Ischemic-Type Biliary Lesions After Liver Transplant: Factors Causing Early-Onset Versus Late-Onset Disease.

OBJECTIVES: Biliary complications such as an ischemic-type biliary lesion can increase morbidity and mortality after liver transplant. Former studies have investigated several risk factors, but the underlying pathomechanism remains unclear. The focus of this study was to investigate factors causing early-onset (< 12 mo after liver transplant) versus late-onset ischemic-type biliary lesions (> 12 mo after liver transplant). MATERIALS AND METHODS: This retrospective study included 641 patients. Patients were grouped to those who developed ischemic-type biliary lesion and those who did not. Patients developing ischemic-type biliary lesions were further subgrouped into those diagnosed early (< 12 mo) and late (> 12 mo) after liver transplant. We analyzed demographic data, characteristics, and comorbidities of the recipients and donors, operative variables, and postoperative course, as well as laboratory values. RESULTS: The incidence of ischemic-type biliary lesions was 4.9%. Retransplant was performed more frequently in patients developing ischemic-type biliary lesions. The number of transfusions of blood products was higher in ischemic-type biliary lesion patients, especially in the early-onset ischemic-type biliary lesion group. Bilirubin levels were higher in patients with ischemic-type biliary lesions starting from day 7 after the operation, particularly in the early-onset group. Survival tended to be best in the late-onset ischemic-type biliary lesion group; however, this difference was not significant. CONCLUSIONS: This study serves as a supplement to current data and the understanding of ischemic-type biliary lesions with emphasis on the relevance of disease onset and causes. We could in fact determine transfusion of blood products as a determinant of an early onset of ischemic-type biliary lesion. Bilirubin could be a surrogate marker for ischemic-type biliary lesions, especially in its early-onset form.

Tissue-based miRNA mapping in alcoholic liver cirrhosis: different profiles in cirrhosis with or without hepatocellular carcinoma.

Context: Alcoholic liver cirrhosis is a significant risk factor for the development of hepatocellular carcinoma (HCC). The importance of tumour-associated cirrhosis in the development or progression of HCC is not understood. MiRNAs are important regulators for HCC development, but their role in HCC due to alcoholic liver cirrhosis is unclear.Objective: The aim of this study is the detection of miRNA expression in alcoholic liver cirrhosis, tumour-associated cirrhosis, and HCC.Materials and methods: We analysed the differences in the miRNA profiles of HCC, tumour-associated cirrhosis, and cirrhosis without HCC samples from 30 patients who underwent liver transplantation because of alcoholic liver disease.Results: Microarray analyses revealed 40 significantly differentially expressed miRNAs between HCC tissue and tumour-associated cirrhosis tissue. Furthermore, the microarray analysis discovered 56 differentially expressed miRNAs in tumour-associated cirrhosis and cirrhosis without HCC.Discussion: The differences of miRNA profile in alcoholic liver cirrhosis with and without HCC could improve understanding of HCC development, as well as lead to a new diagnostic tool in HCC screening.Conclusion: We were able to show for the first time, the differences of miRNA profile as promising biomarker in HCC, tumour-associated cirrhosis, and cirrhosis without HCC in context of alcoholic liver disease.

Strengths, Weaknesses, Opportunities, and Threats of Centralized Pancreatic Surgery: a Single-Center Analysis of 3000 Consecutive Pancreatic Resections.

BACKGROUND: Pancreatic surgery at high-volume centers has undergone major changes over the last decades. However, the quality of surgery remains to be considered as one important factor for achieving long-term survival especially in patients at advanced stages of disease. METHODS: Between January 1990 and June 2017, 3000 consecutive patients have undergone pancreatic resections at our institution. Relevant postoperative data and histopathological findings as well as overall survival were analyzed. In addition, a SWOT (strengths, weaknesses, opportunities, threats) analysis of pancreatic surgery at high-volume centers was performed. RESULTS: A total of 2218 pancreatic head resections (74%), 494 distal pancreatectomies (16%), 200 total pancreatectomies (7%), and 88 other resections (3%) were performed within our study period. Despite additional vascular resections in 265 patients (9%) and additional liver resections in 167 patients (6%), overall perioperative mortality did not exceed 3%. Overall survival strongly depended on the underlying disease, as well as on lymph node stage (p = < 0.001) and surgical radicality (p = < 0.001). CONCLUSIONS: The decentralization of pancreatic surgery over the last decades has led to a focus on high-volume centers to perform extended procedures in complex patients. The present SWOT analysis underlines the significance of a centralization of pancreatic surgery for patient safety and to increase the chance of long-term survival.

