Kidney outcomes in patients with liver cirrhosis and chronic kidney disease receiving an orthotopic liver transplant alone.

Kidney transplant in patients with liver cirrhosis and nondialysis chronic kidney disease (CKD) is controversial. We report 14 liver cirrhotic patients who had persistently low MDRD-6 estimated glomerular filtration rate (e-GFR) <40 mL/min/1.73 m2 for ≥3 months and underwent either liver transplant alone (LTA; n=9) or simultaneous liver-kidney transplant (SLKT; n=5). Pretransplant, patients with LTA compared with SLKT had lower serum creatinine (2.5±0.73 vs 4.6±0.52 mg/dL, P=.001), higher MDRD-6 e-GFR (21.0±7.2 vs 10.3±2.0 mL/min/1.73 m2 , P=.002), higher 24-hour urine creatinine clearance (34.2±8.8 vs 18.0±2.2 mL/min, P=.002), lower proteinuria (133.2±117.7 vs 663±268.2 mg/24 h, P=.0002), and relatively normal kidney biopsy and ultrasound findings. Post-LTA, the e-GFR (mL/min/1.73 m2 ) increased in all nine patients, with mean e-GFR at 1 month (49.8±8.4), 3 months (49.6±8.7), 6 months (49.8±8.1), 12 months (47.6±9.2), 24 months (47.9±9.1), and 36 months (45.1±7.3) significantly higher compared to pre-LTA e-GFR (P≤.005 at all time points). One patient developed end-stage renal disease 9 years post-LTA and another patient expired 7 years post-LTA. The low e-GFR alone in the absence of other markers or risk factors of CKD should not be an absolute criterion for SLKT in patients with liver cirrhosis.

Influence of facility type on survival outcomes after pancreatectomy for pancreatic adenocarcinoma.

INTRODUCTION: Although a volume-outcome relationship has been well established for pancreatectomy, little is known about differences in mortality by facility type. The objective of this study is to evaluate the impact of facility type on short-term and long-term survival outcomes for patients with pancreatic adenocarcinoma who underwent pancreatectomy and identify determinants of overall survival (OS). METHODS: A cohort of 33,382 patients with Stage I-III pancreatic adenocarcinoma diagnosed between 1998 and 2011 were evaluated from the National Cancer Data Base. Clinicopathological, sociodemographic and treatment variables were compared among three facility types where patients received resection: (i) community cancer program (CCP), (ii) comprehensive community cancer program (CCCP), and (iii) academic research program (ARP). 5-year OS was calculated using the Kaplan-Meier method. RESULTS: Despite ARP having significantly higher percentage of poorly differentiated tumors, higher T-stage tumors, more positive lymph nodes, and greater circle distance compared to the other facilities, it had the highest 5-yr OS. The 5-yr OS for CCP, CCCP, and ARP was 11.2%, 13.2%, and 16.6%, respectively (P < 0.0001) and the median survival time (months) was 12.4, 15.6 and 19.1, respectively. CONCLUSION: Patients receiving pancreatic resection at an ARP yielded a higher 5-year OS compared to CCP or CCCP.

Does kidney transplantation to iliac artery deteriorate ischemia in the ipsilateral lower extremity with peripheral arterial disease?

OBJECTIVES: This study was conducted to investigate the progression of lower extremity ischemia following kidney transplantation to iliac artery in patients with peripheral arterial disease. METHODS: A retrospective chart review of all renal transplant patients completed at a university teaching medical center from January 2006 to December of 2011 was performed. A total of 219 patients underwent successful kidney transplantation to the common, external, or internal iliac artery. Pre- and post-transplantation ischemic changes in the ipsilateral lower extremity were reviewed and analyzed. RESULTS: Thirty-eight of the 219 patients had ipsilateral peripheral arterial disease and seven of them were symptomatic. Six of the seven symptomatic patients remained stable and one patient's rest pain improved, postoperatively. Eight patients developed new symptoms of ischemia 12 months later, including four with claudication, two with ischemic ulcers, and two with gangrene toes. The ulcers were healed following superficial femoral artery stenting and wound care. Toe amputation was performed in two patients with gangrene. No major amputation was required up to 48 months of follow-up. CONCLUSIONS: Transplanted kidney to iliac artery does not significantly deteriorate ischemia in adults with ipsilateral lower extremity peripheral arterial disease. Late developed ischemic complications may be due to the progression of underlying arterial disease.

