A preoperative risk score based on early recurrence for estimating outcomes after resection of hepatocellular carcinoma in the non-cirrhotic liver.

BACKGROUND: Liver resection is the mainstay treatment option for patients with hepatocellular carcinoma in the non-cirrhotic liver (NCL-HCC), but almost half of these patients will experience a recurrence within five years of surgery. Therefore, we aimed to develop a rationale-based risk evaluation tool to assist surgeons in recurrence-related treatment planning for NCL-HCC. METHODS: We analyzed single-center data from 263 patients who underwent liver resection for NCL-HCC. Using machine learning modeling, we first determined an optimal cut-off point to discriminate early versus late relapses based on time to recurrence. We then constructed a risk score based on preoperative variables to forecast outcomes according to recurrence-free survival. RESULTS: We computed an optimal cut-off point for early recurrence at 12 months post-surgery. We identified macroscopic vascular invasion, multifocal tumor, and spontaneous tumor rupture as predictor variables of outcomes associated with early recurrence and integrated them into a scoring system. We thus stratified, with high concordance, three groups of patients on a graduated scale of recurrence-related survival. CONCLUSION: We constructed a preoperative risk score to estimate outcomes after liver resection in NCL-HCC patients. Hence, this score makes it possible to rationally stratify patients based on recurrence risk assessment for better treatment planning.

A preoperative nomogram for predicting long-term survival after resection of large hepatocellular carcinoma (>10 cm).

BACKGROUND: It has previously been demonstrated that a fraction of patients with hepatocellular carcinoma (HCC) > 10 cm can benefit from liver resection. However, there is still a lack of effective decision-making tools to inform intervention in these patients. METHODS: We analysed a comprehensive set of clinical data from 234 patients who underwent liver resection for HCC >10 cm at the National Cancer Institute of Peru between 1990 and 2015, monitored their survival, and constructed a nomogram to predict the surgical outcome based on preoperative variables. RESULTS: We identified cirrhosis, multifocality, macroscopic vascular invasion, and spontaneous tumour rupture as independent predictors of survival and integrated them into a nomogram model. The nomogram's ability to forecast survival at 1, 3, and 5 years was subsequently confirmed with high concordance using an internal validation. Through applying this nomogram, we stratified three groups of patients with different survival probabilities. CONCLUSION: We constructed a preoperative nomogram to predict long-term survival in patients with HCC >10 cm. This nomogram is useful in determining whether a patient with large HCC might truly benefit from liver resection, which is paramount in low- and middle-income countries where HCC is often diagnosed at advanced stages.

Single-Cell Transcriptomic Analysis of Human Lung Provides Insights into the Pathobiology of Pulmonary Fibrosis.

Rationale: The contributions of diverse cell populations in the human lung to pulmonary fibrosis pathogenesis are poorly understood. Single-cell RNA sequencing can reveal changes within individual cell populations during pulmonary fibrosis that are important for disease pathogenesis. Objectives: To determine whether single-cell RNA sequencing can reveal disease-related heterogeneity within alveolar macrophages, epithelial cells, or other cell types in lung tissue from subjects with pulmonary fibrosis compared with control subjects. Methods: We performed single-cell RNA sequencing on lung tissue obtained from eight transplant donors and eight recipients with pulmonary fibrosis and on one bronchoscopic cryobiospy sample from a patient with idiopathic pulmonary fibrosis. We validated these data using in situ RNA hybridization, immunohistochemistry, and bulk RNA-sequencing on flow-sorted cells from 22 additional subjects. Measurements and Main Results: We identified a distinct, novel population of profibrotic alveolar macrophages exclusively in patients with fibrosis. Within epithelial cells, the expression of genes involved in Wnt secretion and response was restricted to nonoverlapping cells. We identified rare cell populations including airway stem cells and senescent cells emerging during pulmonary fibrosis. We developed a web-based tool to explore these data. Conclusions: We generated a single-cell atlas of pulmonary fibrosis. Using this atlas, we demonstrated heterogeneity within alveolar macrophages and epithelial cells from subjects with pulmonary fibrosis. These results support the feasibility of discovery-based approaches using next-generation sequencing technologies to identify signaling pathways for targeting in the development of personalized therapies for patients with pulmonary fibrosis.

Lung Injury Combined with Loss of Regulatory T Cells Leads to De Novo Lung-Restricted Autoimmunity.

