Sarcomatoid change in combined hepatocellular carcinoma and cholangiocarcinoma as a poor prognostic factor

Background

Sarcomatoid change is rarely seen in epithelial malignancy that can be observed in diverse organs. Although a sarcomatoid change in combined hepatocellular-cholangiocarcinoma (cHCC-CC) is assumed to be a poor prognostic factor, this issue has not been studied due to its rare incidence. In this study, we aimed to identify the oncological impact of sarcomatoid change in patients with cHCC-CC and verify that sarcomatoid change is a poor prognostic factor for resected cHCC-CC.

Methods

Between January 2006 and December 2020, 102 patients who underwent surgical resection for cHCC-CC were retrospectively reviewed. The hazard ratio (HR) according to sarcomatoid change was calculated using other known prognostic factors for cHCC-CC. In addition, the patients were divided into two groups according to the sarcomatoid change, and their survival was compared.

Results

The multivariate analysis demonstrated that sarcomatoid change in cHCC-CC is a poor prognostic factor {disease-free survival (DFS), HR =3.84 [95% confidence interval (CI): 1.63-9.10], P=0.002; overall survival (OS), HR =3.94 (95% CI: 1.67-9.31), P=0.002}. In the survival analysis, the sarcomatoid change group displayed a worse prognosis compared to the non-sarcomatoid change group {DFS: 4.0 [interquartile range (IQR): 1.2-6.8] vs. 23.0 (IQR: 9.3-36.7) months, P=0.001; OS: 19.0 (IQR: 7.2-30.8) vs. 85.0 (IQR: 31.8-138.2) months, P=0.004}.

Conclusions

Sarcomatoid change is a poor prognostic factor for resected cHCC-CC.

Predicting lymph node metastasis using preoperative parameters in patients with T1 ampulla of vater cancer

BACKGROUND

Lymph node (LN) metastasis is an established prognostic factor for patients with surgically resected ampulla of Vater (AoV) cancer. The standard procedure for radical resection, including removal of regional LNs, is pancreaticoduodenectomy (PD); however, local excision has been considered as an alternative option for patients in the early stage cancer with significant comorbidities. In the present study, we elucidated the preoperative factors associated with LN metastasis to determine the appropriate surgical extent for T1 AoV cancer.

METHODS

We included patients who underwent surgery for T1 AoV cancer at Samsung Medical Center and Severance Hospital between 2000 and 2019. Risk factors were analyzed to identify the preoperative parameters associated with LN metastasis or regional LN recurrence during follow-up. Finally, using the identified risk factors, a prediction model was constructed.

RESULTS

Among 342 patients, 311 patients underwent PD, whereas 31 patients underwent transduodenal ampullectomy. Fourty-eight patients had LN metastasis according to pathology report, and two patients presented with regional LN recurrence. Age, carbohydrate antigen 19 - 9 (CA 19 - 9), and tumor differentiation were identified as factors associated with the increased risk of LN metastasis or regional LN recurrence. The area under the curve of the prediction model with these three factors was 0.728.

CONCLUSION

Our newly developed prediction model using age, CA 19 - 9, and tumor differentiation can help select patients who require PD over local excision. Nevertheless, additional in-depth analysis is warranted to select appropriate surgical extent for patients with presumed T1 AoV cancer.

Surgical strategy for incidental intrahepatic cholangiocarcinoma in terms of lymph node dissection

BACKGROUND

Although many guidelines recommend performing lymph node dissection (LND) during surgery for intrahepatic cholangiocarcinoma (ICC), there is no evidence for patients with incidentally detected ICC who did not undergo LND. This study aimed to identify the role of LND in patients with incidental ICC.

METHODS

The data from 284 patients who had undergone radical surgery for ICC from 2000 to 2020 were retrospectively reviewed. The enrolled patients were divided into 3 groups according to their T stage (T1 vs T2 vs T3 + 4). Moreover, the patients of each T group were divided into 3 groups according to their nodal status (N0 vs N1 vs Nx) and their survival outcomes were compared.