Tumor-stromal cross-talk modulating the therapeutic response in pancreatic cancer.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is a highly malignant solid tumor with a dismal prognosis. The stroma component makes up to 90% of the tumor mass and is thought to be one of the main reasons for the tumor's high chemoresistance. Cancer associated fibroblasts (CAFs) have previously been identified to be the key stromal players. This is the first time we provide detailed in vitro experiments investigating tumor-stromal interactions when exposed to three well-known chemotherapeutic agents. METHODS: Monocultures, indirect and direct co-cultures of two PDAC cell lines (AsPC and Panc-1) and six primary patients derived CAFs were treated with gemcitabine, nab-paclitaxel and the γ-secretase-inhibitor (GSI) DAPT. The cell viability of each component was measured with XTT. Finally, IL-6 concentrations of the supernatants were analyzed. RESULTS: On the contrary to PDAC cell lines, CAF monocultures hardly responded to any treatment which suggested that stroma (CAFs) itself is more resistant to standard chemo-treatments than the epithelial cancer cells. Moreover, only a weak chemotherapeutic response was observed in direct co-cultures of cancer cells with CAFs. A change in the morphology of direct co-cultures was accompanied with the chemoresistance. CAFs were observed to build cage-like structures around agglomerates of tumor cells. High levels of IL-6 were also associated with a reduced response to therapy. Indirect co-cultures make the tumor-stromal interaction more complex. CONCLUSIONS: CAFs are highly chemoresistant. Direct cell-cell contact and high levels of IL-6 correlate with a high chemoresistance.

The value of microparticles in detecting acute rejection episodes after liver transplantation.

CONTEXT: Non-invasive markers for diagnosis of acute rejection (AR) following liver transplantation have not been developed, yet. OBJECTIVE: We analyzed the correlation of plasma microparticle levels (MP) with AR. MATERIALS AND METHODS: MP (CD4, CD8, CD25, CD31, MHC) of 11 AR patients and 11 controls were analyzed within the first week after transplantation. RESULTS: CD4, CD8 and CD31 positive MP were higher in the AR, whereas overall MP count, CD25 and MHCI positive MP proportions did not differ between both groups. DISCUSSION AND CONCLUSION: MP dynamics within the first period of transplantation could help to clarify on-going mechanisms of immunomodulation.

Bile: miRNA pattern and protein-based biomarkers may predict acute cellular rejection after liver transplantation.

CONTEXT: Bile rather than blood depicts the local inflammation in the liver and may improve prediction and diagnosis of acute cellular rejection (ACR) after liver transplantation (OLT). METHODS: Secretome and miRNAs were analyzed during the first two weeks and on clinical suspicion of ACR in the bile of 45 OLT recipients. RESULTS: Levels of CD44, CXCL9, miR-122, miR-133a, miR-148a and miR-194 were significantly higher in bile of patients who developed ACR within the first 6 months after OLT and during ACR. CONCLUSION: Analysis of secretome and miRNA in bile could improve our understanding of the local inflammatory process during rejection.

Single Pass Albumin Dialysis-A Dose-Finding Study to Define Optimal Albumin Concentration and Dialysate Flow.

Several artificial liver support concepts have been evaluated both in vitro and clinically. Single pass albumin dialysis (SPAD) has shown to be one of the most simple approaches for removing albumin-bound toxins and water-soluble substances. Being faced with acute liver failure (ALF) in everyday practice encouraged our attempt to define the optimal conditions for SPAD more precisely in a standardized experimental setup. Albumin concentration was adjusted to either 1%, 2%, 3%, or 4%, while the flow rate of the dialysate was kept constant at a speed of 700 mL/h. The flow rate of the dialysate was altered between 350, 500, 700, and 1000 mL/h, whereas the albumin concentration was continuously kept at 3%. This study revealed that the detoxification of albumin-bound substances could be improved by increasing the concentration of albumin in the dialysate with an optimum at 3%. A further increase of the albumin concentration to 4% did not lead to a significant increase in detoxification. Furthermore, we observed a gradual increase of the detoxification efficiency for albumin-bound substances, from 350 mL/h to 700 mL/h (for bilirubin) or 1000 mL/h (for bile acids) of dialysate flow. Water-soluble toxins (ammonia, creatinine, urea, uric acid) were removed almost completely, regardless of albumin concentration or flow rate. In conclusion, this study confirmed that SPAD is effective in eliminating albumin-bound as well as water-soluble toxins using a simulation of ALF. Furthermore, this project was successful in evaluating the most effective combination of albumin concentration (3%) and dialysate flow (700 mL/h-1000 mL/h) in SPAD for the first time.

Diagnosis of HCC for patients with cirrhosis using miRNA profiles of the tumor-surrounding tissue - A statistical model based on stepwise penalized logistic regression.