More than one third of patients with chronic lung disease undergoing lung transplantation have pre-existing Abs against lung-restricted self-Ags, collagen type V (ColV), and k-α1 tubulin (KAT). These Abs can also develop de novo after lung transplantation and mediate allograft rejection. However, the mechanisms leading to lung-restricted autoimmunity remain unknown. Because these self-Ags are normally sequestered, tissue injury is required to expose them to the immune system. We previously showed that respiratory viruses can induce apoptosis in CD4(+)CD25(+)Foxp3(+) regulatory T cells (Tregs), the key mediators of self-tolerance. Therefore, we hypothesized that lung-tissue injury can lead to lung-restricted immunity if it occurs in a setting when Tregs are impaired. We found that human lung recipients who suffer respiratory viral infections experienced a decrease in peripheral Tregs. Pre-existing lung allograft injury from donor-directed Abs or gastroesophageal reflux led to new ColV and KAT Abs post respiratory viral infection. Similarly, murine parainfluenza (Sendai) respiratory viral infection caused a decrease in Tregs. Intratracheal instillation of anti-MHC class I Abs, but not isotype control, followed by murine Sendai virus infection led to development of Abs against ColV and KAT, but not collagen type II (ColII), a cartilaginous protein. This was associated with expansion of IFN-γ-producing CD4(+) T cells specific to ColV and KAT, but not ColII. Intratracheal anti-MHC class I Abs or hydrochloric acid in Foxp3-DTR mice induced ColV and KAT, but not ColII, immunity, only if Tregs were depleted using diphtheria toxin. We conclude that tissue injury combined with loss of Tregs can lead to lung-tissue-restricted immunity.

Pleural gas analysis for the identification of alveolopleural fistulae.

PURPOSE OF REVIEW: The method for identification of alveolopleural fistulae (APF) by visual inspection of air bubbles in the chest drainage system has several limitations and suffers from poor accuracy. Here we discuss the use of a novel technique of pleural gas analysis in the identification and management of APF. RECENT FINDINGS: We found that pleural gas analysis has higher sensitivity and specificity than visual inspection in identifying APF. Additionally, we demonstrated that intrapleural gas milieu impacts lung healing and reduction of intrapleural carbon dioxide can promote resolution of APF. SUMMARY: Pleural gas analysis is a novel technique to identify and manage APF. Integration of gas analysis in chest drainage systems would provide a more objective method for managing chest tubes and providing a favorable pleural gas environment for lung healing.

Skeletal involvement in Gaucher disease: An observational multicenter study of prognostic factors in the Argentine Gaucher disease patients.

Patients with Gaucher type 1 (GD1) throughout Argentina were enrolled in the Argentine bone project to evaluate bone disease and its determinants. We focused on presence and predictors of bone lesions (BL) and their relationship to therapeutic goals (TG) with timing and dose of enzyme replacement therapy (ERT). A total of 124 patients on ERT were enrolled in a multi-center study. All six TG were achieved by 82% of patients: 70.1% for bone pain and 91.1% for bone crisis. However, despite the fact that bone TGs were achieved, residual bone disease was present in 108 patients on ERT (87%) at time 0. 16% of patients showed new irreversible BL (bone infarcts and avascular osteonecrosis) despite ERT, suggesting that they appeared during ERT or were not detected at the moment of diagnosis. We observed 5 prognostic factors that predicted a higher probability of being free of bone disease: optimal ERT compliance; early diagnosis; timely initiation of therapy; ERT initiation dose ≥45 UI/kg/EOW; and the absence of history of splenectomy. Skeletal involvement was classified into 4 major phenotypic groups according to BL: group 1 (12.9%) without BL; group 2 (28.2%) with reversible BL; group 3 (41.9%) with reversible BL and irreversible chronic BL; and group 4 (16.9%) with acute irreversible BL. Our study identifies prognostic factors for achieving best therapeutic outcomes, introduces new risk stratification for patients and suggests the need for a redefinition of bone TG. Am. J. Hematol. 91:E448-E453, 2016. © 2016 Wiley Periodicals, Inc.

Clinical Features of Metastatic Hepatic Malignancies.

The liver is a common site for gastrointestinal tumor metastases as it is the first major organ reached by blood draining the portal venous system. With the development of more effective chemotherapeutic agents which may eradicate residual microscopic disease in the liver and help reduce known tumor burden, partial hepatectomy to remove gross metastatic disease will likely become increasingly utilized in the future. This chapter discusses the presentation and clinical factors in liver directed surgical resection.