RESULTS

Survival outcomes of Nx group were statistically similar to that of N0 group in T1 stage (Nx vs N0: disease-free survival [DFS] [months], 129.0 [75.6-182.4] vs 125.0 [65.7-184.3], P = .948; overall survival [OS] [months], 175.0 [153.9-196.1] vs 173.0 [109.0-237.0], P = .443). In contrast, survival outcomes of Nx group in the other T stage (T2 and T3 + 4) were poorer than that of N0 group and were better than that of N1 group. In addition, in the Nx subgroup analysis according to T stage, T1 group showed significantly better survival outcomes than the other groups (T1 vs T2 vs T3 + 4: DFS [months], 129.0 [75.9-182.1] vs 16.0 [9.8-22.2] vs 13.0 [0.3-25.7], P < .001; OS [months], 175.0 [153.9-196.1] vs 53.0 [30.8-75.2] vs 37.0 [17.6-56.4], P < .001).

CONCLUSION

Patients with ICC incidentally diagnosed as having T2 or above T stage may consider additional LND.

Preoperative Prediction of Microvascular Invasion with Gadoxetic Acid-Enhanced Magnetic Resonance Imaging in Patients with Single Hepatocellular Carcinoma: The Implication of Surgical Decision on the Extent of Liver Resection

Introduction

Microvascular invasion (MVI) is one of the most important prognostic factors for hepatocellular carcinoma (HCC) recurrence, but its application in preoperative clinical decisions is limited. This study aimed to identify preoperative predictive factors for MVI in HCC and further evaluate oncologic outcomes of different types and extents of hepatectomy according to stratified risk of MVI.

Methods

Patients with surgically resected single HCC (≤5 cm) who underwent preoperative gadoxetic acid-enhanced magnetic resonance imaging (MRI) were included in a single-center retrospective study. Two radiologists reviewed the images with no clinical, pathological, or prognostic information. Significant predictive factors for MVI were identified using logistic regression analysis against pathologic MVI and used to stratify patients. In the subgroup analysis, long-term outcomes of the stratified patients were analyzed using the Kaplan-Meier method with log-rank test and compared between anatomical and nonanatomical or major and minor resection.

Results

A total of 408 patients, 318 men and 90 women, with a mean age of 56.7 years were included. Elevated levels of tumor markers (alpha-fetoprotein [α-FP] ≥25 ng/mL and PIVKA-II ≥40 mAU/mL) and three MRI features (tumor size ≥3 cm, non-smooth tumor margin, and arterial peritumoral enhancement) were independent predictive factors for MVI. As the MVI risk increased from low (no predictive factor) and intermediate (1-2 factors) to high-risk (3-4 factors), recurrence-free and overall survival of each group significantly decreased (p = 0.001). In the high MVI risk group, 5-year cumulative recurrence rate was significantly lower in patients who underwent major compared to minor hepatectomy (26.6 vs. 59.8%, p = 0.027).

Conclusion

Tumor markers and MRI features can predict the risk of MVI and prognosis after hepatectomy. Patients with high MVI risk had the worst prognosis among the three groups, and major hepatectomy improved long-term outcomes in these high-risk patients.

Association of gustatory dysfunction and Alzheimer

BACKGROUND

Chemosensory dysfunction has been reported to be involved in the pathogenesis of Alzheimer’s disease (AD). Compared with olfaction, gustatory dysfunction in AD has not been evaluated in depth. We reviewed previously published studies regarding gustatory dysfunction in patients with AD compared with healthy controls.

METHODS

A systematic review was conducted by searching the MEDLINE, Cochrane Library, Embase, and PubMed databases covering publications from January 2000 to February 2023. The search was performed using the keyword "Alzheimer* AND (gustatory OR taste OR gustation)." Only studies that performed gustatory function testing and compared the results between patients with AD and healthy controls were included. A random-effects meta-analysis was performed.

RESULTS

Twelve articles were finally included, and various gustatory tests including taste strips, the taste disk test, taste solutions, and subjective questionnaires were applied. Overall gustatory function based on the taste strip test was significantly decreased in patients with AD compared with controls in two out of three papers. The overall gustatory function of patients with AD was significantly decreased in all studies based on the taste disk and taste solution tests. We also found that the sweet taste test showed low heterogeneity across all the included studies, and there was low publication bias. In studies using subjective questionnaires, gustatory function was not significantly different between patients with AD and healthy controls in the meta-analysis.

