Post-transplant malignancy in liver transplantation: a single center experience

We aim to determine the incidence of malignancy after liver transplantation (LT) compared to general population. The records of patients who received LTs at our center from October 1989 and November 2012 were retrospectively reviewed. The standardized incidence ratio (SIR) of cancer in the patients was compared to general population using the data from the Taiwan Cancer Registry. Survival was estimated using the Kaplan-Meier method. A total of 444 patients were included. Malignancy was found in 46 (28 de novo and 19 recurrent malignancies) patients (10.4%) with the median follow up of 4.2±4.2 years. The median time of cancer occurrence after transplant was 1.2±1.9 years (range, 0.2-9.1 years). Post-transplant lymphoproliferative disorder was the most frequent de novo malignancy (57.1% [16/28]). The cumulative incidence rates of all malignancies were 5.1%, 10.4%, 12.8%, 15.8%, and 15.8% at 1, 3, 5, 10, and 15 years, respectively. The cumulative incidence rates of de novo malignancies were 3.4%, 5.97%, 7.7%, 10.9%, and 10.9 % at 1, 3, 5, 10, and 15 years. Compared to general population, transplant recipients had significantly higher incidence of all de novo cancers (SIR: 3.26, 95% confidence interval [CI]: 2.17-4.72), hematologic (SIR: 58.4; 95% CI, 33.3-94.8), and bladder (SIR: 10.2, 95% CI: 1.1-36.7) cancers. The estimated mean survivals after transplantation in cancer-free, de novo cancer, and recurrent cancer patients were 17.7±0.5, 11.3±1.2, and 3.6±0.6 years, respectively. There is a significantly increased risk of malignancies after LT in the Taiwanese population.

Prophylactic liver transplantation for high-risk recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death in the world. Radical treatment of HCC in early stages results in a long disease-free period and improved overall survival. The choice of optimal management strategy for HCC mainly depends on the severity of the underlying liver disease. For patients with decompensated liver cirrhosis and HCC within Milan criteria (MC), liver transplant (LT) is the choice of treatment. However, for patients with good residual liver reserve and HCC within MC, selection of other curative treatments such as liver resection (LR) or radiofrequency ablation may be a reasonable alternative. For patients without cirrhosis, LR can result in an overall survival similar to that provided by LT. Therefore, it is an accepted alternative to LT especially in areas with organ shortage. However, the cumulative 5-year recurrence rate of HCC post LR might be as high as 70%. For initial transplant-eligible (within MC) patients with recurrent HCC post LR, salvage liver transplant (SLT) was first proposed in 2000. However, most patients with recurrent HCC considered for SLT are untransplantable cases due to HCC recurrence beyond MC or comorbidity. Thus, the strategy of opting for SLT results in the loss of the opportunity of LT for these patients. Some authors proposed the concept of "de principe liver transplant" (i.e., prophylactic LT before HCC recurrence) to prevent losing the chance of LT for these potential candidates. Factors associated with the failure of SLT will be dissected and discussed in three parts: Patient, tumor, and underlying liver disease. Regarding patient-related factors, the rate of transplantability depends on patient compliance. Patients without regular follow-up tend to develop HCC recurrence beyond MC at the time of tumor detection. Advancing age is another factor related to severe comorbidities when LT is considered for HCC recurrence, and these elderly candidates become ineligible as time goes by. Regarding tumor-related factors, histopathological features of the resected specimen are used mostly for determining the prognosis of early HCC recurrences. Such prognostic factors include the presence of microvascular invasion, poor tumor differentiation, the presence of microsatellites, the presence of multiple tumors, and the presence of the gene-expressing signature associated with aggressive HCC. These prognostic factors might be used as a selection tool for SLT or prophylactic LT, while remaining mindful of the fact that most of them are also prognostic factors for post-transplant HCC recurrence. Regarding underlying liver disease-related factors, progression of chronic viral hepatitis and high viral load may contribute to the development of late (de novo) HCC recurrence as a consequence of sustained inflammatory reaction. However, correlation between the severity of liver fibrosis and tumor recurrence is still controversial. Some prognostic scoring systems that integrate these three factors have been proposed to predict recurrence patterns after LR for HCC. Theoretically, after excluding patients with high risk of post-transplant HCC recurrence, either by observation of a cancer-free period or by measurement of biological factors (such as alpha fetoprotein), prophylactic LT following curative resection of HCC could be considered for selected patients with high risk of recurrence to provide longer survival.