Pancreatic acinar cell carcinoma with bilateral ovarian metastases, panniculitis and polyarthritis treated with FOLFIRINOX chemotherapy regimen. A case report and review of the literature.

Pancreatic acinar cell carcinoma (PACC) is a rare pancreatic tumor, with an estimated frequency of less than 1% of pancreatic malignancies. There are no prospective studies to guide diagnostic or therapeutic algorithms. We report the case of a 36 year-old woman, diagnosed of a pancreatic tumor with liver and peritoneal metastases that was initially managed as a neuroendocrine tumor with temozolomide and capecitabine. After two cycles a severely painful arthritis developed in her left ankle with panniculitis and extensive fat necrosis, and CT scan demonstrated progressive disease. Pathology of the primary was reassessed establishing the diagnosis of PACC. The patient started treatment with FOLFIRINOX regimen, achieving clinical benefit and disease stabilization. We also briefly reviewed the literature on this rare subtype of pancreatic tumor.

Efficacy and Safety of CT-Guided Kidney Biopsy for the Diagnosis of Glomerular Diseases in Complicated Patients.

INTRODUCTION: Kidney biopsy is the cornerstone for the diagnosis of glomerular diseases and to guide treatment. Percutaneous ultrasound-guided kidney biopsy is currently the gold standard to obtain cortical specimens. However, in cases where ultrasound-guided kidney biopsy is not deemed safe (obese patients, deep kidneys, or kidneys with a complicated anatomy), CT-guided kidney biopsy could be a convenient alternative to obtain renal tissue samples. The aim of this study was to describe the diagnostic yield and complications of CT-guided kidney biopsies in patients with glomerular diseases that were previously discarded for ultrasound-guided kidney biopsy. MATERIAL AND METHODS: We performed a retrospective, single-center, observational study including patients who underwent CT-guided native kidney biopsies in our center after being contraindicated for ultrasound-guided biopsy. Patients' records were reviewed retrieving baseline characteristics and pre-biopsy clinical, laboratory parameters and concomitant medication. The biopsy needle gauge, site of puncture, and number of needle passes were recorded. The diagnostic yield was evaluated by the number of glomeruli obtained, the rate of specimens that were adequate to reach diagnosis, and the number of biopsies that had to be repeated. Complications were defined as minor (hypotension, hematoma) and major (arteriovenous fistulae, major bleeding requiring embolization, or nephrectomy). The diagnostic yield and complications were compared to ultrasound-guided native kidney biopsies performed during the same period. RESULTS: 56 CT-guided native kidney biopsies were performed during the study period. The number of glomeruli obtained per patient was 11.5 ± 6.3, which was inferior to that obtained from ultrasound-guided biopsies (14.08 ± 8.47, p < 0.05). However, the rate of specimens that were adequate to reach a diagnosis was similar (92.9% vs. 90.8%, p = 0.437). The number of needle passes was higher in CT-guided kidney biopsies (2.0 ± 0.7 vs. 1.7 ± 0.5, p < 0.05), as well as the incidence of post-biopsy perirenal asymptomatic hematomas (66.1% vs. 24.5%, p < 0.01). There were no significant differences in other post-biopsy minor complications (1.8% vs. 2.5%, p = 0.621). There were no major complications after CT-guided kidney biopsies. CONCLUSIONS: CT-guided percutaneous kidney biopsy is a valid alternative for the diagnosis of glomerular diseases in patients with special characteristics such as obesity or deep kidneys that contraindicate ultrasound-guided biopsy. In this population, CT-guided kidney biopsies are safe and provide a high diagnostic yield, reaching a diagnosis in >90% of patients that had been previously discarded for ultrasound-guided biopsy.

Primary Graft Dysfunction in Lung Transplantation: A Review of Mechanisms and Future Applications.

Lung allograft recipients have worse survival than all other solid organ transplant recipients, largely because of primary graft dysfunction (PGD), a major form of acute lung injury affecting a third of lung recipients within the first 72 h after transplant. PGD is the clinical manifestation of ischemia-reperfusion injury and represents the predominate cause of early morbidity and mortality. Despite PGD's impact on lung transplant outcomes, no targeted therapies are currently available; hence, care remains supportive and largely ineffective. This review focuses on molecular and innate immune mechanisms of ischemia-reperfusion injury leading to PGD. We also discuss novel research aimed at discovering biomarkers that could better predict PGD and potential targeted interventions that may improve outcomes in lung transplantation.