CONCLUSIONS

Based on these studies, gustatory dysfunction diagnosed by gustatory function testing was closely related to AD. However, the results of subjective questionnaires were not significantly different between patients with AD and healthy controls in the current meta-analysis. As the number of studies and enrolled subjects was limited and unified gustatory function testing was lacking, further studies are needed to confirm this relationship.

The prognostic value of the number of metastatic lymph nodes on the long-term survival of intrahepatic cholangiocarcinoma using the SEER database

Background

In the 8th edition of the American Joint Committee on Cancer, the nodal staging of intrahepatic cholangiocarcinoma (ICC) is classified as N0 and N1 in accordance with lymph node (LN) metastases. Recently, several studies have reported that the number of metastatic LNs is associated with prognosis in patients with ICC. However, the majority of these studies were published in Eastern countries, and there are few available data for Western countries. This study aimed to investigate the association between metastatic LN number and prognosis in ICC patients using the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Data from 658 ICC patients in the SEER database who underwent hepatectomy with LN dissection from 2000 to 2018 were retrospectively reviewed. Hazard ratios (HRs) according to increasing numbers of metastatic LN were calculated. The patients were then divided into three groups according to their metastatic LN numbers (N0: no metastatic LNs; N+ <4: 1-3 metastatic LNs; N+ ≥4: ≥4 metastatic LNs), and cause-specific survival (CSS) was compared.

Results

Metastatic LN number was a prognostic factor of oncologic survival [CSS: HR =1.300; 95% confidence interval (CI): 1.225-1.379; P<0.001]. In survival analysis, an increasing number of metastatic LNs was significantly correlated with poorer oncologic outcomes [CSS: N0 vs. N+ <4 vs. N+ ≥4: 40.856 (95% CI: 38.806-42.919) vs. 22.000 (95% CI: 18.283-25.717) vs. 15.000 (95% CI: 11.520-18.480) months, P<0.001]. In post hoc analysis, a significant difference was found between adjacent groups (N0 vs. N+ <4, P<0.001; N+ <4 vs. N+ ≥4, P=0.004).

Conclusions

Patients with ICC in the SEER database were reaffirmed to have worse prognosis with an increasing number of metastatic LNs.

Preoperative Fistula Risk Prediction Using Computed Tomography Image Before Pancreatoduodenectomy

BACKGROUND

Although many formulas for predicting postoperative pancreatic fistula (POPF) have been introduced, POPF is generally predicted during pancreatic surgery due to pancreatic texture. This study was designed to verify the correlation between Hounsfield units (HU) and pancreatic texture and to suggest a fistula risk score (FRS) that can be used before surgery.

METHODS

Data from 545 patients who underwent pancreatoduodenectomy for malignant disease between January 2008 and December 2019 were retrospectively reviewed. The HU level of the pancreas was measured, and odds ratio (OR) of the HU for POPF was analyzed. Additionally, the assessed HU was compared with the pancreatic texture (soft vs. hard) and calculated cutoff level. Finally, the preoperatively chosen pancreatic texture according to HU level was applied to the FRS formula (preoperative-FRS: p-FRS), and the results were compared with a previously reported FRS formula (updated alternative-FRS: ua-FRS).

RESULTS

The Hounsfield unit levels were correlated with clinically relevant POPF (CR-POPF) (odds ratio [OR]: 1.04 (1.01-1.07), p = 0.015). In the receiver operating characteristic curve, the HU showed significant prediction potential for pancreatic texture (area under the curve [AUC]: 0.744, p < 0.001). The p-FRS also showed acceptable results in predicting CR-POPF (AUC = 0.702, p < 0.001). There was no statistically significant difference in the DeLong's test compared with the ua-FRS (p = 0.314). In the Hosmer-Lemeshow test, observed probabilities were correlated with predicted probabilities (p = 0.596).

CONCLUSIONS

The HU level on preoperative computed tomography (CT) is a predictive factor for POPF and could represent for pancreatic texture.