Curative resection of pancreatic adenocarcinoma with major venous resection/repair is safe procedure but will not improve survival.

OBJECTIVE: To evaluate the safety and survival benefit of combined curative resection (CR) of the pancreas and major venous resection in the management of borderline resectable pancreatic adenocarcinoma. METHODS: In this IRB approved retrospective cohort study, patients who had pancreatic surgery (n=274) between 1998-2012 were reviewed. One hundred and seventy-five patients had malignant causes, of which 119 underwent CR. One hundred and two patients who did not require venous resection/repair (Group-I) were compared with 17 patients who had major vascular involvement (portal-vein/superior-mesenteric-vein) and underwent a vascular resection/repair (Group-II) during the CR. Demographics, operative and follow-up data were reviewed. RESULT: Type of the operations were: standard Whipple (n=53), pylorus-sparing-Whipple (n=41), total pancreatectomy (n=11), and distal pancreatectomy (n=13). In Group-II, venous involvement was excised and primarily repaired (n=12), or repaired using other veins (n=4) or a synthetic patch (n=1). Group-II had a significantly larger tumor size and more perineural invasion and peripancreatic soft tissue involvement (P<0.05). While complication rate, margin status, and duration of stay were not different between the groups, the median-overall-survival was higher for Group-I (15.34 months) than Group-II patients (7.18 months) (P=0.003). CONCLUSION: Pancreatic CR requiring intra-operative venous resection/repair is feasible and safe, but the survival of the patients who have pancreatic adenocarcinoma with venous involvement is poor irrespective of a successful venous resection.

Aberrant left main bile duct draining directly into the cystic duct or gallbladder: an unreported anatomical variation and cause of bile duct injury during laparoscopic cholecystectomy.

Despite recent advances, iatrogenic bile duct injury remains one of the most common complications of laparoscopic cholecystectomy. Aberrant biliary tract anatomy is one of the major risk factors for iatrogenic bile duct injury. In this case report, for the first time, we report a case of aberrant left main bile duct draining directly into the cystic duct or gallbladder that presented with bile duct injury after laparoscopic cholecystectomy. We hope that the diagnostic and management approach used in this case will help physicians to identify and manage their patients should they face such a rare anatomy.

Mucinous cystic neoplasm of pancreas in a male patient: a case report and review of the literature.

Mucinous cystic neoplasms (MCNs) are among the most common primary cystic neoplasms of pancreas. These lesions usually occur in body and tail of the pancreas and are characterized by the presence of ovarian type stroma in the pathological evaluation. Mucinous cystic neoplasms have significant malignant potential; therefore, their diagnosis and resection is of utmost importance. Mucinous cystic neoplasms typically occur in women. Only a few cases have been previously reported in male patients. In this case report, we present a 48-year-old man who was referred to our center due to an incidentally found cystic lesion in the tail of the pancreas that was increasing in size in serial evaluation. The patient underwent open distal pancreatectomy. The pathology showed mucinous cystic neoplasm with characteristic ovarian type stroma and positive staining for estrogen and progesterone receptors. This case report shows that mucinous cystic neoplasms can occur in men and should be considered in differential diagnosis of cystic pancreatic lesions in this population.

Portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation provides an easy access for evaluation of pancreatic allograft dysfunction: six-year experience at a single center.

BACKGROUND: The aim of this study is to report our six-year experience with portal-endocrine and gastric-exocrine drainage technique of pancreatic transplantation, which was first developed and implemented at our center in 2007. METHODS: In this study, the outcomes of all patients at our center who had pancreas transplantation with portal-endocrine and gastric-exocrine drainage technique were evaluated. RESULTS: From October 2007 to November 2013, 38 patients had pancreas transplantation with this technique - 31 simultaneous kidney pancreas and seven pancreas alone. Median duration of follow-up was 3.8 years. One-, three-, and five-year patient and graft survival rates were 94%, 87%, 70% and 83%, 65%, 49%, respectively. For pancreas allograft dysfunction evaluation, 51 upper endoscopies were performed in 14 patients; donor duodenal biopsies were successfully obtained in 45 (88%). We detected nine episodes of acute rejection (eight patients) and seven episodes of cytomegalovirus (CMV) duodenitis (six patients). No patient developed any complication due to upper endoscopy. CONCLUSIONS: Portal-endocrine and gastric-exocrine drainage technique of pancreas transplantation provides lifelong easy access to the transplanted duodenum for evaluation of pancreatic allograft dysfunction.

