Liver transplantation for hepatic tumors:a systematic review

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the “up-to-seven criteria”. Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because of the frequent multifocal, intrahepatic nature of the disease. LT is a very promising procedure for both primary and secondary liver malignancies; however, it needs an accurate evaluation of the costs and benefits for each indication to balance the chances of cure with actual organ availability.

Prophylaxis for venous thromboembolism after resection of hepatocellular carcinoma on cirrhosis: Is it necessary?

AIM: To assess the safety and effectiveness of prophylaxis for venous thromboembolism (VTE) in a large population of patients with hepatocellular carcinoma (HCC) on cirrhosis.METHODS: Two hundred and twenty nine consecutive cirrhotic patients with HCC who underwent hepatic resection were retrospectively evaluated to assess whether there was any difference in the incidence of thrombotic or hemorrhagic complications between those who received and those who did not receive prophylaxis with low-molecular weight heparin.Differences and possible effects of the following parameters were investigated: age,sex,Child-Pugh and model for end-stage liver disease (MELD) score,platelet count,presence of esophageal varices,type of hepatic resection,duration of surgery,intraoperative transfusion of blood and fresh frozen plasma (FFP),body mass index,diabetes and previous cardiovascular disease.RESULTS: One hundred and fifty seven of 229 (68.5%) patients received antithromboembolic prophylaxis (group A) while the remaining 72 (31.5%) patients did not (group B).Patients in group B had higher Child-Pugh and MELD scores,lower platelet counts,a higher prevalence of esophageal varices and higher requirements for intraoperative transfusion of FFP.The incidence of VTE and postoperative hemorrhage was 0.63% and 3.18% in group A and 1.38% and 1.38% in group B,respectively;these differences were not significant.None of the variables analyzed including prophylaxis proved to be risk factors for VTE,and only the presence of esophageal varices was associated with an increased risk of bleeding.CONCLUSION: Prophylaxis is safe in cirrhotic patients without esophageal varices;the real need for prophylaxis should be better assessed.

Pancreas-preserving segmental duodenectomy for gastrointestinal stromal tumor of the duodenum and splenectomy for splenic angiosarcoma

BACKGROUND: Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract and occur rarely in the duodenum. Splenic angiosarcoma is an aggressive neoplasm with an extremely poor prognosis. METHODS: We report a case of a 70-year-old man hospitalized for abdominal pain in the upper quadrants, dyspepsia and nausea, previously treated for Hodgkin lymphoma 30 years ago. Abdominal CT showed a solid nodular lesion in the third portion of the duodenum, the presence of retropancreatic, aortic and caval lymph nodes, and four nodular splenic masses. 111 In-octreotide scintigraphy revealed pathological tissue accumulation in the duodenal region, and in the retropancreatic, retroduodenal, aortic and caval lymph nodes, suggesting a nonfunctioning neuroendocrine peripancreatic tumor. RESULTS: At exploratory laparotomy, an exophytic soft tumor was found originating from the third portion of the duodenum. Pancreas-preserving duodenectomy with duodenojejunostomy, splenectomy and lymphnodectomy of retropancreatic aortic and caval lymph nodes were performed. Pathological evaluation and immunohistochemical studies showed the presence of a duodenal gastrointestinal stromal tumor with low mitotic activity and a well-differentiated angiosarcoma localized to the spleen and invading lymph nodes.CONCLUSIONS: We speculated that the angiosarcoma and duodenal gastrointestinal stromal tumors of this patient were due to the treatment of Hodgkin lymphoma with radiotherapy 30 years ago. Pancreas-preserving segmental duodenectomy can be used to treat non-malignant neoplasms of the duodenum and avoid extensive surgery. Splenectomy is the treatment of choice for localized angiosarcomas but a strict follow-up is mandatory because of the possibility of recurrence.

Long-term leukocyte natural α-interferon and ribavirin treatment in hepatitis C virus recurrence after liver transplantation

AIM:To evaluate the effect of long-term treatment with leukocyte natural-interferon(ln-α-IFN)plus ribavirin(RBV).METHODS:Forty-six patients with hepatitis C virus(HCV)recurrence received 3 MU three times a week of ln-α-IFN plus RBV for 1 mo;then,patients with good tolerability(n=30)were switched to daily IFN administration,while the remaining were treated with the same schedule.Patients have been treated for 12 mo after viral clearance while non-responders(NR)entered in the longterm treatment group.Liver biopsies were planned at baseline,1 year after sustained virological response(SVR)and at 36 mo after start of therapy in NR.MedCalc software package was used for statistical analysis.RESULTS:About 16.7%of genotype 1-4 and 70%of genotype 2-3 patients achieved SVR.Nine patients withdrew therapy because of non-tolerance or noncompliance.A significant improvement in serum biochemistry and histological activity was observed in all SVR patients and long-term treated;100%of patients with SVR achieved a histological response(fibrosis stabilization or improvement)with a significant reduction in mean staging value(from 2.1 to 1.0;P=0.0031);histological response was observed in 84%of long-term treated patients compared to 57%of drop-out.Six patients died during the entire study period(follow-up 40.6±7.7 mo);of them,5 presented with severe HCV recurrence on enrollment.Diabetes(OR=0.38,95%CI:0.08-0.59,P=0.01),leukopenia(OR=0.54,95%CI:0.03-0.57,P=0.03)and severe HCV recurrence(OR=0.51,95%CI:0.25-0.69,P=0.0003)were variables associated to survival.Long-term treatment was well tolerated;no patients developed rejection or autoimmune disease.CONCLUSION:Long-term treatment improves histology in SVR patients and slows disease progression also in NR,leading to a reduction in liver decompensation,graft failure and liver-related death.