Associations among the workplace violence, burnout, depressive symptoms, suicidality, and turnover intention in training physicians: a network analysis of nationwide survey

Depression and anxiety are the most common mental disorders among physicians, who have a greater risk of suicide than those in other professional occupations. Relationships among a demanding workload, workplace violence, burnout, and intention to turnover have also been reported. The current study examined the principal components and propagating patterns of mental health and working environment interactions in training physicians. A total of 1981 training physicians completed online self-report questionnaires during September-October (midpoint of the training year) 2020. Regularized partial correlations in a mixed graphical model (MGM) and joint probability distributions (directed acyclic graph; DAG) were estimated for four subtypes of workplace violence (verbal abuse/physical violence perpetrated by clients/hospital staff), three burnout subdomains (Maslach Burnout Inventory), thoughts about quitting, and nine depressive symptoms, including suicidality, comprising the DSM-5 diagnostic criteria for major depressive disorder (assessed using the Patient Health Questionnaire-9). Thoughts of death/self-harm showed directional dependencies on the joint probability distributions of psychomotor agitation/retardation, concentration difficulty, self-reproach, and sadness in the DAG. In the MGM, a partial correlation with psychomotor agitation/retardation (r = 0.196) accounted for 56.5% of the variance in thoughts of death/self-harm. Partial correlations with concentration difficulties (r = 0.294), self-reproach (r = 0.257), changes in appetite (r = 0.184), and worker-on-worker physical violence (r = 0.240) in the MGM accounted for 54.4% of the variance in psychomotor agitation/retardation. Thoughts about quitting were partially correlated with and dependent upon the joint probability distributions of emotional exhaustion (r = 0.222), fatigue (r = 0.142), anhedonia (r = 0.178), and sadness (r = 0.237). In contrast, worker-on-worker (r = 0.417) and client-on-physician (r = 0.167) verbal abuse had regularized partial correlations with directional dependencies on thoughts about quitting. Organization-level interventions aiming to reduce the worker-on-worker violence and individual-level approaches of clinical screening program and psychiatric counseling clinic are required. Follow-up studies to verify the effectiveness of these interventions for training physicians are needed.

Treatment Outcomes of Stereotactic Body Radiation Therapy for Pulmonary Metastasis from Sarcoma: A Multicenter, Retrospective Study

PURPOSE/OBJECTIVE(S)

The aim of this study was to evaluate the treatment outcomes and potential dose-response relationship of stereotactic body radiation therapy (SBRT) for pulmonary metastasis of sarcoma.

MATERIALS/METHODS

A retrospective review of 39 patients and 71 lesions treated with SBRT from two institutions was performed. The patients had oligometastatic or oligoprogressive disease, or were receiving palliation. Doses of 20-60 Gy were delivered in 1-5 fractions. The local control per tumor (LCpT) was evaluated according to the biologically effective dose with an α/β ratio of 10 (BED10) of the prescribed dose (BED10 ≥ 100 Gy vs. BED10 < 100 Gy). Clinical outcomes per patient, including local control per patient (LCpP), pulmonary progression-free rate (PPFR), any progression-free rate (APFR), and overall survival (OS) were investigated.

RESULTS

The median follow-up period was 27.2 months. The 1-, 2-, and 3-year LCpT rates for the entire cohort were 100.0%, 88.3%, and 73.6%, respectively. There was no observed difference in LCpT between the two BED10 groups (p = 0.180). The 3-year LCpP, PPFR, APFR, and OS rates were 78.1%, 22.7%, 12.9%, and 83.7%, respectively. Five (12.8%) patients with oligometastasis had long-term disease-free intervals, with a median survival period of 40.7 months. Factors that were associated with a worse prognosis were oligoprogression (vs. oligometastasis), multiple pulmonary metastases, and simultaneous extrathoracic metastasis.

CONCLUSION

SBRT for pulmonary metastasis of sarcoma is effective. Some selected patients may achieve durable response. Considerations of SBRT indication and disease extent may be needed as they may influence the prognosis.

Efficacy and Safety of Image-Guided Hypofractionated Radiotherapy for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

PURPOSE/OBJECTIVE(S)

To evaluate the efficacy and safety of image-guided 10-fraction hypofractionated radiotherapy (RT) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT).