Indications, Techniques, and Barriers for Pancreas Transplant Biopsy: A Consensus Perspective From a Survey of US Centers.

BACKGROUND: Pancreas transplant biopsy practices for the diagnosis of rejection or other pathologies are not well described. METHODS: We conducted a survey of staff at US pancreas transplant programs (March 22, 2022, to August 22, 2022) to assess current program practices and perceptions about the utility and challenges in the performance and interpretation of pancreas allograft biopsies. RESULTS: Respondents represented 65% (76/117) of active adult pancreas transplant programs, capturing 66% of recent pancreas transplant volume in the United States. Participants were most often nephrologists (52%), followed by surgeons (46%), and other staff (4%). Pancreas allograft biopsies were performed mostly by interventional radiologists (74%), followed by surgeons (11%), nephrologists (8%), and gastroenterologists (1%). Limitations in the radiologist's or biopsy performer's comfort level or expertise to safely perform a biopsy, or to obtain sufficient/adequate samples were the two most common challenges with pancreas transplant biopsies. Pancreas transplant biopsies were read by local pathologists at a majority (86%) of centers. Challenges reported with pancreas biopsy interpretation included poor reliability, lack of reporting of C4d staining, lack of reporting of rejection grading, and inconclusive interpretation of the biopsy. Staff at a third of responding programs (34%) stated that they rarely or never perform pancreas allograft biopsies and treat presumed rejection empirically. CONCLUSIONS: This national survey identified significant variation in clinical practices related to pancreas allograft biopsies and potential barriers to pancreas transplant utilization across the United States. Consideration of strategies to improve program experience with percutaneous pancreas biopsy and to support optimal management of pancreas allograft rejection informed by histology is warranted.

Liver Transplant Costs and Activity After United Network for Organ Sharing Allocation Policy Changes.

Importance: A new liver allocation policy was implemented by United Network for Organ Sharing (UNOS) in February 2020 with the stated intent of improving access to liver transplant (LT). There are growing concerns nationally regarding the implications this new system may have on LT costs, as well as access to a chance for LT, which have not been captured at a multicenter level. Objective: To characterize LT volume and cost changes across the US and within specific center groups and demographics after the policy implementation. Design, Setting, and Participants: This cross-sectional study collected and reviewed LT volume from multiple centers across the US and cost data with attention to 8 specific center demographics. Two separate 12-month eras were compared, before and after the new UNOS allocation policy: March 4, 2019, to March 4, 2020, and March 5, 2020, to March 5, 2021. Data analysis was performed from May to December 2022. Main Outcomes and Measures: Center volume, changes in cost. Results: A total of 22 of 68 centers responded comparing 1948 LTs before the policy change and 1837 LTs postpolicy, resulting in a 6% volume decrease. Transplants using local donations after brain death decreased 54% (P < .001) while imported donations after brain death increased 133% (P = .003). Imported fly-outs and dry runs increased 163% (median, 19; range, 1-75, vs 50, range, 2-91; P = .009) and 33% (median, 3; range, 0-16, vs 7, range, 0-24; P = .02). Overall hospital costs increased 10.9% to a total of $46 360 176 (P = .94) for participating centers. There was a 77% fly-out cost increase postpolicy ($10 600 234; P = .03). On subanalysis, centers with decreased LT volume postpolicy observed higher overall hospital costs ($41 720 365; P = .048), and specifically, a 122% cost increase for liver imports ($6 508 480; P = .002). Transplant centers from low-income states showed a significant increase in hospital (12%) and import (94%) costs. Centers serving populations with larger proportions of racial and ethnic minority candidates and specifically Black candidates significantly increased costs by more than 90% for imported livers, fly-outs, and dry runs despite lower LT volume. Similarly, costs increased significantly (>100%) for fly-outs and dry runs in centers from worse-performing health systems. Conclusions and Relevance: Based on this large multicenter effort and contrary to current assumptions, the new liver distribution system appears to place a disproportionate burden on populations of the current LT community who already experience disparities in health care. The continuous allocation policies being promoted by UNOS could make the situation even worse.

