with HCC and 6 with mCRC. There was 1 grade 3 adverse event (AE) before surgery and 18 after surgery; 6 AEs were deemed to be related to BTG-002814. Surgical resection was not delayed. Vandetanib was present in the plasma of all patients 12 days after treatment, with a mean maximum concentration of 24.3 ng/mL (standard deviation ± 13.94 ng/mL), and in resected liver tissue up to 32 days after treatment (441–404,000 ng/g). The median percentage of tumor necrosis was 92.5% (range, 5%–100%). There were no significant changes in perfusion imaging parameters after TACE.ConclusionsBTG-002814 has an acceptable safety profile in patients before surgery. The presence of vandetanib in the tumor specimens up to 32 days after treatment suggests sustained anticancer activity, while the low vandetanib levels in the plasma suggest minimal release into the systemic circulation. Further evaluation of this TACE combination is warranted in dose-finding and efficacy studies.     

Subnormothermic machine perfusion for non-heart-beating donor liver grafts preservation in a Swine model: a new strategy to increase the donor pool?

We previously reported that subnormothermic machine perfusion (sMP; 20°C) is able to improve the preservation of livers obtained from non-heart-beating donors (NHBDs) in rats. We have compared sMP and standard cold storage (CS) to preserve pig livers after 60 minutes of cardiac arrest. In the sMP group livers were perfused for 6 hours with Celsior at 20°C. In the CS group they were stored in Celsior at 4°C for 6 hours as usual. To simulate liver transplantation, both sMP- and CS-preserved livers were reperfused using a mechanical continuous perfusion system with autologus blood for 2 hours at 37°C. At 120 min after reperfusion aspartate aminotransferase levels in sMP versus CS were 499 ± 198 versus 7648 ± 2806 U/L (P < .01); lactate dehydrogenase 1685 ± 418 versus 12998 ± 3039 U/L (P < .01); and lactic acid 4.78 ± 3.02 versus 10.46 ± 1.79 mmol/L (P < .01) respectively. The sMP group showed better histopathologic results with significantly less hepatic damage. This study confirmed that sMP was able to resuscitate liver grafts from large NHBD animals.     

心脏死亡器官捐献获取流程探讨

目的总结并进一步探讨心脏死亡器官捐献(DCD)获取流程的初步经验。方法回顾性分析2009年7月至2012年1月期间广州军区总医院28例DCD者的临床资料、供体入选标准及器官获取流程。结果 28例DCD供体均成功实施了器官捐献,其中MaastrichtⅢ类3例(10.7%),MaastrichtⅣ类1例(3.6%),脑-心双死亡捐献(DBCD)供体24例(85.7%)。3例MaastrichtⅢ类供体实施了标准DCD器官获取流程(简称DCD流程),1例MaastrichtⅣ类供体采用DBCD器官获取流程(简称DBCD流程)非体外膜肺氧合(ECMO)模式,24例DBCD采用了DBCD流程ECMO模式。供体器官热缺血时间:DBCD为0 min,MaastrichtⅣ类为18 min,MaastrichtⅢ类平均25 min(22～28 min)。本组共获取了28个肝脏、40个肾脏、2个心脏,分别成功用于肝移植、肾移植和心脏移植。结论我国DCD器官获取可分为DCD流程和DBCD流程,后者又分为ECMO模式和非ECMO模式。ECMO模式可避免器官热缺血损伤且没有伦理学争议,对我国公民DCD器官有着十分重要的作用。     

肝移植术后新发食管癌1例临床分析并文献复习

目的探讨肝移植术后新发食管癌的发病情况、危险因素、预防及治疗。方法对2003年8月至2008年12月中山大学附属第三医院肝移植中心行肝移植术后生存半年以上并能接受定期随访的416例受者,观察其新发恶性肿瘤的情况,分析新发食管癌患者的临床资料,同时进行文献复习。结果该中心肝移植术后新发食管癌1例,发生率为0．24％（国外平均发生率为0．11％）。该例男性患者肝移植时年龄为49岁,术前有长期吸烟史和嗜酒史,术后不完全戒酒、戒烟,术后46个月发现食管癌,从确诊新发食管癌至死亡历时10个月,死于肿瘤进展、多器官功能衰竭。结论烟酒史、免疫抑制过强是肝移植术后新发恶性肿瘤的危险因素,针对高危因素进行规范随诊以及优化免疫抑制方案,是早期防治和提高疗效的关键。