Harnessing immunotherapy for liver recipients with hepatocellular carcinoma: a review from a transplant oncology perspective

Without stringent criteria, liver transplantation for hepatocellular carcinoma (HCC) can lead to high cancer recurrence and poor prognosis in the current treatment context. Checkpoint inhibitors can lead to long survival by targeting coinhibitory pathways and promoting T-cell activity; thus, they have great potential for cancer immunotherapy. Therapeutic modulation of cosignaling pathways may shift paradigms from surgical prevention of recurrence to oncological intervention. Herein, we review the available evidence from a therapeutic perspective and focus on immune microenvironment perturbation by immunosuppressants and checkpoint inhibitors. Partial and reversible interleukin-2 signaling blockade is the mainstream strategy of immunosuppression for graft protection. Programmed cell death protein 1 (PD-1) is abundantly expressed on human liver allograft-infiltrating T-cells, which proliferate considerably after programmed death-ligand 1 (PD-L1) blockade. Clinically, checkpoint inhibitors are used in heart, liver, and kidney recipients with various cancers. Rejection can occur after checkpoint inhibitor administration through acute T-cell-mediated, antibody-mediated, or chronic allograft rejection mechanisms. Nevertheless, liver recipients may demonstrate favorable responses to treatment for HCC recurrence without rejection. Pharmacodynamically, substantial degrees of receptor occupancy can be achieved with lower doses, with favorable clinical outcomes. Manipulation of the immune microenvironment is a therapeutic niche that balances seemingly conflicting anticancer and graft protection needs. Additional translational and clinical studies emphasizing the comparative effectiveness of signaling networks within the immune microenvironment and conducting overall assessment of the immune microenvironment may aid in creating a therapeutic window and benefiting future liver recipients with HCC recurrence.

First Case Genotype 4 Hepatitis E Infection After a Liver Transplant

Chronic hepatitis in immunosuppressed patients because of infection with hepatitis E virus is increasingly recognized, but there is a paucity of knowledge about hepatitis E virus infection in solid-organ transplant recipients. Herein, we reported the first confirmatory case of hepatitis E virus genotype 4 infection in a 47-year-old woman who underwent a liver transplant recipient in Taiwan. The patient presented with unexplained hepatitis and severe jaundice. Hepatitis E virus RNA was present in serum and identified as the genotype 4 by reverse transcription polymerase chain reaction. Pathological findings revealed that prominent zone 3 canalicular and hepatocellular cholestasis with a few acidophilic bodies and giant cell transformation, which was typical of hepatitis E virus hepatitis. Even undergoing ribavirin treatment, she had worse cholestasis and recurrent urinary tract infections. She died from encephalopathy and sepsis 6 months after the initial presentation. So far, compared with genotype 3 hepatitis E virus hepatitis, genotype 4 hepatitis E virus infection in solid-organ transplant recipients has been reported less frequently in the literature, and that warrants further accumulation of experiences.

Intestinal tuberculosis previously mistreated as Crohn's disease and complicated with perforation: a case report and literature review

INTRODUCTION

Tuberculosis is known as a notorious mimicker and distinguishing between intestinal tuberculosis and Crohn's disease is a huge diagnostic challenge.

CASE DESCRIPTION

Here, we report a case of hollow organ perforation due to intestinal tuberculosis that was previously mistreated as Crohn's disease. Staged operation with emergency resection of the diseased small bowel and temporary ileostomy was performed for the perforation, followed by 6-month standard treatment for miliary tuberculosis, which was diagnosed on the basis of the presence of acid-fast bacilli in the diseased bowel and positive culture of Mycobacterium tuberculosis from sputum, ascites, and stool samples. Ileostomy takedown was performed, and the continuity of the gastrointestinal tract was restored 6 months after the first surgery. The patient recovered well thereafter.