MATERIALS/METHODS

Between 2016 and March 2022, 69 HCC with PVTT patients received RT (40-50Gy/10fx) in our institutions. The median prescribed dose of 50 Gy (range, 40-50 Gy, BED10; 56-75 Gy10) was delivered in 10 fractions in all patients. Follow-up imaging was performed at three-month intervals after the completion of RT. The extent of PVTT was described according to the Liver Cancer Study Group of Japan classification: Vp0 = no PVTT, Vp1 = segmental portal vein branch, Vp2 = right/left anterior/posterior portal vein, Vp3 = right/left portal vein and Vp4 = main portal vein. Response evaluation was performed using response evaluation criteria in solid tumors, version 1.1. Freedom from local progression (FFLP), progression-free survival (PFS), and overall survival (OS) were calculated from the start date of RT.

RESULTS

In this cohort, 4.3% of patients had Vp1 PVTT, 20.3% had Vp2, 37.7% had Vp3, and 37.7% had Vp4. The median PTV volume was 105.3 cc (interquartile range [IQR], 74.1-179.4 cc). Fifty-two (75.4%) patients received 50 Gy in 10 fractions. With a median follow-up of 10.2 months (IQR, 6-21 months), the median OS was 18.5 months, and 1-year FFLP, PFS, and OS rates were 84.8%, 26.9%, and 62.2% respectively. At 3 months after RT, 13.0% had a complete response, 36.2% had a partial response, 46.4% had a stable disease and 4.4% had a progressive disease. In the multivariate analysis, AFP ≥ 600 IU/ml (HR 2.06, p = 0.03), Child-Pugh Class B or C (HR 2.30, p = 0.02), and modified Union for International Cancer Control (mUICC) stage IVA or IVB (4.05, p = 0.02) were significantly related to OS. During the follow-up period, there were 2 (2.8%) cases of grade ≥3 toxicity: grade 3 AST/ALT elevation (n = 1), and acute cholangitis (n = 1).

CONCLUSION

Hypofractionated RT demonstrated promising local PVTT control with acceptable toxicity. These data suggest that 10-fraction image-guided hypofractionated RT (BED10 = 56-75 Gy10) is a feasible treatment option for PVTT in HCC patients.

Validation of quantitative prognostic prediction using ADV score for resection of hepatocellular carcinoma: A Korea-Japan collaborative study with 9200 patients

BACKGROUND

A score derived from the concentrations of α-fetoprotein (AFP) and des-γ-carboxy prothrombin (DCP) and tumor volume (TV), called ADV score, has been shown to be prognostic of hepatocellular carcinoma (HCC) recurrence following hepatic resection (HR) or liver transplantation.

METHODS

This multicenter, multinational validation study included 9200 patients who underwent HR from 2010 to 2017 at 10 Korean and 73 Japanese centers, and were followed up until 2020.

RESULTS

AFP, DCP, and TV showed weak correlations (ρ ≤ .463, r ≤ .189, p < .001). Disease-free survival (DFS), overall survival (OS), and post-recurrence survival rates were dependent on 1.0 log and 2.0 log intervals of ADV scores (p < .001). Receiver operating characteristic (ROC) curve analysis showed that ADV score cutoffs of 5.0 log for DFS and OS yielded the areas under the curve ≥ .577, with both being significantly prognostic of tumor recurrence and patient mortality at 3 years. ADV score cutoffs of ADV 4.0 log and 8.0 log, derived through K-adaptive partitioning method, showed higher prognostic contrasts in DFS and OS. ROC curve analysis showed that an ADV score cutoff of 4.2 log was suggestive of microvascular invasion, with both microvascular invasion and an ADV score cutoff of 4.2 log showing similar DFS rates.

CONCLUSIONS

This international validation study demonstrated that ADV score is an integrated surrogate biomarker for post-resection prognosis of HCC. Prognostic prediction using ADV score can provide reliable information that can assist in planning treatment of patients with different stages of HCC and guide individualized post-resection follow-up based on the relative risk of HCC recurrence.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study

Background

SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods.

Methods

We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018.

Results

A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®.

