Transplantation for hepatocellular carcinoma in younger patients has an equivocal survival advantage as compared with resection.

Whereas some investigators in the surgical field advocate liver resection for the treatment of hepatocellular carcinoma (HCC), orthotopic liver transplantation (OLT) shows a significant survival advantage. Age was used to stratify survival in these groups to analyze beneficence. The Surveillance, Epidemiology, and End Results database (1998-2008) was used to identify 2355 patients who underwent either a segmentectomy, lobectomy, or extended lobectomy (resection) and 1873 patients who underwent an OLT for HCC. These patients were further stratified according to age and their relative survival was calculated. As shown in previous studies, the survival advantage is maintained in patients 40 to 59 and 60 to 79 years of age with HCC treated with OLT. However, within the 20 to 39-year-old age group, this advantage is insignificant. In this younger age group, resection patients (n = 157) have a 5-year survival rate of 50.9% whereas the OLT group (n = 40) has a 5-year survival rate of 58.9% (P = .42). Moreover, when assessing patient with lesions within the Milan criteria ages 20 to 39 years, resection shows a slight, although insignificant 4-year survival advantage: 78.2% for resection (n = 56) and 64.4% for OLT (n = 21; P = .283). This data may temper the enthusiasm for OLT in younger patients given the possibility of equivalent treatment with surgical resection.

Fewer than 12 lymph nodes can be expected in a surgical specimen after high-dose chemoradiation therapy for rectal cancer.

PURPOSE: Lymph node harvest of >or=12 has been adopted as a marker for adequacy of resection for colorectal cancer. We have noted a paucity of lymph nodes in rectal cancer specimens after neoadjuvant therapy, positing that the number of lymph nodes depends on the response to radiation and may not be an appropriate benchmark. Our purpose was to determine whether the number of lymph nodes harvested after neoadjuvant therapy is a useful quality indicator. METHODS: A database of rectal cancer patients was queried to identify patients undergoing total mesorectal excision after neoadjuvant chemoradiation between January 1997 and August 2007. We compared patients with <12 lymph nodes to those with >or=12 lymph nodes relative to multiple patient and treatment factors. RESULTS: One hundred seventy-six patients were identified (119 men; mean age, 60.4 y (range, 22-87)). Mean lymph node harvest was 10.1 (range, 1-38). Only 28% had >or=12 lymph nodes and 32% had <6 lymph nodes. There was no statistically significant difference in lymph node harvest relative to radiation dosage, age, tumor response, or type of surgery. There was no correlation between the number of lymph nodes harvested and the number of nodes positive for cancer. CONCLUSIONS: With a standardized surgical technique and pathologic evaluation, the number of lymph nodes present after neoadjuvant chemoradiation and total mesorectal excision for rectal cancer varies greatly.

Transanal endoscopic microsurgery for the treatment of rectal cancer: comparison of wound complication rates with and without neoadjuvant radiation therapy.

BACKGROUND: Neoadjuvant therapy for rectal cancer has led to improved tumor downstaging and higher complete pathologic response rates. At the same time, the introduction of transanal endoscopic microsurgery (TEM) technique has renewed interest in local excision of rectal cancer. There has been concern that radiation may make the more radical local excision with TEM unsuitable. Our study compared morbidity rates and wound complication rates for patients undergoing TEM and local excision with and without neoadjuvant radiation to determine whether this could be accomplished safely. METHODS: Data for all patients undergoing TEM are prospectively entered into a database. This database was queried for patients with rectal cancer undergoing TEM from November 1997 to June 2007. Of 64 patients identified, 2 were excluded because of previous radiation to the pelvis. RESULTS: The study enrolled 62 patients with a final pathologic diagnosis of rectal cancer: 43 treated using neoadjuvant therapy with radiation (XRT) and 19 patients treated with TEM alone. The patients in the XRT group were 67 years of age (range, 29-86 years) and included 13 women. The patients in the non-XRT group were 66 years of age (range, 40-89 years) and included 8 women. Neither group had any mortalities. The overall morbidity rate was 33% for the XRT group and 5.3% for the non-XRT group, and this difference was statistically significant (p < 0.05). The wound complication rates were 25.6% for the XRT group (11 patients) and 0% for the non-XRT group (p = 0.015). Nine patients in the XRT group (82%) had minor wound separations, and two patients (18%) had major wound separation. Ten patients with wound separations were treated as outpatients and administered long-term oral antibiotics. One patient required additional surgery (diverting stoma). CONCLUSIONS: Not unexpectedly, the wound complication rate was higher in the XRT group. However, 82% of those wounds were minor, and 91% were treated without any additional surgery or intervention. Although a significant concern, wound complications do not prohibit TEM treatment after neoadjuvant treatment.