CONCLUSION

Timely surgical intervention can help establish the finial diagnosis of tuberculosis, rescue the patient from abdominal emergency, and provide a chance for cure.

Dynamic Prognostication in Transplant Candidates with Acute-on-Chronic Liver Failure

We aimed to extensively investigate clinical markers that are sufficiently dynamic for prognosis of acute-on-chronic liver failure (ACLF). Defined by the Asian Pacific Association for the Study of the Liver (APASL) criteria, patients with ACLF on the liver transplant waitlist in a tertiary center were retrospectively reviewed. Laboratory results and severity scores at three time points (days 1, 7, and 14 after admission) were analyzed. From 2015 to 2019, 64 patients with ACLF were enrolled, of which 24 received a liver transplant from 22 live donors. The hospital mortality rate was 31% (8% for transplant; 45% for nontransplant groups), and the 3-month survival was crucial for determining long-term outcomes. The number of significant variables for mortality, and, specifically, the hazards of international normalized ratio of prothrombin time (INR) and APASL ACLF Research Consortium (AARC) score were increased within two weeks. In multivariable analysis, INR and AARC score (D-14) were associated with poor survival and liver transplant was a protective factor in all patients, while AARC score (D-14) was significant in the nontransplant group. AARC score at day 14 is an independent risk factor for mortality in ACLF. Liver transplant from live donors reversed poor outcomes in patients with ACLF in a timely manner.

Experience of applying threshold concepts in medical education

BACKGROUND

Practical barriers exist in applying threshold-concept-based clinical teaching. We applied the practice model to the subject of acute liver failure and reported the experiences in teaching and learners' reactions.

METHODS

The course comprised a 10-min online preclass video and a 1-h class with in-depth discussion. The video explained six extracted threshold concepts, which were labelled TC1-TC6. Three sets of feedback questionnaires were given to students. Questionnaires were provided after they watched the online video (Q1), after class (Q2), and before the end of the curriculum section (Q3). All the feedback questionnaires were analysed.

RESULTS

Of the 136 attendees in the academic year 2018, 127 (93.4%), 69 (50.7%), and 112 (82.4%) completed the Q1, Q2, and Q3 questionnaires, respectively, and 48 (42.6%) provided comments. The degree of comprehension varied among threshold concepts and individual students. TC1 and TC2 were viewed as transformative for all three surveys. The threshold-concept-based learning process was satisfactory, and students could auto-reflect on the defining features of a threshold concept. Students became aware of their deficiencies in knowledge and acknowledged room for development with regard to their mindset for future patient management.

CONCLUSION

Threshold-concept-based clinical teaching is a feasible strategy. Students' reflections indicate that thresholds were crossed, which does not guarantee that students' mindsets are ready for future clinical practice.

Artificial Intelligence in Medical OSCEs: Reflections and Future Developments

With the advent of the age of Artificial Intelligence (AI), we seek to consider how AI could shape clinical examinations, specifically Objective Structured Clinical Examinations (OSCEs). OSCEs, whilst having its own limitations, could be further enhanced with new technologies like AI to help better assess and prepare our future clinicians. With the everchanging requirements on the modern clinician, we deliberate the strengths and weaknesses of AI, and the need for emphasis on different skills to complement rather than resist the tides of change. In conclusion, we feel that AI has the potential to be a strong driving force in remodelling OSCEs to support future doctors and could serve as a new frontier in medical education and beyond. That being said, we recognize the technology and its applications are still in its infancy, and further study will be needed to eluciate the role of AI in medical education and in the greater landscape of medical practice.

Efficient undergraduate learning of liver transplant: building a framework for teaching subspecialties to medical students

BACKGROUND

Liver recipients may develop various diseases after transplant. However, because of inadequate study of liver transplant during undergraduate education, the quality of post-transplant care provided to these patients remains suboptimal. Herein, we introduce an innovative and integrated multimodal pedagogical approach to effectively disseminate key information regarding liver transplant to undergraduate students. The goal is to examine this approach through students' assessment in multiple dimensions.