Association of clinical events with everolimus exposure in kidney transplant patients receiving reduced cyclosporine.

BACKGROUND: The association between clinical events and everolimus exposure in patients receiving reduced-exposure calcineurin inhibitor therapy is poorly explored. METHODS: In a pre-planned, descriptive analysis of data from a randomized controlled trial, events were correlated with everolimus trough concentrations in 556 newly transplanted kidney transplant patients receiving everolimus with reduced-exposure cyclosporine (CsA) and steroids. Influence of everolimus exposure on clinical events was stratified according to predefined time-normalized concentrations. RESULTS: The incidence of treated biopsy-proven acute rejection and graft loss at month 12 was highest in patients with everolimus <3 ng/mL (36.4% and 28.6%, respectively, vs. 9.1-15.3% and 0.9-5.0% with higher concentration ranges). A higher mortality rate was observed in patients with an everolimus trough concentration ≥ 12 ng/mL (10.0% vs. 1.7-5.6% with lower concentration ranges). The lowest rates of renal dysfunction (defined as poor renal function [estimated GFR, serum creatinine] or proteinuria), wound healing events, peripheral edema, new-onset diabetes mellitus, hypercholesterolemia and hypertriglyceridemia were generally observed with everolimus trough concentration in the range 3-8 ng/mL and CsA <100 ng/mL. Proteinuria occurred most frequently in patients with very low or very high everolimus trough concentrations. CONCLUSIONS: These results support an exposure-response relationship between clinical events and everolimus trough concentrations in kidney transplant patients receiving reduced-exposure CsA.

Graftula: a composite access consisting of a graft used to repair a dysfunctional hemodialysis fistula.

Nonmaturing or dysfunctional hemodialysis fistulas are often repaired with interposition grafts placed either within the fistula (fistula-to-fistula configuration), or connected to another vein (fistula-to-vein configuration). The goal of this study was to compare the survival and usefulness of the composite accesses thus created, which we call "graftulas," with upperarm grafts. This was a retrospective study wherein we determined the survival and thrombosis rates of graftulas (n=24) and upper arm grafts (n=31) placed 1/1/07 through 12/31/09 and followed through 11/30/10. Graftulas resembled grafts as most (96%) were successfully cannulated in 65 ± 43 days. Survival of graftulas was also similar to grafts (58%, 47%, and 32% vs. 56%, 47%, and 39% at 1, 2, and 3 years respectively, p=0.60). However, graftulas had a lower thrombosis rate than grafts (0.5 vs. 1.2 per patient year, p=0.04), and in the fistula-to-fistula configuration, a 2-year thrombosis-free survival of 78%. Total survival of the access site (fistula+graftula) was 92%, 73%, and 42% at 1, 3, and 5 years, respectively. Graftulas possess certain beneficial properties of fistulas and grafts that allows for continued use of the original access site.

Accuracy of multi-detector computed tomography, fluorodeoxyglucose positron emission tomography-CT, and CA 19-9 levels in detecting recurrent pancreatic adenocarcinoma.

CONTEXT: We compared the accuracy of fluorodeoxyglucose positron emission tomography-CT (FDG-PET-CT), multi-detector computed tomography (MDCT) and CA 19-9 levels in detecting pancreatic cancer recurrence in patients with resected CA 19-9 positive pancreatic adenocarcinomas. METHODS: We retrospectively evaluated 122 patients with pancreatic adenocarcinomas who underwent surgical resection of the tumor between January 2002 and December 2011. Twenty-five patients had MDCT, FDG-PET-CT and CA 19-9 levels performed no less than six weeks post-operation and within 8 weeks of each other for detection of tumor recurrence. Of these, 20 patients had high pre-operative CA 19-9 levels that dropped to a normal level postoperatively which will be the focus of this study. The sensitivity, specificity, positive and negative predictive value (PPV, NPV), and accuracy of MDCT, FDG-PET-CT, and CA 19-9 in detecting recurrence were compared. RESULTS: Operations performed included pyloric sparing pancreaticoduodenectomy (n=9), pancreaticoduodenectomy (n=7), distal pancreatectomy (n=3) and total pancreatectomy (n=1). Three patients had no recurrence, but local recurrence and distant metastasis were seen in 8 (40%) and 12 (60%) patients, respectively. In our study, sensitivity, specificity, PPV, NPV and diagnostic effectiveness (accuracy) were: 82%, 100%, 100%, 50%, 85% for MDCT; 82%, 100%, 100%, 50%, 85% for FDG-PET-CT and 94%, 100%, 100%, 75%, 95% for CA 19-9. The difference in recurrence detection accuracy of the tests was not statistically significant. A combination of CA 19-9 with MDCT or FDG-PET-CT was 100% accurate in detecting cancer recurrence in our patients. CONCLUSION: Our data suggests that CA 19-9 levels can be used reliably to detect recurrent pancreatic adenocarcinomas in patients with CA 19-9-positive primary tumors. Combination of CA 19-9 with MDCT or FDG-PET-CT is potentially the most accurate approach in detecting pancreatic cancer recurrence.

