The number of hepatocellular carcinoma foci as predictor of poor response to tumor-directed therapies in patients awaiting liver transplantation: a prospective cohort study

BACKGROUND AND AIMS

Tumor-directed therapies (TDTs) are a constitutive part of hepatocellular carcinoma (HCC) treatment in patients awaiting liver transplantation (LT). While most patients benefit from TDTs as a bridge to LT, some patients drop out from the waiting list due to tumor progression. The study aimed to determine the risk factors for poor treatment outcome following TDTs among patients with HCC awaiting LT.

METHODS

A total of 123 patients with HCC were evaluated with 92 patients meeting Milan Criteria enrolled in the prospective cohort study. Tumor response was evaluated using the modified Response Evaluation Criteria for Solid Tumors for HCC 1 month after the procedure. The risk factors for progressive disease (PD) and dropout were evaluated.

RESULTS

After TDT, 55 patients (59.8%) achieved complete or partial response (44.6% and 15.2% respectively), 17 patients (18.5%) had stable disease, and 20 patients (21.7%) were assessed as PD. Multivariate analysis revealed a significant and independent association between the number of HCC foci and PD ( P  = 0.03, OR = 2.68). There was no statistically significant association between treatment response and demographics, MELDNa score, pre-and post-treatment alpha-fetoprotein (AFP), cumulative tumor burden the largest tumor size, or TDT modality. PD was the major cause of dropout in our cohort. Pre-treatment AFP levels ≥200 ng/ml had a strong association with dropout after TDTs ( P  = 0.0005).

CONCLUSION

This study demonstrated the presence of multifocal HCC is the sole prognostic factor for PD following TDTs in HCC patients awaiting LT. We recommend prioritizing patients with multifocal HCC within Milan criteria by exception points for LT to improve the dropout rate.

Clinical, biochemical and histological correlations in a group of non-drinker subjects with non-alcoholic fatty liver disease

The correlation between biochemistry, imaging-studies and histology is a matter of controversy in non-alcoholic fatty liver disease (NAFLD) and the major pathophysiology of non-alcoholic steatohepatitis (NASH) is still unknown. We aimed to perform a comparative analysis between clinical, biochemical and histological variables of NAFLD. One-hundred and five NAFLD patients (F/M: 51/54), were studied, all with no-alcohol intake. The groups were followed-up for six months. Necroinflammation and fibrosis were more severe in patients with diabetes (p = 0.002, and p = 0.0001, respectively). In comparing NAFL to NASH, plasma nitric-oxide and malondialdehyde levels were significantly higher (p = 0.05, for-both), and vitamin-E and-C levels were significantly lower in NASH (p = 0.002, and 0.001, respectively). The serum ferritin levels were higher in NASH patients (p = 0.016). While the ultrasonographic grade was significantly higher, the liver-spleen density gradient was significantly lower in NASH group (p = 0.017, and 0.005, respectively). Within a six month period, serum ALT levels dropped into the normal range in 23/76 (30.3%) patients and serum ALT in the 6th month correlated significantly with the severity of steatosis, inflammation and fibrosis in initial biopsy (p = 0.023, 0.035, 0.011, respectively). In conclusion, the probability of severe liver disease is higher in patients with elevated-ALT in NAFLD. Serum ferritin levels have some prognostic significance in liver damage and fibrosis. Overt diabetes is predictive of advanced fibrosis and inflammation. However impaired glucose-tolerance is not. The advice on diet and exercise for six months after diagnosis may be a good strategy in NAFLD. The patients with normal-ALT without hepatomegaly, morbid-obesity and diabetes seem to have a good prognosis, however some of these patients may still require liver biopsy.

Extra-thoracic Extrinsic Compression: An Unusual Cause of Dysphagia

BACKGROUND

Dysphagia affects one in twenty-five adults yearly in the United States.

OBJECTIVE

While dysphagia may be common, the prevalence of dysphagia may be underestimated primarily due to under-reporting. Dysphagia may be caused by intraluminal, intrinsic, extrinsic, or motility disorders.

METHOD/RESULTS

We present a case of dysphagia caused by extra-thoracic extrinsic compression due to bra use.

CONCLUSION

Despite many published reports on dysphagia caused by other diagnoses, we occasionally overlook extrinsic abdominal compression as the cause for dysphagia.

Infliximab use in ulcerative colitis flare with clostridium difficile infection: A report of two cases and literature review

Clostridium difficile infection (CDI) is a major cause of morbidity and mortality in patients with inflammatory bowel disease (IBD), especially in ulcerative colitis (UC). The incidence and severity of CDI in IBD has shown an increasing trend in the last two decades. Patients with IBD are predisposed to CDI secondary to the recurrent use of antibiotics, corticosteroids, and immunosuppressants and secondary to dysbiosis. It is clinically challenging to distinguish the symptoms of CDI from an IBD flare. The worsening of IBD symptoms demands escalation of steroids or initiation of biologics. However, the management of CDI in IBD, not responding to antibiotics, is not well described beyond a few case reports. We report two cases of CDI with active UC flare. The patients did not respond to antibiotics or intravenous corticosteroids but had rapid resolution of CDI symptoms after receiving infliximab infusion. The optimal dosing and infusion frequency of infliximab in management of CDI in UC/IBD remains to be established.

The effect of melatonin application on lipid peroxidation during cyclophosphamide therapy in female rats

OBJECTIVE

Our purpose was to investigate whether melatonin has any protective effect against lipid peroxidation induced by cyclophosphamide.

MATERIAL AND METHODS

We used an animal model to study the effect of melatonin. Fifteen female Wistar rats (180-200 gram in weight) were randomly assigned to three different groups. Group 1 (n = 5) received saline injections as a control. Group 2 (n = 5) received cyclophosphamide. Group 3 (n = 5) received cyclophosphamide + melatonin. The animals were sacrificed two hours after cyclophosphamide administration and blood samples were taken and used for assaying superoxide dismutase (SOD) activity, glutathione peroxidase (GP) activity for the antioxidative enzymes, and malondialdehyde (MDA) level as an index of lipid peroxidation.

RESULTS

MDA levels were more increased in the second group compared with the control group (p < 0.01). In the third group, they were significantly lower than in the second group (p < 0.05). SOD and GP activities were found to be decreased significantly in the second group compared with the control group (p < 0.05 and p < 0.01, respectively). They were found to be elevated in the third group compared with the second group (p > 0.05 and p < 0.05, respectively).

CONCLUSIONS

The above results suggest that melatonin has a protective role in cyclophosphamide induced lipid peroxidation in rats. Besides scavenging the highly toxic free radicals, melatonin also stimulates the antioxidant enzyme activity of GP.