METHODS

This prospective observational study evaluated student reactions to our pedagogical approach. Fifth-year medical students during the academic year 2015-2016 attended a 2-h session on what nontransplant doctors should know about liver transplants. The pedagogical strategy consisted of an online preclass self-learning exercise, an in-class interactive discussion (facilitated by the class teacher who is a liver transplant specialist to avoid distractions within the short-time frame), and a postclass essay assignment (to integrate and apply concepts). After the class, questionnaires were distributed to individual students to collect data, if returned, concerning the students' learning experience and feedback to improve teaching quality. Descriptive statistics, Mann-Whitney U tests, chi-squared tests, and McNemar's tests were used to analyze quantitative data. Qualitative data were content-coded through a descriptive approach using thematic analysis.

RESULTS

Of the 266 attendees, 263 (98.9%) completed the questionnaires and 182 (69.2%) provided comments. Student feedback indicated they "felt better" and "more satisfied" compared with problem-based learning (PBL) (51.0 and 63.1%, respectively) or large-lecture class (92.0 and 88.6%, respectively) approaches. Regarding confidently managing liver transplant patients in future, 80 (30.4%) and 246 (93.5%) students expressed preclass and postclass confidence, respectively (p < 0.001). The bell curve of the postclass self-assessment score of learning shifted toward right and became steeper compared with that of the preclass score (p < 0.001), suggesting students acquired considerable knowledge. The course was typically perceived to be cost-effective, practical, tension-free, and student-friendly.

CONCLUSION

This pedagogical approach effectively propagated knowledge concerning liver transplant to medical students, who expressed considerable satisfaction with the approach.

Appendicitis-mimicking presentation in fishbone induced microperforation of the distal duodenum: A case report

BACKGROUND

Upper gastrointestinal fishbone microperforations are rare and not commonly reported in medical literature. Despite the increasing use of computer tomography (CT) imaging and the employment of the Alvardo criteria, misdiagnosis of acute appendicitis can still occur. We report the rare case of an elderly Chinese gentleman who had a fish-bone induced microperforation of the duodenum that closely mimicked the symptoms of acute appendicitis.

CASE SUMMARY

This 79-year-old man presented with migratory lower abdominal pain that localized at his periumbilical region and right lower quadrant. He had associated pyrexia, general malaise and was noted to have an elevated white cell count. CT investigations initially revealed a distended appendix which was resected laparoscopically but showed no obvious signs of gross inflammation. The patient then deteriorated clinically and had increased oxygen requirements immediately after the surgery. This prompted further investigations. A further review of his CT scan revealed a fine fishbone microperforation in the distal duodenum associated with retroperitoneal abscess formation and seepage extending into the right lower quadrant. He was then started on broad spectrum intravenous antibiotics and subsequently underwent a laparotomy 12 h later to manage the obscure aetiology and to drain the abscess. The post-operative course was uneventful and he was discharged 11 d later including a 2-d stay in the intensive care unit.

CONCLUSION

This case offers an insight into a potential mimic of acute appendicitis and the diagnostic difficulties experienced in such presentations.

Fatal acute-on-chronic liver failure in amiodarone-related steatohepatitis: a case report

BACKGROUND

Amiodarone is an antiarrhythmic drug that has been recognized to induce hepatotoxicity. We report a case of acute-on-chronic liver failure (ACLF) in a patient who was receiving amiodarone for more than 2 years. The patient developed cirrhosis and suppurative microabscesses of the liver and died of progressive liver failure.

CASE PRESENTATION

A 69-year-old woman with risk factors for nonalcoholic fatty liver disease (NAFLD) was treated with oral amiodarone at a daily dose of 400 mg for more than 2 years, until she developed epigastralgia and vomiting. Initial laboratory findings included leukocytosis and elevated liver enzymes. Images of abdominal computed tomography scan revealed diffusely increased hepatic attenuation density (in contrast to decreased density in NAFLD), hepatomegaly, periportal edema, and ascites. Liver biopsy targeting the hotspot identified through positron emission tomography confirmed the diagnosis of amiodarone-associated chronic steatohepatitis and superimposed microabscesses. The patient died of progressive ACLF despite intensive supportive care.