Acinar cell carcinoma presenting as a duodenal mass: review of the literature and a case report.

Heterotopic pancreatic tissue is not uncommon. Although the cancerous transformation of heterotopic pancreatic tissue is a theoretical possibility, it is an extremely rare phenomenon. The majority of the heterotopic pancreatic malignancies reported in the literature are adenocarcinomas (32 cases). An Acinar Cell Carcinoma (ACC) arising from heterotopic pancreatic tissue is even less common with only six cases being reported. This report presents an extremely rare case of heterotopic pancreatic ACC presenting as a duodenal mass. We propose that heterotopic pancreatic ACC should be considered as a possibility in the differential diagnosis of a duodenal mass.

Strategy for effective percutaneous drainage of pancreatic collections: results on 121 patients.

UNLABELLED: There is a lack of technical guidelines for image-guided percutaneous drainage (IGPD) of pancreatic fluid collections (PFCs). To fill that void, we present a strategy and guidelines for systematic IGPD for effective PFCs evacuation. METHODS: Institutional Review Board (IRB)-approved study of 121 pancreatitis patients with symptomatic PFCs that underwent IGPD. IGPD strategy aimed at evacuation of the PFCs compartments using vigorous catheter drainage and manipulations. PFCs resolution and patients' outcome were measured. RESULTS: Pancreatitis pathogenesis and etiology included: necrotizing, 79 patients (alcoholic, 40; biliary, 20; hyperlipidemia, 8; other, 11); traumatic, 32 patients; and chronic ductal, 10 patients (pseudocysts). An ipsilateral retroperitoneal access was used for pararenal spaces PFCs (61, 50% patients), a transabdominal IGPD approach for anterior PFCs (49 patients, 41%), an intercostal/subcostal access for left subphrenic PFCs (22 patients, 18%), and a transgastric drainage route for retrogastric PFCs (9 patients, 7%). Table 1 lists the site of the pancreatic fluid collections and number and size of the catheter(s) used for IGPD of the PFCs in the 121 patients. Fifty-seven (47%) patients had positive cultures PFCs. Of these, 24 (20%) had polymicrobial infections, and 18 (15%) had fungal infections. There were 20 (11%) patients with multi-compartment drainage. PFCs resolution occurred in 102 (84%) patients. PFCs recurrence was treated by surgery (four patients) or IGPD (one patient). Pancreatic fistulas closed, except in one patient. Nine patients (7%) experienced multiorgan failure/death; 5 (4%) were lost to follow-up.

Intraductal papillary mucinous neoplasm of the intrahepatic bile duct: a review of literature and a rare case report.

Background: Intraductal papillary neoplasm of the bile duct is a rare variant of bile duct tumors, which is characterized by papillary or villous growth inside the bile duct. Having papillary and mucinous features such as those found in pancreatic intraductal papillary mucinous neoplasm (IPMN) is extremely rare. We report a rare case of intraductal papillary mucinous neoplasm of the intrahepatic bile duct. Case report: A 65-year-old male Caucasian with multiple comorbidities presented to the emergency room with moderate constant pain at the right upper quadrant (RUQ) abdomen for the last several hours. On physical examination, he was found to have normal vital signs, with icteric sclera and pain on deep palpation at the RUQ region. His laboratory results were significant for jaundice, elevated liver function tests and creatinine, hyperglycemia, and leukocytosis. Multiple imaging studies revealed a 5 cm heterogeneous mass in the left hepatic lobe that demonstrated areas of internal enhancement, mild gall bladder wall edema, dilated gall bladder with mild sludge, and 9 mm common bile duct (CBD) dilatation without evidence of choledocholithiasis. He underwent a CT-guided biopsy of this mass, which revealed intrahepatic papillary mucinous neoplasm. This case was discussed at the hepatobiliary multidisciplinary conference, and the patient underwent an uneventful robotic left partial liver resection, cholecystectomy, and lymphadenectomy. Conclusion: IPMN of the biliary tract may represent a carcinogenesis pathway different from that of CBD carcinoma arising from flat dysplasia. Complete surgical resection should be performed whenever possible because of its significant risk of harboring invasive carcinoma.