Conclusions

SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Gorlin-Goltz Syndrome: A Case Report and Literature Review with PTCH1 Gene Sequencing

Gorlin-Goltz syndrome, also known as nevoid basal cell carcinoma syndrome, is an autosomal dominant disease characterized by multisystemic developmental defects caused by pathogenic variants such as patched-1 ( PTCH1 ) gene variants and/or SUFU gene variants. The presence of either two main criteria or one major and two minor criteria are required for the diagnosis of Gorlin-Goltz syndrome. Recently, a major criterion for molecular confirmation has also been proposed. In this article, we report the case of an 80-year-old male who was admitted at our department for multiple brown-to-black papules and plaques on the entire body. He was diagnosed with Gorlin-Goltz syndrome with clinical, radiologic, and pathologic findings. While the diagnosis was made based on the clinical findings in general, confirmation of the genetic variants makes an ideal diagnosis and suggests a new treatment method for target therapy. We requested a genetic test of PTCH1 to ideally identify the molecular confirmation in the hedgehog signaling pathway. However, no pathogenic variants were found in the coding region of PTCH1, and no molecular confirmation was achieved.

Effect of local treatment in patients with oligo-recurrence after surgery of distal bile duct cancer: A bi-institutional study

BACKGROUND

Distal extrahepatic bile duct (EHBD) cancer is highly recurrent. More than 50% of patients suffer from disease relapse after curative resection. Some patients present with oligo-recurrence which could be a single loco-regional mass or lesions limited to a single solid organ. The aim of this study was to examine the effect of local control (surgical resection or radiofrequency ablation) on survival outcomes in patients with oligo-recurrent distal EHBD cancer.

METHODS

Data of 1219 patients who underwent surgery for distal EHBD cancer from 2000 to 2018 were retrospectively reviewed. Clinicopathological characteristics and survival outcomes of patients with recurrence were investigated. Post-recurrence survival (PRS) was analyzed according to modalities of re-treatment (local treatment or systemic therapy alone).

RESULTS

Among 654 patients with recurrence, 90 patients who had oligo-recurrence showed better recurrence-free and overall survival than patients with non-oligo-recurrent disease. Lymph node ratio and perineural invasion at initial pathology, timing of recurrence, and platelet-to-lymphocyte ratio at recurrence were independent risk factors for PRS in the oligo-recurrent group. Patients with local treatment for oligo-recurrence had better 3- and 5-year PRS than those with systemic treatment alone (38.3% vs. 14.1%, p = 0.04; 28.3% vs. 7.1%, p = 0.04, respectively). Recurrence within 24 months after initial surgery was the only significant factor for PRS in the local treatment group.

CONCLUSION

In patients with oligo-recurrence after resection of distal EHBD cancer, post-recurrence local treatment could improve survival outcomes, particularly for those with recurrence more than 2 years after initial resection.

Left-sided Hepatectomy Leads to Less Postoperative Liver Failure and Comparable Overall Survival to Right-sided Hepatectomy in Type II or IV Perihilar Cholangiocarcinoma

INTRODUCTION

Right-side hepatectomy (RH) is used in oncological resection for perihilar cholangiocarcinoma (PHC); however, the decision between performing left-side hepatectomy (LH) or RH is still controversial. We compared surgical and oncologic outcomes of LH and RH in PHC type II or IV where either hepatectomy was expected to have a negative margin.

METHODS

From 2001 to 2020, 99 patients underwent major liver resection for type II or IV PHC. Patients with unilateral vascular invasion, unilateral tumor growth, and atrophy of unilateral liver were excluded. Preoperative characteristics, perioperative, and long-term outcomes were compared between the remaining RH and LH patients.

RESULTS

After excluding 47 cases with side predominance, the RH group (n = 29) and LH group (n = 23) were compared. Clinical characteristics and disease severity did not differ between the groups. Portal vein embolization (RH: 48.3% vs. LH: 0.0%, p < 0.001) and days from diagnosis to operation (RH: 31.0 ± 16.2 vs. LH: 18.8 ± 13.4, p = 0.006) were significantly higher in the RH group. The RH group had statistically higher rate of postoperative hepatic failure (RH: 55.2% vs. LH: 21.7%, p = 0.015) and a higher mortality rate that was not significant (RH: 13.8% vs. LH: 0%, p = 0.120). The R0 resection rate (RH: 72.4% vs. LH: 78.3%, p = 0.629), median disease-free (p = 0.620), and overall (p = 0.487) survival did not differ between groups. R1 resection and lymph node metastasis were significant risk factors for disease-free survival in multivariate analysis.