CONCLUSION

Accumulation of amiodarone can result in chronic liver disease and pose an additional risk of ACLF following infection.

Is the Rationale of Anatomical Liver Resection for Hepatocellular Carcinoma Universally Adoptable? A Hypothesis-Driven Review

Surgical resection is the first-line curative treatment modality for resectable hepatocellular carcinoma (HCC). Anatomical resection (AR), described as systematic removal of a liver segment confined by tumor-bearing portal tributaries, may improve survival by reducing the risk of tumor recurrence compared with non-AR. In this article, we propose the rationale for AR and its universal adoption by providing supporting evidence from the advanced understanding of a tumor microenvironment and accumulating clinical experiences of locoregional tumor ablation therapeutics. AR may be advantageous because it completely removes the en-bloc by interrupting tumor vascular supply and thus extirpates the spreading of tumor microthrombi, if they ever exist, within the supplying portal vein. However, HCC is a hypervascular tumor that can promote neoangiogenesis in the local tumor microenvironment, which in itself can break through the anatomical boundary within the liver and even retrieve nourishment from extrahepatic vessels, such as inferior phrenic or omental arteries. Additionally, increasing clinical evidence for locoregional tumor ablation therapies, such as radiofrequency ablation, predominantly performed as a non-anatomical approach, suggests comparable outcomes for surgical resection, particularly in small HCC and colorectal, hepatic metastases. Moreover, liver transplantation for HCC, which can be considered as AR of the whole liver followed by implantation of a new graft, is not universally free from post-transplant tumor recurrence. Overall, AR should not be considered the gold standard among all surgical resection methods. Surgical resection is fundamentally reliant on choosing the optimal margin width to achieve en-bloc tumor niche removal while balancing between oncological radicality and the preservation of postoperative liver function. The importance of this is to liberate surgical resilience in hepatocellular carcinoma. The overall success of HCC treatment is determined by the clearance of the theoretical niche. Developing biomolecular-guided navigation device/technologies may provide surgical guidance toward the total removal of microscopic tumor niche to achieve superior oncological outcomes.

Reappraisal of surgical decision-making in patients with splenic sclerosing angiomatoid nodular transformation: Case series and literature review

BACKGROUND

Many clinicians and surgeons are unfamiliar with the sclerosing angiomatoid nodular transformation (SANT), which is gaining recognition as a benign splenic tumor. We challenge that SANT is rare and whether surgical intervention could be avoided through critical imaging review.

AIM

To evaluate the incidence of SANT among splenic tumors and the decision-making process of SANT management.

METHODS

Twenty hospitalized patients who underwent splenectomy in 2018 and 2019 in a tertiary university hospital were retrospectively reviewed, and their data on imaging, diagnosis, surgical indications, and courses were recorded. All pathology results were confirmed by pathologist. Discriminative features differentiating SANT from other non-SANT splenic tumors were descriptively analyzed in this case series.

RESULTS

Fourteen out of 20 patients who underwent splenectomy had splenic tumors, including 3 SANTs (21% splenic tumors), 6 non-SANT benign lesions (43%), 2 metastatic tumors, and 3 lymphomas. Hypointensity on T2-weighted magnetic resonance imaging (MRI), spoke wheel enhancing pattern in contrasted computed tomography or MRI, and cold spot (low fluorodeoxyglucose uptake) in positron emission tomography (PET) scan helped establish the diagnosis of SANT. Lymphoma, presenting with a hot spot on the PET scan were differentiated from SANT. Surgical indications were reformatted for splenic tumors. Splenectomy need not be performed in patients with typical imaging features of SANT.

CONCLUSION

SANT is not a rare disease entity in clinical practice. Splenectomy should not be routinely indicated as the only management option for SANT with typical imaging features.

Comprehensive evaluation of liver resection procedures: surgical mind development through cognitive task analysis

BACKGROUND

Liver resection is a complex procedure for trainee surgeons. Cognitive task analysis (CTA) facilitates understanding and decomposing tasks that require a great proportion of mental activity from experts.