The presence of hepatocellular carcinoma (HCC) is a significant complication of cirrhosis because it changes the prognosis and the treatment of the patients. By now, contrast-enhanced CT and MR scans are the most reliable tools for the diagnosis of HCC; however, in some cases, a biopsy of the tumor is necessary for the final diagnosis. The aim of the study was to develop a diagnostic tool using the microRNA (miRNA) profiles of the tissue surrounding the HCC tumor combined with clinical parameters in statistical models. At a transplantation setting, 32 patients with HCC and cirrhosis (B) were compared to 22 patients suffering from cirrhosis only (A). The diagnosis and exclusion of HCC was confirmed following the histopathological examination of the explanted liver. The HCC patients were significantly older than the patients with cirrhosis only (B: 60.6 and A: 49.9, p<0.001) and showed higher levels of ALT (A: 0.76µkat/l, B: 1.02µkat/, p=0.006) and AFP (A: 5.8ng/ml, B: 70.3ng/ml, p<0.001), whereas the bilirubin levels were higher in the cirrhosis only group (p=0.002). Using age (cut-off 50.23years) and AFP (cut-off 4.2ng/ml) thresholds, the levels of expression of miR-1285-3p and miR-943 differentiated between the patients with HCC and cirrhosis from those with cirrhosis only with an accuracy of 96.3%. This is the first report about the use of stepwise penalized logistic regression and decision tree analyses of miRNA expressions in the tumor-surrounding tissue combined with clinical parameters for the diagnosis of HCC.

Long-term Survival After Surgical Treatment of Renal Cell Carcinoma Metastasis Within the Pancreas.

BACKGROUND: The role of radical pancreatic surgery for metastatic lesions of renal cell carcinoma (RCC) remains unclear. PATIENTS AND METHODS: In this analysis, 19 patients underwent pancreatic resections for metastases of RCC between 2000 and 2014. RESULTS: Pancreatic metastases were diagnosed 10.2±27.1 years after primary diagnosis of RCC. Surgical approaches included pylorus preserving pancreatoduodenectomy (PPPD) (n=10, 55.6%), followed by distal pancreatectomy (n=5, 27.8%) and total pancreatectomy (n=4, 22.2%). The survival after 1, 3 and 5 years was 88.9%, 80% and 71.4%, respectively. Patients after PPPD procedure had a significant worse survival (p=0.030). RCC stage VI tumors seem to be associated with decreased short- and long-term survival rates (p=0.03). Additional metastatic lesions in the further postoperative course had no impact on outcome. CONCLUSION: The results of our analysis demonstrate promising long-term results with regard to disease-free and overall survival after surgical therapy for pancreatic metastases of renal cell carcinoma.

CD44 and CXCL9 serum protein levels predict the risk of clinically significant allograft rejection after liver transplantation.

The diagnosis of acute cellular rejection (ACR) after liver transplantation is based on histological analysis of biopsies because noninvasive biomarkers for allograft rejection are not yet established for clinical routines. CD31, CD44, and chemokine (C-X-C motif) ligand (CXCL) 9 have previously been described as biomarkers for cross-organ allograft rejection. Here, we assessed the predictive and diagnostic value of these proteins as serum biomarkers for clinically significant ACR in the first 6 months after liver transplantation in a prospective study. The protein levels were measured in 94 patients immediately before transplantation, at postoperative days (PODs) 1, 3, 7, and 14 and when biopsies were performed during episodes of biochemical graft dysfunction. The CD44 serum protein levels were significantly lower at POD 1 in patients who experienced histologically proven ACR in the follow-up compared with patients without ACR (P < 0.001). CXCL9 was significantly higher before transplantation (P = 0.049) and at POD 1 (P < 0.001) in these patients. Low CD44 values (cutoff, <200.5 ng/mL) or high CXCL9 values (cutoff, >2.7 ng/mL) at POD 1 differentiated between rejection and no rejection with a sensitivity of 88% or 60% and a specificity of 61% or 79%, respectively. The combination of both biomarker cutoffs at POD 1 had a positive predictive value of 91% and a negative predictive value of 67% for clinically significant ACR. Moreover, CD44 was significantly lower at the time of ACR (P < 0.001) and differentiated the rejection group from patients with graft dysfunction due to other reasons. Our results suggest that CD44 and CXCL9 may serve as predictive biomarkers to identify liver allograft recipients at risk for clinically significant ACR.

Long term combination treatment with bevacizumab, pegylated liposomal doxorubicin and regional abdominal hyperthermia in platinum refractory ovarian cancer: a case report and review of the literature.

BACKGROUND: Platinum resistance constitutes a therapeutic challenge in the treatment of ovarian cancer, with overall unsatisfactory response rates to standard chemotherapy and correspondingly low survival. Regional abdominal hyperthermia and bevacizumab are treatment options that have both shown the capacity to improve the results of standard chemotherapy in the platinum-resistant situation, when added to the treatment schedule. CASE REPORT: We report on a 29-year-old patient with primary platinum-refractory ovarian cancer, who was treated with a combination of pegylated liposomal doxorubicin, regional abdominal hyperthermia and bevacizumab in a four-week cycle over a long-term period of 38 months. Due to an excellent clinical and radiologic response resulting in stable disease, with a concomitant mild toxicity profile consisting only of intermitted diarrhoea and mild fatigue [corrected] , the treatment was continued in an ambulatory setting. DISCUSSION: To our knowledge we describe the first experience with combination treatment of pegylated liposomal doxorubicin with regional abdominal hyperthermia and bevacizumab in a long term setting of almost 2 years. Excellent response with comparably low toxicity was demonstrated. Further evaluation as a therapeutic option in this heavily pretreated and highly palliative patient population is warranted.