Improvement in Cheyne-Stokes respiration following cardiac resynchronisation therapy.

The effect of standard cardiac resynchronisation therapy (CRT) on the severity of Cheyne-Stokes respiration (CSR) in patients with congestive heart failure was studied. It was hypothesised that CRT, through its known beneficial effects on cardiac function, would stabilise the control of breathing and reduce CSR. Twenty-eight patients who were eligible for CRT and receiving optimised medical treatment for congestive heart failure were referred for overnight polysomnography, including monitoring of thoracic and abdominal movements to identify CSR and obstructive sleep apnoea events. Patients underwent repeat polysomnography after 6 months of CRT to re-evaluate sleep quality and sleep-disordered breathing. Twelve of the 28 patients had significant CSR (43%); 10 patients had a successful implantation and underwent repeat polysomnography a mean+/-SD 27+/-7 weeks after continuous biventricular pacing. Six of the 10 patients experienced a significant decrease in CSR severity following CRT, associated with correction of congestive heart failure-related hyperventilation and hypocapnia. Circulation time, oxygen saturation, frequency of obstructive apnoeas and sleep quality did not change. In conclusion, cardiac resynchronisation therapy is associated with a reduction in Cheyne-Stokes respiration, which may contribute to improved clinical outcome in patients treated with cardiac resynchronisation therapy.

Comparison of primary and secondary treatment in squamous oral cancer.

A popular rule of thumb has often prevailed in treating oral cancer: Try one modality first; if it fails, try the other--the chance for cure will still be good. To study this dogma, a group of 160 consecutive patients with oral cavity squamous carcinoma were reviewed. A hypothesis was formed: secondary treatment for recurrent cancer, whether surgery after radiation failure or vice versa, would salvage essentially as many patients as primary treatment, say within 15%. Results show a large difference in success rates between first and second treatments when all stages are considered together, a difference well over 15 percentage points. Regarding each stage separately, the largest difference occurs in stage II (28 percentage points); other stages exceed 15 point differences. No significant differences in successful salvage occur between "home" failures and "elsewhere" failures. Local recurrence was a major cause of failure in both groups (55%). We conclude that recurrence of oral squamous cancer after first treatment markedly reduces patients' chance for cure.

Pathologic findings of an explanted silicone intraocular lens.

We present a clinicopathological analysis of an explanted STAAR model B silicone intraocular lens (IOL) that was sent to the Center for Intraocular Lens Research for evaluation. Extracapsular cataract extraction (ECCE), using phacoemulsification and insertion of the silicone IOL, had been accomplished through a 3-mm scleral tunnel incision. The IOL was folded and inserted into the ciliary sulcus. Complications, including blurred vision, movement of the IOL within the eye, and glaucoma, eventually led to IOL exchange at three months post-ECCE. After removal of the silicone IOL, a modified J-loop IOL was placed in the intact capsular bag, with subsequent resolution of the increased intraocular pressure and a 20/20 + 3 visual acuity. Pathologic examination of the explanted silicone lens revealed grooves indented into the optic, extensive molding flash, and opalescence of the optic.

Hydrolysis of glutathione by human liver gamma-glutamyltransferase.

We studied the catalytic hydrolysis of glutathione by human liver gamma-glutamyltransferase [(gamma-glutamyl)-peptide:amino acid gamma-glutamyltransferase, EC 2.3.2.2]. Glutamate production from glutathione was maximal at pH 7.4 (37 degrees C). Kinetically, the liver enzyme is similar to human kidney gamma-glutamyltransferase: their respective Km values with glutathione as substrate are similar (0.096 x 10(-3) mol/L and 0.097 x 10(-3) mol/L, respectively). S-Methylglutathione was hydrolyzed at a slightly higher rate than glutatione by liver gamma-glutamyltransferase. From these findings and other established properties of liver and kidney gamma-glutamyltransferase we propose that human liver is an important site of glutathione catabolism and that gamma-glutamyltransferase in liver catalyzes the first step of the catabolism of glutathione and glutathione conjugates in this organ.

Increased creatine kinase isoenzyme MB values in patients without myocardial infarct.

Six of 13 randomly selected patients in a medical intensive-care unit with above-normal creatine kinase MB activities had diagnoses other than myocardial infarction. These data, which indicate the need for further study, were obtained during evaluation of a commercially available column procedure (Biodynamics/bmc).