METHODS

Using CTA and video-based coaching to compare liver resection by open and laparoscopic approaches, we decomposed the task of liver resection into exposure (visual field building), adequate tension made at the working plane (which may change three-dimensionally during the resection process), and target processing (intervention strategy) that can bridge the gap from the basic surgical principle.

RESULTS

The key steps of highly-specialized techniques, including hanging maneuvers and looping of extra-hepatic hepatic veins, were shown on video by open and laparoscopic approaches.

CONCLUSIONS

Familiarization with laparoscopic anatomical orientation may help surgeons already skilled at open liver resection transit to perform laparoscopic liver resection smoothly. Facilities at hand (such as patient tolerability, advanced instruments, and trained teams of personnel) can influence surgical decision making. Application of the rationale and realizing the interplay between the surgical principles and the other paramedical factors may help surgeons in training to understand the mental abstractions of experienced surgeons, to choose the most appropriate surgical strategy effectively at will, and to minimize the gap.

Preclinical Application of Reduced Manipulated Processing Strategy to Collect Transplantable Hepatocytes: A Pilot and Feasibility Study

BACKGROUND

The complex isolation and purification process of hepatocytes for transplantation is labor intensive and with great contamination risk. Here, as a pilot and feasibility study, we examined in vitro and in vivo hepatocyte isolation feasibility and cell function of Cell Saver® Elite®, an intraoperative blood-cell-recovery system.

METHODS

Rat and pig liver cells were collected using this system and then cultured in vitro, and their hepatocyte-specific enzymes were characterized. We then transplanted the hepatocytes in an established acute liver-injured (retrorsine+D-galactosamine-treated) rat model for engraftment. Recipient rats were sacrificed 1, 2, and 4 weeks after transplantation, followed by donor-cell identification and histological, serologic, and immunohistopathological examination. To demonstrate this Cell Saver® strategy is workable in the first place, traditional (classical) strategy, in our study, behaved as certainty during the cell manufacturing process for monitoring quality assurance throughout the course, from the start of cell isolation to post-transplantation.

RESULTS

We noted that in situ collagenase perfusion was followed by filtration, centrifugation, and collection in the Cell Saver® until the process ended. Most (>85%) isolated cells were hepatocytes (>80% viability) freshly demonstrating hepatocyte nuclear factor 4α and carbamoyl-phosphate synthase 1 (a key enzyme in the urea cycle), and proliferating through intercellular contact in culture, with expression of albumin and CYP3A4. After hepatocyte transplantation in dipeptidyl peptidase IV (-/-) rat liver, wild-type donor hepatocytes engrafted and repopulated progressively in 4 weeks with liver functional improvement. Proliferating donor hepatocyte-native biliary ductular cell interaction was identified. Post-transplantation global liver functional recovery after Cell Saver and traditional methods was comparable.

CONCLUSIONS

Cell Saver® requires reduced manual manipulation for isolating transplantable hepatocytes.

Cross-Match as an Immuno-Oncological Risk Factor for Hepatocellular Carcinoma Recurrence and Inferior Survival After Living Donor Liver Transplantation: A Call for Further Investigation

BACKGROUND

The success of immunotherapy for patients with hepatocellular carcinoma (HCC) suggests that immune dysregulation occurs in HCC patients. This warrants an immuno-oncological risk assessment in the platform of liver transplantation.

METHODS

This retrospective single-center study analyzed risk factors for-particularly cross-matching performed through conventional complement-dependent cytotoxicity cross-match tests-and the outcomes of HCC recurrence following living donor liver transplant.

RESULTS

A total of 71 patients were included. The median follow-up period was 29.1 months; 17 (23.9%) patients had posttransplant HCC recurrence, and their 1-, 3-, and 5-year-survival rates were 70.6%, 25.7%, and 17.1%, respectively, which were inferior to those of patients without HCC recurrence (87.0%, 80.7%, and 77.2%, respectively; P < .001). In addition to microvascular invasion, positive cross-match results for B cells at 37°C (B- 37°C) or T cells at 4°C (T- 4°C) were associated with inferior overall survival in multivariable analysis after adjustment for tumor status beyond Milan criteria and elevated alpha-fetoprotein levels. Rejection alone cannot be the mechanism underlying the effects of positive cross-match results on patient outcomes. Adjusted survival curves suggested that positive cross-match B- 37°C or T- 4°C was associated with inferior recurrence-free and patient survival, but the robustness of the finding was limited by insufficient power.

