Selection of patients with hepatocellular carcinoma before liver transplantation:need to combine alpha-fetoprotein with morphology?

Liver transplantation is the best treatment for selected patients with unresectable hepatocellular carcinoma (HCC). While candidate selection has been historically based on the restrictive Milan

What factors are important to new patients when selecting an orthopedic oncologist?

BACKGROUND Understanding how patients choose a provider may improve the overall experience by identifying ways to tailor a clinical practice.AIM To identify factors that patients consider important when choosing an orthopedic oncologist.METHODS New patients presenting to an orthopedic oncology clinic within a tertiary academic medical center from January 2019 to August 2020 were invited to complete an anonymous survey.The questionnaire consisted of 27 items including a Likert-type assessment of the importance of selection factors.RESULTS A total of 101 new patients with a median age of 66 years(range,14 years to 91 years)responded.Most were referred by another doctor(n=63,62.4%),and of the referring providers,the most frequent specialty was orthopedic surgery(n=32,51%).Using a Likert-type scale with 1 representing‘least important’and 5 representing‘most important’,the most important factor was the hospital reputation(mean,4.65;SD,0.85).Additional factors of importance were the number of years in practice(3.87±1.3)and a primary care provider referral(3.71±1.6).Patients younger than 40 years old found social media(P=0.016)and internet presence(P=0.035)of their surgeon to be more important than older patients.In contrast,older patients considered care within an academic center to be of greater importance than younger patients(P=0.014).CONCLUSION This investigation suggests a primary care referral,as well as hospital and physician reputation,are among the most important factors when selecting an orthopedic oncologist.Furthermore,social media utilization appears to be more important for younger patients.

Liver transplantation benefits selected patients with hilar cholangiocarcinoma and colorectal liver metastases

Hilarcholangiocarcinoma(HCCA)isanaggressivemalignancy with a dismal prognosis. The 5-year survival rate has been reported to range from 39%to 50%if an R0 resection is obtained [1]. Approximately 25%patients with early stage HCCA of all cases can be treated with radical surgical resection [2], while most patients do not have a chance to receive a surgical procedure due to the advanced stage at the time of diagnosis. The poor prognosis is gen-

Feasibility of percutaneous coronary intervention via transulnar artery approachin selective patients with coronary heart disease

Objective To probe the clinic feasibility of percutaneous coronary intervention(PCI) via transulnar artery approach (PCI TRU).Methods Fourty patients with unstable ischemic manifestation(male 34,female 6;age 59.3 ±9.10 years)whose radial artery of right hand was thin with a weak pulse that was not suitable to transradial artery PCI while whose ulnar artery was thick with a strong pulse based on their larger diameter in ulnar artery as compared with those in radial artery ( 3.30 ±0.22mm vs 2.43 ±0.33 mm, P <0.05 ) by the investigation of vessel echography,but revesered Allen’s test for radial and ulnar artery was positive,were selected as the subjects for PCI TRU. The radio of ulnar artery versus radial artery was 1.35:1.00 and the time of Allen’s test in ulnar artery side was shorter than that in radial artery side ( 2.70 ±0.36 s vs 4.68 ±0.52s , P <0.05 ) before PCI. The efficiency of PCI TRU was evaluated. The time of manipulative duration for each procedure of PCI TRU was recorded. The time of Allen’s test, luminal diameter (mm) , cross area of vessel lumin (mm 2), blood velocity (Vs max), blood resistance (RI) in ulnar artery and radial artery and the level of blood oxygen in finger (PaO 2、SatO 2) were measured and recorded , respectively , as well were compared quantitatively before and after 1 month of procedure . Results Fourty eight lesion segments of 42 vessels in all patients were angioplasticized successfully via TRU by 6F guiding catheter including 23 segments of type B1 , 14 segments of type B2 and 11 segments of type C. PCI TRU in all of 40 patients was performed successfully. Fourty eight stents were implanted including 2 lesions of intrastent restenosis angioplasticized with cutting balloon technique before re stenting . The average time of manipulative duration of guiding catheters engaging in osicum of target coronary, crossing the vessel lesions of guidewire, dilatation and implantation of stents,and under X ray fluoroscopy were 4.30 ±0.59 min , 2.52 ±0.40min , 2.66 ±0.40 min ,and 25.9 ±0.49 min , respectively, and the total time of the whole procedure was 56.6 ±14.8 min . When the ulnar introducer was taken off, the access site in ulnar artery was suppressed by tourniquet with no bleeding in the access site and no limitation of physical activation under maintaining infusion of heparin immediately after procedure . There was no significant change in the diameter of ulnar artery and the time of Allen’s test after 1 month of PCI procedure as compared with those before procedure ( 3.22 ±0.48mm vs 3.26 ±0.22 mm , P >0.05 ; 2.96 ±0.98 s vs 2.72 ±0.47 s , P >0.05 ). No significant change was found in the parameters of blood velocity , cross area of vessel lumin, blood resistance and the level of blood oxygen in finger after 1 month of PCI procedure. The average total hospital stay was 5.21 ±0.43 days. Following up 1 month, no complications such as occlusion of ulnar artery, abnormal sensitivity and movement disability were found in right hands in all patients.Conclusions The ulnar artery might be selected as one approach of antebrachial artery for PCI in the patients with coronary heart disease whose radial artery was difficulty as access vessels of PCI, while reversed Allen’s test for radial and ulnar artery are positive and the luminal diameter of ulnar artery was larger than that of radial artery.