A rare synchrony of adenocarcinoma of the ampulla with an ileal gastrointestinal stromal tumor: A case report.

BACKGROUND: This is a unique case of a patient who was found to have two extremely rare primary malignancies synchronously, i.e., an ampullary adenocarcinoma arising from a high-grade dysplastic tubulovillous adenoma of the ampulla of Vater (TVAoA) with a high-grade ileal gastrointestinal stromal tumor (GIST). Based on a literature review and to the best of our knowledge, this is the first report of this synchronicity. Primary ampullary tumors are extremely rare, with an incidence of four cases per million population, which is approximately 0.0004%. Distal duodenal polyps are uncommon and have a preponderance of occurring around the ampulla of Vater. An adenoma of the ampulla ( AoA) may occur sporadically or with a familial inheritance pattern, as in hereditary genetic polyposis syndrome such as familial adenomatous polyposis syndrome (FAPS). We report a case of a 77-year-old male who was admitted for painless obstructive jaundice with a 40-pound weight loss over a two-month period and who was subsequently diagnosed with two extremely rare primary malignancies, i.e., an adenocarcinoma of the ampulla arising from a high-grade TVAoA and a high-grade ileal GIST found synchronously. CASE SUMMARY: A 77-year-old male was admitted for generalized weakness with an associated weight loss of 40 pounds in the previous two months and was noted to have painless obstructive jaundice. The physical examination was benign except for bilateral scleral and palmar icterus. Lab results were significant for an obstructive pattern on liver enzymes. Serum lipase and carbohydrate antigen-19-9 levels were elevated. Computed tomography (CT) of the abdomen and pelvis and magnetic resonance cholangiopancreatography were consistent with a polypoid mass at the level of the common bile duct (CBD) and the ampulla of Vater with CBD dilatation. The same lesions were visualized with endoscopic retrograde cholangiopancreatography. Histopathology of endoscopic forceps biopsy showed TVAoA. Histopathology of the surgical specimen of the resected ampulla showed an adenocarcinoma arising from the TVAoA. Abdominal and pelvic CT also showed a coexisting heterogeneously enhancing, lobulated mass in the posterior pelvis originating from the ileum. The patient underwent ampullectomy and resection of the mass and ileo-ileal side-to-side anastomosis followed by chemoradiation. Histopathology of the resected mass confirmed it as a high-grade, spindle cell GIST. The patient is currently on imatinib, and a recent follow-up positron emission tomography (PET) scan showed a complete metabolic response. CONCLUSION: This case is distinctive because the patient was diagnosed with two synchronous and extremely rare high-grade primary malignancies, i.e., an ampullary adenocarcinoma arising from a high-grade dysplastic TVAoA with a high-grade ileal GIST. An AoA can occur sporadically and in a familial inheritance pattern in the setting of FAPS. We emphasize screening and surveillance colonoscopy when one encounters an AoA in upper endoscopy to check for FAPS. An AoA is a premalignant lesion, particularly in the setting of FAPS that carries a high risk of metamorphism to an ampullary adenocarcinoma. Final diagnosis should be based on a histopathologic study of the surgically resected ampullary specimen and not on endoscopic forceps biopsy. The diagnosis of AoA is usually incidental on upper endoscopy. However, patients can present with constitutional symptoms such as significant weight loss and obstructive symptoms such as painless jaundice, both of which occurred in our patient. Patient underwent ampullectomy with clear margins and ileal GIST resection. Patient is currently on imatinib adjuvant therapy and showed complete metabolic response on follow up PET scan.