CONCLUSIONS

Additional large-scale studies are required to validate positive cross-match as an immuno-oncological factor associated with HCC recurrence and inferior patient survival.

Pneumatosis cystoides intestinalis: Not uncommon cause of free air in acute abdomen

Pneumatosis cystoides intestinalis is generally benign in course and sometimes, if cysts ruptured, behave as the not uncommon cause of free air in acute abdomen. In our case, we illustrate ruptured isolated cysts of pneumatosis cystoides intestinalis are responsible for pneumoperitoneum in a 94-year-old male patient. Laparotomy with gastrotomy for decompression of intraluminal aeropressure was performed, with an uneventful recovery. This paper presents with preoperative and intraoperative images of high educational value for this, often underdiagnosed, clinical entity.

Viral Status and Treatment Efficacy in Recurrent Hepatocellular Carcinoma After Primary Resection

BACKGROUND

The impact of viral background on long-term effectiveness of different treatment modalities for recurrent hepatocellular carcinoma (HCC) was not fully analyzed.

METHOD

Consecutive 726 patients who developed intrahepatic recurrence after primary hepatectomy for HCC between 2008 and 2015 were retrospectively studied. Post-recurrence survival (PRS) and rerecurrence-free survival (R-RFS) and risk factors were analyzed.

RESULTS

After a median follow-up period of 56 months, the 5-year PRS rates of the patients who underwent rehepatectomy, radiofrequency ablation (RFA), and transarterial chemoembolization (TACE) were 79.4%, 83.0%, and 54.6%, respectively. The treatment benefit for PRS was consistently observed in patients with hepatitis B virus (HBV) and non-B, non-C subgroups, but not hepatitis C virus (HCV). For patients with late recurrence of HCC, R-RFS was superior in HBV subgroup and HCV subgroup which received antiviral treatment (compared to naïve HCV subgroup). Survival difference triaged by viral status was lost in the counterpart with early recurrence. Overall, RFA improved PRS and R-RFS in patients receiving antiviral treatment.

CONCLUSION

To achieve long-term survival after HCC recurrence, rehepatectomy and RFA were comparably effective, particularly among those with HBV. Antiviral treatment complemented survivals of patients with HCV after RFA, particularly in late first recurrence.

Circuitous Path to Live Donor Liver Transplantation from the Coordinator's Perspective

Background: The live donor liver transplantation (LDLT) process is circuitous and requires a considerable amount of coordination and matching in multiple aspects that the literature does not completely address. From the coordinators' perspective, we systematically analyzed the time and risk factors associated with interruptions in the LDLT process. Methods: In this retrospective single center study, we reviewed the medical records of wait-listed hospitalized patients and potential live donors who arrived for evaluation. We analyzed several characteristics of transplant candidates, including landmark time points of accompanied live donation evaluation processes, time of eventual LDLT, and root causes of not implementing LDLT. Results: From January 2014 to January 2021, 417 patients (342 adults and 75 pediatric patients) were enrolled, of which 331 (79.4%) patients completed the live donor evaluation process, and 205 (49.2%) received LDLT. The median time from being wait-listed to the appearance of a potential live donor was 19.0 (interquartile range 4.0-58.0) days, and the median time from the appearance of the donor to an LDLT or a deceased donor liver transplantation was 68.0 (28.0-188.0) days. The 1-year mortality rate for patients on the waiting list was 34.3%. Presence of hepatitis B virus, encephalopathy, and hypertension as well as increased total bilirubin were risk factors associated with not implementing LDLT, and biliary atresia was a positive predictor. The primary barriers to LDLT were a patient's critical illness, donor's physical conditions, motivation for live donation, and stable condition while on the waiting list. Conclusions: Transplant candidates with potential live liver donors do not necessarily receive LDLT. The process requires time, and the most common reason for LDLT failure was critical diseases. Aggressive medical support and tailored management policies for these transplantable patients might help reduce their loss during the process.