Liver transplantation following two conversions in a patient with huge hepatocellular carcinoma and portal vein invasion:A case report

BACKGROUND Surgical resection and liver transplantation(LT)are the most effective curative options for hepatocellular carcinoma(HCC).However,few patients with huge HCC(>10 cm in diameter),especially those with portal vein tumor thrombus(PVTT),can receive these treatments.Selective internal radiation therapy(SIRT)can be used as a conversion therapy for them because it has the dual benefit of shrinking tumors and increasing residual hepatic volume.However,in patients with huge HCC,high lung absorbed dose often prevents them from receiving SIRT.CASE SUMMARY A 35-year-old man was admitted because of emaciation and pain in the hepatic region for about 1 month.The computed tomography scan showed a 20.2 cm×19.8 cm tumor located in the right lobe–left medial lobes with right portal vein and right hepatic vein invasion.After the pathological type of HCC was confirmed by biopsy,two conversions were presented.The first one was drug-eluting bead transarterial chemoembolization plus hepatic arterial infusion chemotherapy and lenvatinib and sintilimab,converted to SIRT,and the second one was sequential SIRT with continued systemic treatment.The tumor size significantly decreased from 20.2 cm×19.8 cm to 16.2 cm×13.8 cm,then sequentially to 7.8 cm×6.8 cm.In the meantime,the ratio of spared volume to total liver volume increased gradually from 34.4%to 55.7%,then to 62.9%.Furthermore,there was visualization of the portal vein,indicating regression of the tumor thrombus.Finally,owing to the new tumor in the left lateral lobe,the patient underwent LT instead of resection without major complications.CONCLUSION Patients with inoperable huge HCC with PVTT could be converted to SIRT first and accept surgery sequentially.

Predicting disease progression in cirrhotic patients after transjugular intrahepatic portosystemic shunt implantation:A sexstratified analysis

BACKGROUND Transjugular intrahepatic portosystemic shunt(TIPS)has been extensively used to treat portal hypertension-associated complications,including cirrhosis.The prediction of post-TIPS prognosis is important for cirrhotic patients,as more aggressive liver transplantation is needed when the post-TIPS prognosis is poor.AIM To construct a nutrition-based model that could predict the disease progression of cirrhotic patients after TIPS implantation in a sex-dependent manner.METHODS This study retrospectively recruited cirrhotic patients undergoing TIPS implantation for analysis.Muscle quality was assessed by measuring the skeletal muscle index(SMI)by computed tomography.Multivariate Cox proportional hazard models were utilized to determine the association between SMI and disease progression in cirrhotic patients after TIPS implantation.RESULTS This study eventually included 186 cirrhotic patients receiving TIPS who were followed up for 30.5±18.8 mo.For male patients,the 30-mo survival rate was significantly lower and the probability of progressive events was higher(3.257-fold)in the low-level SMI group than in the high-level SMI group.According to the multivariate Cox analysis of male patients,SMI<32.8 was an independent risk factor for long-term adverse outcomes after TIPS implantation.A model was constructed,which involved creatinine,plasma ammonia,SMI,and acute-on-chronic liver failure and hepatic encephalopathy occurring within half a year after surgery.This model had an area under the receiver operating characteristic curve of 0.852,sensitivity of 0.926,and specificity of 0.652.According to the results of the DeLong test,this model outperformed other models(Child-Turcotte-Pugh,Model for End-Stage Liver Disease,and Freiburg index of post-TIPS survival)(P<0.05).CONCLUSION SMI is strongly associated with poor long-term outcomes in male patients with cirrhosis who underwent TIPS implantation.

Early prediction of survival in hepatocellular carcinoma patients treated with transarterial chemoembolization plus sorafenib

AIM To identify clinical biomarkers that could early predict improved survival in patients with advanced-stage hepatocellular carcinoma(HCC) treated with transarterial chemoembolization combined with sorafenib(TACE-S).METHODS We retrospectively evaluated the medical records of consecutive patients with advanced-stage HCC who underwent TACE-S from January 2012 to December 2015. At the first follow-up 4-6 wk after TACE-S(median, 38 d; range, 33-45 d), patients exhibiting the modified Response Evaluation Criteria in Solid Tumors(m RECIST)-evaluated complete response, partial response, and stable disease were categorized as early disease control. At this time point, multiple variables were analyzed to identify the related factors affecting survival.RESULTS Ninety-five patients were included in this study, and 60 of these patients achieved early disease control, with an overall disease control rate(DCR) of 63.2%. Patients who got sorafenib at the first TACE(no previous TACE) and patients without portal vein tumor thrombus(PVTT) had a higher DCR than those who underwent previous TACE before TACE-S(72.4% vs 48.6%, P = 0.019) and those with PVTT(75.5% vs 50.0%, P = 0.010). Early disease control after TACE-S, no previous TACE, and no PVTT were the independent prognostic factors for survival in the uni-and multivariate analyses.CONCLUSION The first follow-up 4-6 wk after TACE-S can be used as the earliest time point to assess the response to TACE-S, and patients with m RECIST-evaluated early disease control, no previous TACE, and no PVTT had better survival.

Renal aspergillosis after liver transplantation: Clinical and imaging manifestations in two cases

Renal aspergillosis(RAsp)is a rare complication in liver transplant(LT)recipients.Here we report RAsp in two LT recipients.In both patients,RAsp occurred more than 90 d after allogenetic orthotropic LT,and all the clinical findings were unspecific.RAsp involved unilateral kidney in Case one and bilateral kidneys in Case two.Both computed tomography(CT)and magnetic resonance imaging(MRI)revealed renal abscesses,with progressively enhanced walls and separationsand unenhanced alveolate areas after contrast agent administration.On unenhanced CT images they showed inhomogeneous hypo-attenuation.On fat-suppressed T2-weighted images(T2WIs),the walls and separations of the abscesses showed slightly low signal intensity and the central parts of the lesions showed slightly high signal intensity.Both on CT and MRI,there were some hints of renal infarction or chronic ischemia.Both cases were treated by radical nephrectomy followed by adjuvant antifungal treatment.They all recovered well.

Role of interventional therapy in hepatic artery stenosis and non-anastomosis bile duct stricture after orthotopic liver transplantation

AIM： To analyze the clinical manifestations and the effectiveness of therapy in patients with orthotopic liver bansplantation （OLT）-associated hepatic artery stenosis （HAS） and non-anastomosis bile duct stricture.METHODS： Nine cases were diagnosed as HAS and non-anastomosis bile duct stricture. Percutaneous transluminal angioplasty （PTA） was performed in four HAS cases, and expectant treatment in other five HAS cases, percutaneous transhepatic bile drainage, balloon dilation, stent placement were performed in all nine cases.RESULTS： Diffuse intra- and extra-bile duct stricture was observed in nine cases, which was associated with bile mud siltation and biliary infection. Obstruction of the bile duct was improved obviously or removed. Life span/ follow-up period was 13-30 mo after PTA of four HAS cases, 6-23 mo without PTA of other five cases.CONCLUSION： Progressive, non-anastomosis, and diffuse bile duct stricture are the characteristic manifestations of HAS and non-anastomosis bile duct stricture after OLT. These are often associated with bile mud siltation, biliary infection, and ultimate liver failure. Interventional therapy is significantly beneficial.

Role of multi-detector computed tomography for biliary complications after liver transplantation

AIM: To investigate the diagnostic performance of multi-detector computed tomography (MDCT) in detecting biliary complications after orthotopic liver transplantation (OLT).