CONCLUSIONS

In type II or type IV PHC where either LH or RH was feasible, LH provided a shorter period of preoperative preparation, lower postoperative hepatic failure rate, similar R0 rate, and comparable long-term outcomes. LH should be considered a reasonable option in type II or IV PHC.

Risk factors for prolonged hospitalization and delayed treatment completion after laparoscopic appendectomy in patients with uncomplicated acute appendicitis

PURPOSE

We sought to identify the risk factors for prolonged hospitalization and delayed treatment completion after laparoscopic appendectomy in patients with uncomplicated acute appendicitis.

METHODS

The study retrospectively analyzed 497 patients who underwent laparoscopic appendectomies for uncomplicated appendicitis between January 2018 and December 2020. The patients were divided into an early discharge group (≤2 days) and a late discharge group (>2 days) based on the length of hospital stay (LOS). The patients were also divided into uneventful and complicated groups according to the need for additional treatment after standard follow-up.

RESULTS

Thirty-seven patients (7.4%) were included in the late discharge group. The mean LOS of the late discharge groups was 3.9 days. There were significant differences according to age, preoperative C-reactive protein (CRP), and operative time between the 2 groups. Only operative time was significantly associated with prolonged LOS in multivariate analysis. Thirty-five patients (7.0%) were included in the complicated group. The mean duration of treatment in the uneventful and complicated groups was 7.4 and 25.3 days, respectively. Significant differences existed between the uneventful and complicated groups in preoperative body temperature, preoperative CRP levels, maximal appendix diameter, and the presence of appendicoliths. In multivariate analysis, preoperative CRP levels and maximal appendix diameter were independent predictors of delayed treatment completion.

CONCLUSION

Shorter operative time is desirable to ensure minimal hospital stay in patients with uncomplicated appendicitis. Further efforts are needed to ensure that patients with uncomplicated appendicitis do not experience delayed treatment completion after laparoscopic appendectomies.

Effectiveness of Acupuncture, Mind and Body Practices, and Natural Products for Insomnia: an overview of systematic reviews

Objectives

This overview summarizes the evidence for the effectiveness and safety of complementary therapies for insomnia through systematic reviews (SRs) and meta-analyses (MAs).

Methods

A comprehensive literature search on SRs and MAs for complementary therapies for insomnia was conducted using six databases.

Results

This overview included 30 SRs/MAs. The Pittsburgh Sleep Quality Index (PSQI) analysis of insomnia included 383 randomized controlled trials and 31,748 participants. Twenty-four SRs/MAs (80%) out of 30 SRs/MAs reported a positive result, and six SRs/MAs reported a partially positive result. The most frequently used form of acupuncture reported a positive effect in 89.5% (17/19) of SRs/MAs and a superior effect to western medicine, sham/placebo, and no treatment. The lack of protocol registration and the excluded studies list resulted in generally poor methodological and reporting quality in SRs/MAs with AMSTAR 2.

Conclusion

This overview confirmed that complementary therapies positively affected the PSQI scores in patients with insomnia. However, better-designed primary studies are needed to strengthen the relevant evidence in the future. A more stringent assessment of multiple systematic reviews 2 must be followed when performing SR and MA.

Extracellular Citrate Treatment Induces HIF1α Degradation and Inhibits the Growth of Low-Glycolytic Hepatocellular Carcinoma under Hypoxia

HCC is well known for low glycolysis in the tumors, whereas hypoxia induces glycolytic phenotype and tumor progression. This study was conducted to evaluate the expression of SLCs in human HCCs and investigated whether extracellular nutrient administration related to SLCs in low-glycolytic HCC can prevent hypoxic tumor progression. SLCs expression was screened according to the level of glycolysis in HCCs. Then, whether extracellular nutrient treatment can affect hypoxic tumor progression, as well as the mechanisms, were evaluated in an in vitro cell line and an in vivo animal model. Low-glycolytic HCCs showed high SLC13A5/NaCT and SLC16A1/MCT1 but low SLC2A1/GLUT1 and HIF1α/HIF1α expression. Especially, high SLC13A5 expression was significantly associated with good overall survival in the Cancer Genome Atlas (TCGA) database. In HepG2 cells with the highest NaCT expression, extracellular citrate treatment upon hypoxia induced HIF1α degradation, which led to reduced glycolysis and cellular proliferation. Finally, in HepG2-animal models, the citrate-treated group showed smaller tumor with less hypoxic areas than the vehicle-treated group. In patients with HCC, SLC13A5/NaCT is an important SLC, which is associated with low glycolysis and good prognosis. Extracellular citrate treatment induced the failure of metabolic adaptation to hypoxia and tumor growth inhibition, which can be a potential therapeutic strategy in HCCs.