Precise prediction model and simplified scoring system for sustained combined response to interferon-α

AIM:To establish a predictive algorithm which may serve for selecting optimal candidates for interferon-α(IFN-α) treatment.METHODS:A total of 474 IFN-α treated hepatitis B virus e antigen(HBeAg)-positive patients were enrolled in the present study.The patients' baseline characteristics,such as age,gender,blood tests,activity grading(G) of intrahepatic inflammation,score(S) of liver fibrosis,hepatitis B virus(HBV) DNA and genotype were evaluated;therapy duration and response of each patient at the 24th wk after cessation of IFN-α treatment were also recorded.A predictive algorithm and scoring system for a sustained combined response(CR) to IFN-α therapy were established.About 10% of the patients were randomly drawn as the test set.Responses to IFN-α therapy were divided into CR,partial response(PR) and non-response(NR).The mixed set of PR and NR was recorded as PR+NR.RESULTS:Stratified by therapy duration,the most significant baseline predictive factors were alanine aminotransferase(ALT),HBV DNA level,aspartate aminotransferase(AST),HBV genotype,S,G,age and gender.According to the established model,the accuracies for sustained CR and PR+NR,respectively,were 86.4% and 93.0% for the training set,81.5% and 91.0% for the test set.For the scoring system,the sensitivity and specificity were 78.8% and 80.6%,respectively.There were positive correlations between ALT and AST,and G and S,respectively.CONCLUSION:With these models,practitioners may be able to propose individualized decisions that have an integrated foundation on both evidence-based medicine and personal characteristics.

Ex vivo liver resection followed by autotransplantation in radical resection of gastric cancer liver metastases:A case report

BACKGROUND Radical resection of gastric cancer liver metastases(GCLM)can increase the 5-year survival rate of GCLM patients.However,patients may lose the theoretical feasibility of surgery due to the critical location of liver metastasis in some cases.CASE SUMMARY A 29-year-old woman had a chief complaint of chronic abdominal pain for 1 year.Abdominal computed tomography and magnetic resonance imaging examinations suggested a mass of unknown pathological nature located between the first and second hila and the margin of the lower segment of the right lobe of the liver.The anterior wall of the gastric antrum was unevenly thickened.The diagnosis of(gastric antrum)intramucosal well-differentiated adenocarcinoma was histopathologically confirmed by puncture biopsy with gastroscopy guidance.She underwent radical resection(excision of both gastric tumors and ex vivo liver resection followed by autotransplantation simultaneously)followed by XELOX adjuvant chemotherapy.Without serious postoperative complications,the patient was successfully discharged on the 20th day after the operation.Pathological examination of the excised specimen indicated that gastrectomy with D2 lymph node dissection for primary gastric tumors and R0 resection for liver metastases were achieved.The resected mass was confirmed to be poorly differentiated gastric carcinoma(hepatoid adenocarcinoma with neuroendocrine differentiation)with liver metastases in segments VIII.No recurrence or metastasis within the liver was found during a 7.5-year follow-up review that began 1 mo after surgery.CONCLUSION Application of ex vivo liver resection followed by autotransplantation in radical resection for GCLM can help selected patients with intrahepatic metastases located in complex sites obtain a favorable clinical outcome.

Development and internal validation of the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score:is the patient suitable for Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)?

Background:Preoperative patient selection in Associating Liver Partition and Portal vein ligation for Staged hepatectomy(ALPPS)is not always reliable with currently available scores,particularly in patients with primary liver tumor.This study aims to(I)to determine whether comorbidities and patients characteristics are a risk factor in ALPPS and(II)to create a score predicting 90-day mortality preoperatively.Methods:Thirteen high-volume centers participated in this retrospective multicentric study.A risk analysis based on patient characteristics,underlying disease and procedure type was performed to identify risk factors and model the Comprehensive ALPPS Preoperative Risk Assessment(CAPRA)score.A nonparametric receiver operating characteristic analysis was performed to estimate the predictive ability of our score against the Charlson Comorbidity Index(CCI),the age-adjusted CCI(aCCI),the ALPPS risk score before Stage 1(ALPPS-RS1)and Stage 2(ALPPS-RS2).The model was internally validated applying bootstrapping.Results:A total of 451 patients were included.Mortality was 14.4%.The CAPRA score is calculated based on the following formula:(0.1×age)−(2×BSA)+1(in the presence of primary liver tumor)+1(in the presence of severe cardiovascular disease)+2(in the presence of moderate or severe diabetes)+2(in the presence of renal disease)+2(if classic ALPPS is planned).The predictive ability was 0.837 for the CAPRA score,0.443 for CCI,0.519 for aCCI,0.693 for ALPPS-RS1 and 0.807 for ALPPS-RS2.After 1,000 cycles of bootstrapping the C statistic was 0.793.The accuracy plot revealed a cut-off for optimal prediction of postoperative mortality of 4.70.Conclusions:Comorbidities play an important role in ALPPS and should be carefully considered when planning the procedure.By assessing the patient’s preoperative condition in relation to ALPPS,the CAPRA score has a very good ability to predict postoperative mortality.