External Beam Radiation Therapy for Primary Liver Cancers: An ASTRO Clinical Practice Guideline.

PURPOSE: This guideline provides evidence-based recommendations for the indications and technique-dose of external beam radiation therapy (EBRT) in hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (IHC). METHODS: The American Society for Radiation Oncology convened a task force to address 5 key questions focused on the indications, techniques, and outcomes of EBRT in HCC and IHC. This guideline is intended to cover the definitive, consolidative, salvage, preoperative (including bridge to transplant), and adjuvant settings as well as palliative EBRT for symptomatic primary lesions. Recommendations were based on a systematic literature review and created using a predefined consensus-building methodology and system for grading evidence quality and recommendation strength. RESULTS: Strong recommendations are made for using EBRT as a potential first-line treatment in patients with liver-confined HCC who are not candidates for curative therapy, as consolidative therapy after incomplete response to liver-directed therapies, and as a salvage option for local recurrences. The guideline conditionally recommends EBRT for patients with liver-confined multifocal or unresectable HCC or those with macrovascular invasion, sequenced with systemic or catheter-based therapies. Palliative EBRT is conditionally recommended for symptomatic primary HCC and/or macrovascular tumor thrombi. EBRT is conditionally recommended as a bridge to transplant or before surgery in carefully selected patients. For patients with unresectable IHC, consolidative EBRT with or without chemotherapy should be considered, typically after systemic therapy. Adjuvant EBRT is conditionally recommended for resected IHC with high-risk features. Selection of dose-fractionation regimen and technique should be based on disease extent, disease location, underlying liver function, and available technologies. CONCLUSIONS: The task force has proposed recommendations to inform best clinical practices on the use of EBRT for HCC and IHC with strong emphasis on multidisciplinary care. Future studies should focus on further defining the role of EBRT in the context of liver-directed and systemic therapies and refining optimal regimens and techniques.

Management of giant liver cysts.

BACKGROUND: Liver cysts are often asymptomatic. Symptomatic liver cysts are uncommon and can be managed by percutaneous aspiration, laparoscopic/open marsupialization, or resection. Our aim is to review our experience with management of giant liver cysts (GLC). MATERIALS AND METHODS: An IRB approved chart review of patients with liver cysts between 1995-2009 was performed. There were 34 GLC in 24 patients, 20 (83%) were females (mean age of 59.2 y). Pain was the main symptom in 20 patients. The average cyst size was 15.66 cm (6-32 cm) with 14 cysts over 15 cm in size. Two patients with GLC (11 and 15 cm) decided not to have surgery; 16 patients underwent laparoscopic surgery with one recurrence. One patient with laparoscopic marsupialization at another center was managed by open marsupialization and repair of the bile leak. Four of the patients underwent open marsupialization and one underwent open resection. Four patients with prior percutaneous aspiration had recurrences (100%), three underwent laparoscopic and one open marsupialization. An 8-wk pregnant patient underwent percutaneous aspiration of a 32 cm cyst to alleviate symptoms until delivery. RESULTS: The mean hospital stay for laparoscopic marsupialization was 5.57 d compared with 9.2 d for open procedure. Three (18.7%) postoperative complications (bile leak, recurrence, bleeding) occurred in the laparoscopic group, and one (20%) bile leak in the open group, with a mean follow-up of 41 mo. CONCLUSION: Laparoscopic marsupialization of GLC is as effective and safe as open procedures in preventing cyst recurrence regardless of cyst size and location, and affords a relatively shorter hospital stay.

Addressing the worldwide hepatocellular carcinoma: epidemiology, prevention and management.

Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world with rising incidence. Globally, there has been substantial variation in prevalence of risk factors for HCC over years, like control of viral hepatitis in developing countries but growing epidemic of fatty liver disease in developed world. Changing epidemiology of HCC is related to trends in these risk factors. HCC remains asymptomatic until it is very advanced which makes early detection by surveillance important in reducing HCC related mortality. Management of HCC. depends on stage of the tumor and severity of underlying liver disease. At present, resection and transplant are still the best curative options for small HCC, but recent advances in locoregional therapy and molecular targeted systemic therapy has changed the management for HCC at intermediate and advanced stages. This review is overview of global epidemiology, prevention, surveillance and emerging therapies for hepatocellular carcinoma.