Syntheses, thermal reactivities, and computational studies of aryl-fused quinoxalenediynes: effect of extended benzannelation on Bergman cyclization energetics.

A series of [b]-fused 6,7-diethynylquinoxaline derivatives have been synthesized through an imine condensation strategy to examine the effect of extended benzannelation on the thermal reactivity of enediynes. Absorption and emission spectra of the highly conjugated quinoxalenediynes were red-shifted approximately 100-200 nm relative to those of 1,2-diethynylbenzene. Strong exotherms indicative of enediyne cyclization were observed by differential scanning calorimetry, while solution cyclizations in the presence of 1,4-cyclohexadiene confirmed C(1)-C(6) Bergman cyclization. To provide further insight into Bergman cyclization energetics, computational studies were performed to compare changes in the cyclization enthalpy barrier, reaction enthalpy, and barrier of retro-Bergman ring-opening. Extension of benzannelation from 1,2-diethynylbenzene to either 2,3-diethynylnaphthalene or the 6,7-diethynylquinoxalines had a minimal effect on the cyclization barrier. In comparison, the enthalpies of cyclization were increased upon linearly extended benzannelation, which resulted in reduced barriers to retro-Bergman ring-opening. In addition, the orientation of extended benzannelation was found to have a significant effect on the cyclization endothermicity. In particular, 5,6-diethynylquinoxaline exhibited a 6.9 kcal/mol decrease in cyclization enthalpy compared to 6,7-diethynylquinoxaline due to increased aromatic stabilization energy in the respective angularly versus linearly fused azaacene cyclized products.

Residual endotoxin induces primary graft dysfunction through ischemia/reperfusion-primed alveolar macrophages.

Despite the widespread use of antibiotics, bacterial pneumonias in donors strongly predispose to the fatal syndrome of primary graft dysfunction (PGD) following lung transplantation. We report that bacterial endotoxin persists in human donor lungs after pathogen is cleared with antibiotics and is associated with neutrophil infiltration and PGD. In mouse models, depletion of tissue-resident alveolar macrophages (TRAMs) attenuated neutrophil recruitment in response to endotoxin as shown by compartmental staining and intravital imaging. Bone marrow chimeric mice revealed that neutrophils were recruited by TRAM through activation of TLR4 in a MyD88-dependent manner. Intriguingly, low levels of endotoxin, insufficient to cause donor lung injury, promoted TRAM-dependent production of CXCL2, increased neutrophil recruitment, and led to PGD, which was independent of donor NCMs. Reactive oxygen species (ROS) increased in human donor lungs starting from the warm-ischemia phase and were associated with increased transcription and translocation to the plasma membrane of TLR4 in donor TRAMs. Consistently, scavenging ROS or inhibiting their production to prevent TLR4 transcription/translocation or blockade of TLR4 or coreceptor CD14 on donor TRAMs prevented neutrophil recruitment in response to endotoxin and ameliorated PGD. Our studies demonstrate that residual endotoxin after successful treatment of donor bacterial pneumonia promotes PGD through ischemia/reperfusion-primed donor TRAMs.

Long-Term Impact of Cytomegalovirus Serologic Status on Lung Transplantation in the United States.

BACKGROUND: Cytomegalovirus (CMV) infection has been associated with poor outcomes after solid organ transplantation. The long-term impact of donor and recipient CMV serological status on lung transplant outcomes remains unclear. Accordingly, we evaluated the impact of donor and recipient CMV status on long-term patients as well as allograft survival after single (SLT) and double lung transplantation (BLT). METHODS: The Scientific Registry of Transplant Recipients was used to track all adult lung transplants in United States from May 2005 to June 2016. Patient mortality and bronchiolitis obliterans syndrome were determined up to 5 years using Cox proportional hazards modeling. Additionally, landmark analysis was performed conditional on survival at 1 year. RESULTS: Compared with donor negative-recipient CMV-IgG negative (D-R-), donor positive-recipient negative (D+R-) and donor positive-recipient positive (D+R+) groups had increased mortality at 1 and 5 years after BLT, with the former demonstrating highest risk. Although mortality was not increased with CMV seropositive donors after SLT at 1 year, both D+R- and D+R+ groups demonstrated greater mortality at 5 years. Risk of bronchiolitis obliterans syndrome was not affected by CMV serological status. Conditional landmark analysis confirmed that lungs from CMV seropositive donors conferred highest risk for long-term mortality. CONCLUSIONS: CMV seronegative recipients undergoing either BLT or SLT from CMV seropositive donors have the highest risk of long-term mortality that extends beyond the first year. Further studies are needed to determine the causes of higher mortality observed in the CMV seronegative recipients and risks and benefits of extension of CMV prophylaxis, particularly in the high-risk group.

