Clinical-endoscopic relevance of incidental colorectal lesions detected by PET-CT.

AIM: to determine the proportion of incidental colon lesions detected by PET-CT and their correlation with the endoscopic and histological findings. In addition, to determine the maximum standardized uptake value (SUVmax) that can discriminate between benign and malignant lesions in our series of cases. METHODS: this was a retrospective study of 3,000 patients evaluated by PET-CT for staging or response to treatment of primary neoplasms, between 2011 and 2015. Patients with incidental uptake in the colon were included in the study. Exclusion criteria included an incomplete, poorly prepared or abandoned colonoscopy, inflammatory bowel disease and treatment with metformin. RESULTS: the study cohort comprised 71 patients evaluated by PET-CT and subsequently analyzed by endoscopy; 69% were male with a mean age of 65.77 ± 11.2. The rate of incidental colon lesions found by PET-CT was 1.73%, with 52 incidental colonic uptakes reported in 50 patients. The location of the uptake was the rectum (19.23%), sigmoid colon (34.62%), descending colon (13.46%), transverse colon (1.9%), ascending colon (19.23%), cecum (9.62%) and ileocolic anastomosis (1.92%). Thirty-five pathological colonoscopies (71.15%) were identified: the findings included five neoplasms (13.51%), two inflammatory lesions (5.4%) and 30 adenomatous polyps (81.1%). Significant differences were found between neoplastic SUVmax (11.7 g/ml; p = 0.03) and polyps (9.26 g/ml; p = 0.04) in relation to inflammatory lesions and normal endoscopies (6.05 g/ml). There were no differences in terms of the size of the polyps, nor the presence or absence of high grade dysplasia (p = 0.12 and 0.33). Both PET-CT and endoscopy proved consistent for locating lesions (k 0.90; CI 95% 0.86-0.93). CONCLUSION: there is a good correlation between the findings identified by PET-CT and the endoscopic study. In our study, a SUVmax > 11 g/ml suggests a malignant pathology, which aids the prioritization of an endoscopic study.

Lack of agreement for defining 'clinical suspicion of rejection' in liver transplantation: a model to select candidates for liver biopsy.

The gold standard to diagnose acute cellular rejection (ACR) after liver transplantation (LT) is histological evaluation, but there is no consensus to select patients for liver biopsy. We aimed to evaluate the agreement among clinicians to select candidates for liver biopsy early after LT. From a protocol biopsy population (n = 690), we randomly selected 100 LT patients in whom the biopsy was taken 7-10 days after LT. The clinical information between LT and protocol biopsy was given to nine clinicians from three transplant centres who decided whether a liver biopsy was needed. The agreement among clinicians to select candidates for liver biopsy was poor: κ = 0.06-0.62, being κ < 0.40 in 76% of comparisons. The concordance between indication for liver biopsy and moderate-severe ACR in the protocol biopsy was κ < 0.30 in all cases. A multivariate model based on the product age-by-MELD (OR = 0.81; P = 0.013), delta eosinophils (OR = 1.5; P = 0.002) and mean tacrolimus trough concentrations <6 ng/ml within the prior 4 days (OR = 11.4; P = 0.047) had an AUROC = 0.84 to diagnose moderate-severe histological ACR. In conclusion, the agreement among clinicians to select patients for liver biopsy is very poor. If further validated the proposed model would provide an objective method to select candidates for liver biopsy after LT.

Reduced exposure to calcineurin inhibitors early after liver transplantation prevents recurrence of hepatocellular carcinoma.

BACKGROUND & AIMS: Recurrence of hepatocellular carcinoma (HCC) is a major complication after liver transplantation (LT). The initial immunosuppression protocol may influence HCC recurrence, but the optimal regimen is still unknown. METHODS: 219 HCC consecutive patients under Milan criteria, who received an LT at 2 European centres between 2000 and 2010, were included. Median follow-up was 51 months (IQR 26-93). Demographic characteristics, HCC features, and immunosuppression protocol within the first month after LT were evaluated against HCC recurrence by using Cox regression. RESULTS: In the explanted liver, 110 patients (50%) had multinodular HCC, and largest nodule diameter was 3±2.1cm. Macrovascular invasion was incidentally detected in 11 patients (5%), and microvascular invasion was present in 41 patients (18.7%). HCC recurrence rates were 13.3% at 3 years and 17.6% at 5 years. HCC recurrence was not influenced by the use/non-use of steroids and antimetabolites (p=0.69 and p=0.70 respectively), and was similar with tacrolimus or cyclosporine (p=0.25). Higher exposure to calcineurin inhibitors within the first month after LT (mean tacrolimus trough concentrations >10ng/ml or cyclosporine trough concentrations >300ng/ml), but not thereafter, was associated with increased risk of HCC recurrence (27.7% vs. 14.7% at 5 years; p=0.007). The independent predictors of HCC recurrence by multivariate analysis were: high exposure to calcineurin inhibitors defined as above (RR=2.82; p=0.005), diameter of the largest nodule (RR=1.31; p<0.001), microvascular invasion (RR=2.98; p=0.003) and macrovascular invasion (RR=4.57; p=0.003). CONCLUSIONS: Immunosuppression protocols with early CNI minimization should be preferred in LT patients with HCC in order to minimize tumour recurrence.