Prognostic impact of the metastatic lymph node number in intrahepatic cholangiocarcinoma

BACKGROUND

Lymph node metastasis in intrahepatic cholangiocarcinoma is a poor prognostic factor after radical surgery. However, unlike other biliary tract malignancies, the nodal stage of intrahepatic cholangiocarcinoma only reflects the presence of metastatic lymph nodes, not the number of metastatic lymph nodes. This study aimed to identify the prognostic impact of the metastatic lymph node number in intrahepatic cholangiocarcinoma.

METHODS

The data from 87 patients with intrahepatic cholangiocarcinoma who had undergone hepatectomy with 5 or more harvested lymph nodes and covering stations 12 and 8 based on the previous criteria from January 2006 to December 2019 were retrospectively reviewed. The hazard ratio according to the increasing metastatic lymph node number was calculated with other known prognostic factors for intrahepatic cholangiocarcinoma. The patients were then divided into 3 groups according to the metastatic lymph node number (N0 [n = 45]: no metastatic lymph nodes; N⁺ <4 [n = 32]: 1 to 3 metastatic lymph nodes; N⁺ ≥4 [n = 10]: ≥4 metastatic lymph nodes). Disease-free survival and overall survival were also analyzed.

RESULTS

The metastatic lymph node number was a prognostic factor of oncologic survival (disease-free survival: hazard ratio = 1.18 [1.05-1.32], P = .005; overall survival: hazard ratio = 1.21 [1.06-1.37], P = .004). Survival analysis revealed significantly poorer outcomes with an increasing metastatic lymph node number (disease-free survival: N0 vs N⁺ <4 vs N⁺ ≥4: 36.0 [0.0-76.0] vs 8.0 [0.0-16.9] vs 2.0 [0.0-5.1] months, P < .001; overall survival: N0 vs N⁺ <4 vs N⁺ ≥4: 69.0 [24.5-113.5] vs 28.0 [18.9-37.1] vs 11.0 [6.4-15.6] months, P < .001). In post hoc analysis, a significant difference was found between adjacent groups (disease-free survival and overall survival: N⁺ <4 vs N⁺ ≥4, P = .001).

CONCLUSION

With proper lymph node dissection, the number of metastatic lymph nodes is a prognostic factor of intrahepatic cholangiocarcinoma.

Anti-Cancer Effects of YAP Inhibitor (CA3) in Combination with Sorafenib against Hepatocellular Carcinoma (HCC) in Patient-Derived Multicellular Tumor Spheroid Models (MCTS)

PURPOSE

To assess the expression levels of YAP and TAZ in patient-derived HCC tissue and identify the effects of YAP/TAZ inhibition depending on the baseline YAP/TAZ expression when combined with sorafenib using a patient-derived multicellular tumor spheroid (MCTS) model.

METHODS

Primary HCC cell lines were established from patient-derived tissue. Six patient-derived HCC cell lines were selected according to YAP/TAZ expression on Western blot: high, medium, low. Then, MCTS was generated by mixing patient-derived HCC cells and stroma cells (LX2, WI38, and HUVECs) and YAP/TAZ expression was assessed using Western blot. Cell viability of MCTS upon 48 h of drug treatment (sorafenib, sorafenib with CA3 0.1 µM, and CA3 (novel YAP1 inhibitor)) was analyzed.

RESULTS

Out of six patient-derived HCC cell lines, cell lines with high YAP/TAZ expression at the MCTS level responded more sensitively to the combination therapy (Sorafenib + CA3 0.1 μM) despite the potent cytotoxic effect of CA3 exhibited in all of the patient-derived HCCs.

CONCLUSION

Targeting YAP/TAZ inhibition using the novel YAP1 inhibitor CA3 could be a promising therapeutic strategy to enhance sensitivity to sorafenib especially in HCCs with high YAP/TAZ expression in MCTS.