A Mouse Model of Vascularized Heterotopic Spleen Transplantation for Studying Spleen Cell Biology and Transplant Immunity.

The spleen is a unique lymphoid organ that plays a critical role in the homeostasis of the immune and hematopoietic systems. Patients that have undergone splenectomy regardless of precipitating causes are prone to develop an overwhelming post-splenectomy infection and experience increased risks of deep venous thrombosis and malignancies. Recently, epidemiological studies indicated that splenectomy might be associated with the occurrence of cardiovascular diseases, suggesting that physiological functions of the spleen have not yet been fully recognized. Here, we introduce a mouse model of vascularized heterotopic spleen transplantation, which not only can be utilized to study the function and behavioral activity of splenic immune cell subsets in different biologic processes, but also can be a powerful tool to test the therapeutic potential of spleen transplantation in certain diseases. The main surgical steps of this model include donor spleen harvest, the removal of recipient native spleen, and spleen graft revascularization. Using congenic mouse strains (e.g., mice with CD45.1/CD45.2 backgrounds), we observed that after syngeneic transplantation, both donor-derived splenic lymphocytes and myeloid cells migrated out of the graft as early as post-operative day 1, concomitant with the influx of multiple types of recipient cells, thus generating a unique chimera.  Despite relatively challenging techniques, this procedure can be performed with >90% success rate. This model allows tracking the fate, longevity, and function of splenocytes during steady state and in a disease setting following a spleen transplantation, thereby offering a great opportunity to discover the distinct role for spleen-derived immune cells in different disease processes.

A novel strategy for cardiopulmonary support during lung transplantation.

Contemporary modalities for cardiopulmonary support during lung transplantation include traditional cardiopulmonary bypass (CPB) and venoarterial extracorporeal membrane oxygenation (VA-ECMO). While highly effective, both are associated with morbidities such as arteriopathy and bleeding diathesis. In this report, we describe a novel approach for cardiopulmonary support during double lung transplantation in a patient with end-stage lung disease, pulmonary hypertension and moderate right ventricle (RV) dysfunction, using a percutaneous dual lumen cannula placed via the jugular vein which allowed us to achieve both RV bypass and membrane oxygenation. The cannula was left in place to provide ongoing RV support and the patient was successfully decannulated at bedside on post-operative day (POD) 2. Lack of arterial cannulation, percutaneous access, and bedside decannulation are benefits of this strategy, rendering this approach a useful addition to the armamentarium for CPB techniques in lung transplantation.

Association of body mass index with lung transplantation survival in the United States following implementation of the lung allocation score.

BACKGROUND: The association of body mass index (BMI) with survival after lung transplantation remains controversial, owing to conflicting evidence in the literature. Previous reports have used traditional BMI categories, included patients who underwent transplantation before implementation of the lung allocation score (LAS), or were limited by single-center experiences. Here we evaluated the association of individual BMI units with short-term and long-term mortality in a large national database following implementation of the LAS. METHODS: The Scientific Registry of Transplant Recipients database was used to collect data for 17,233 adult lung transplantations performed between May 2005 and June 2016. The primary outcome was all-cause mortality at 90 days and 1 year posttransplantation. Logistic regression modeling was used to independently predict mortality per BMI unit, adjusting for donor and recipient factors. RESULTS: BMI was an independent predictor of mortality at both 90 days and 1 year. At 90 days, a BMI of 25 was associated with the lowest predicted probability of death (0.053; 95% confidence interval [CI], 0.047-0.049), with increased odds of mortality at BMI ≤20 and ≥28. At 1 year, a BMI of 26 was associated with the lowest predicted probability of death (0.12; 95% CI, 0.11-0.13), with increased odds of mortality at BMI ≤24 and ≥28. CONCLUSIONS: Each individual BMI unit has a quantifiable effect on posttransplantation survival, and the patterns of effect do not fit into the predefined BMI categories. The mortality risk associated with BMI should be considered by transplant centers when making listing decisions and by regulatory bodies for estimating expected outcomes.