Surgical Resection of a Recurrent Hepatocellular Carcinoma with Portal Vein Thrombosis: Is It a Good Treatment Option? A Case Report and Systematic Review of the Literature.

BACKGROUND: Hepatocellular carcinoma (HCC) is the sixth most frequent diagnosed tumor worldwide and the third leading cause of cancer related death. According to the EASL Guidelines, HCC with portal vein tumor thrombosis (PVTT) is classified as an advanced stage (BCLC stage C) and the only curative option is represented by systemic therapy. Therefore, treatment of HCC patients with PVTT remains controversial and debated. In this paper, we describe the case of a 66-year-old man with a recurrent HCC with PVTT who underwent surgical resection. A systematic review of the literature, comparing surgical resection with other choices of treatment in HCC patients with PVTT, is reported. METHODS: A systematic review of the literature regarding all prospective and retrospective studies comparing the survival outcomes of HCC patients with PVTT treated with surgical resections (SRs) or other non-surgical treatments (n-SRs) has been conducted. CASE PRESENTATION: A 66-year-old Caucasian man with a history of Hepatitis C Virus (HCV) related liver cirrhosis and previous hepatocellular carcinoma of the VI segment treated with percutaneous ethanol infusion (PEI) seven years before presented to our clinics. A new nodular hypoechoic lesion in the VI hepatic segment was demonstrated on follow-up ultrasound examination. A hepatospecific magnetic resonance imaging (MRI) scan confirmed also the presence of a 18 × 13 mm nodular lesion in the V hepatic segment with satellite micronodules associated with V-VIII sectoral portal branch thrombosis. The case was then discussed at the multidisciplinary team meeting, and it was decided to perform a right hepatectomy. The postoperative course was regular and uneventful, and the discharge occurred seven days after the surgery. At eight-month follow-up, there was no clinical nor radiological evidence of neoplastic recurrence, with well-preserved liver function (Child-Pugh A5). RESULTS: Nine studies were included in the review. Median Overall Survaival (OS) ranged from 8.2 to 30 months for SRs patients and from 7 to 13.3 for n-SRs patients. In SR patients, one-year survival ranged from 22.7% to 100%, two-year survival from 9.8% to 100%, and three-year survival from 0% to 71%. In n-SRs patients, one-year survival ranged from 11.8% to 77.6%, two-year survival from 0% to 47.8%, and three-year survival from 0% to 20.9%. CONCLUSION: The present systematic literature review and the case presented demonstrated the efficacy of surgery as a first-line treatment in well-selected HCC patients with PVTT limited or more distal to the right and left portal branches. However, further studies, particularly randomized trials, need to be conducted in future to better define the surgical indications.

WhatsApp video call communication between oncological patients and their families during COVID-19 outbreak.

BACKGROUND: On March 8th, 2020 the Italian Government implemented extraordinary measures to limit COVID-19 viral transmission. The aim of the study was to verify if the use of WhatsApp facilitates communication, improves health information, perception of safe and security, reduce emotional stress during the COVID-19 emergency. METHODS: In this study we identified two period, in the pre-COVID 1-month period (February 9th - March 8th, 2020) 34 patients underwent elective surgery for malignancies (21) and benign (13) diseases, respectively. We provided patients' families on a daily basis with clinical information face-to-face in the ward regarding their postoperative course. In the post-COVID 1-month period (March 9th - April 5th, 2020), 15 patients with malignancies were treated. In this period, patients and their families given a consent form to let the surgical team to communicate clinical data using WhatsApp. At the end of the study period we collected a satisfaction anonymous questionnaire of both patients and families. RESULTS: Statistically significant differences were observed in the pre- vs. post- COVID period regarding the number of surgical procedures (P=0.004). In the post-COVID period, the satisfaction questionnaire showed a good reliability (Cronbach's α 0.912) and a high percentage of satisfaction of patients and their families for the adopted communication tool, reassurance, privacy protection and reduction of emotional stress. CONCLUSIONS: WhatsApp is a safe and fast technology, it offers the opportunity to facilitate clinical communications, reduce stress, improve patient security, obtain clinical and psychological positive implications in patient's care preserving their privacy in the COVID-19 emergency period.

Acute Kidney Ischemic Injury in a Rat Model Treated by Human Omental Mesenchymal Stem Cells.

BACKGROUND: Mesenchymal stem cells (MSCs) may provide a novel clinical approach for acute kidney injury (AKI), which represents a severe health care condition. The human omentum is an important source of MSCs. We investigated the effects of human omental mesenchymal stem cells (HO-MSCs) after induction of ischemic AKI in a rat model. METHODS: The ischemic-reperfusion injury (IRI) was induced at reperfusion following a 45-minute clamping of renal vessels. Twenty animals were used in this study. Each rat was randomly assigned to 1 of 2 groups: G1 (control, n = 10; IRI infusion of phosphate buffer solution) or G2 (HO-MSCs, n = 10; IRI infusion of HO-MSCs). The infusions were performed in the parenchyma at reperfusion. Renal function at 1, 3, 5, and 7 days was assessed. At sacrifice, histologic samples were analyzed by light, and renal injury was graded. RESULTS: HO-MSCs induced an accelerated renal exocrine functional recovery, demonstrated by biochemical parameters and confirmed by histology showing that histopathological alterations associated with ischemic injury were less severe in cell-treated kidneys as compared with control groups (P < .05). The renal damage degree was significantly less in the animals of the HO-MSC group (P < .0001). CONCLUSIONS: These results suggest that HO-MSCs could be useful in the treatment of AKI in a rat model with possible potential implication in clinical setting.

Partial Portal Vein Arterialization to Treat Toxic Acute Liver Failure in Elderly Rats.

INTRODUCTION: Toxic acute liver failure can be fatal even after liver transplantation. Since there are data only in young rats, the aim of our study was to verify the effectiveness of the increase of oxygen to the liver by partial portal vein arterialization (PPVA) in elderly rats with acute liver failure induced by carbon tetrachloride (CCl4) intoxication. METHODS: Twenty elderly (30 months) Sprague-Dawley rats underwent a CCl4 intoxication (5 mL/kg). Animals were divided after 24 hours (n = 10 per group) to either undergo PPVA (G1, treated group) or be untreated (G2, control group). PPVA consisted of a shunt between the left renal artery and splenic vein after nephrectomy and spelnectomy. The G2 group animals underwent nephrectomy and splenectomy only. The 10-day survival was evaluated. Before euthanasia, blood samples from the portal vein were detected for blood gas analysis. Liver injury was evaluated by the serum alanine aminotransferase (ALT) and prothrombin time levels. Histology was done to evaluate the liver necrosis. Hepatocyte regeneration was assessed by the mitotic index at immunohistochemistry. RESULTS: The PPVA has resulted in a significant increase in the oxygen partial pressure and saturation in portal blood. A survival improvement at 10 days was registered in the PPVA-treated rats (90% vs 30%; P = .0065). After 24 hours from intoxication, ALT was high in both groups. A rapid decrease of ALT was observed in G1 as compared to G2. At the same time, livers showed a severe centrolobular necrosis. In the suviving G2 rats, a moderate necrosis was present, while only a mild necrosis was observed in the G1 rats. An higher mitotic index was detected in rats treated with PPVA. CONCLUSIONS: In our experimental study, the presence of oxygenated blood in the portal venous system following the PPVA procedure had positive effects on liver regeneration and rats' survival. The PPVA treatment had beneficial effects in elderly rats.