Transarterielle Chemoembolisation (TACE) des Hepatozellulären Karzinoms (HCC) bei Patienten mit Pfortaderthrombose - Erfahrungen

PURPOSE

Comparative analysis of the course of disease in patients with initial diagnosis of portal vein thrombosis in HCC treated with sequential TACE. Evaluation of the efficacy and safety of the method in a selected patient cohort.

PATIENTS AND METHODS

The study included 22 patients with HCC that were palliatively treated at least 3 times with TACE. All patients presented a portal vein thrombosis in the initial CT investigation. The TACE-procedure was carried out in regular intervals using a suspension consisting of a fixed dosage of Mitomycin C (10 mg) and 10-20 ml Lipiodol. Follow-up investigations were carried out with contrast enhanced Multislice-CT before and after TACE and control of the laboratory panel (i. e. blood count, liver enzymes and coagulation).

RESULTS

Mean survival was 15.7 months (95%-CI 11.6-19.8) with a mean follow-up after last TACE of 6.1 +/- 4.8 months. The mean number of TACE procedures was 5.5 +/- 2.7. During the investigation period 17 / 22 (77.3%) patients died. In 23.5% retrospective analysis revealed a liver decompensation as the cause of death and in 58.8% patients died from the tumor disease. The cumulative 1-, 2- and 3-year survival was 55.0, 21.0 and 0%. The mean tumor size was 7.2 +/- 3.4 cm. Unifocal tumors were found in 18.2% of the cases whereas multifocal tumors were found in 81.8%. In 59.1% of the patients tumor extended to both liver lobes. In case of tumor infiltration of the portal vein survival was significantly worse compared to patients with no evidence of a tumor thrombosis (p = 0.01; cumulative 1- and 2-year survival 46% and 8% vs. 77% and 46%).

CONCLUSION

The palliative treatment of the HCC with TACE shows an improvement of survival. There was no increase of death due to liver decompensation in our cohort. Patients with a tumor infiltration of the portal vein showed a significantly worsened survival. The presence of a portal vein thrombosis at the initial diagnosis of the HCC is not an absolute contraindication for TACE treatment but patients have to be elected carefully with critical regard to their liver function.

Tacrolimus monotherapy without steroids after liver transplantation--a prospective randomized double-blinded placebo-controlled trial

Early steroid withdrawal after liver transplantation (LT) is desirable in order to reduce steroid side effects. Between February 2000 and August 2004, 110 patients after LT were included in this prospective, randomized, double-blind, placebo-controlled trial. Randomization was performed before LT. In all patients, tacrolimus was used without induction therapy. All patients received methylprednisolon for 14 days, thereafter a double-blinded medication containing either placebo (n = 56) or methylprednisolon (n = 54) for 6 months, which was completely stopped thereafter. End points were patient and graft survival, acute and chronic rejection, and incidence of steroid side effects during the first year after LT. One-year patient survival was 85.7% (placebo) and 88.8% (steroid) (p = 0.572). Twenty-seven (48.2%) and 19 (35.2%) patients experienced acute rejection (placebo versus steroid, respectively; p = 0.116). Two patients in the placebo group but none in the steroid group experienced chronic rejection (p = 0.257). The rates of side effects were (placebo versus steroid, respectively): CMV infection 25% versus 33% (p = 0.336), post-transplant diabetes 30% versus 53% (p = 0.024), hypertension 39% versus 52% (p = 0.248), hypercholesterolemia 10% versus 41% (p = 0.002) and hypertriglyceridemia 32% versus 54% (p = 0.046). In conclusion, early steroid withdrawal after LT is feasible under tacrolimus monotherapy without increased rejection rates and with a lower rate of side effects.

Transarterial chemoembolization (TACE) for inoperable intrahepatic cholangiocarcinoma

The aim of this retrospective study was to determine the safety and efficacy of chemoembolization (TACE) as palliative treatment for patients with unresectable intrahepatic cholangiocarcinoma (CCA) and to compare the results with those in the literature. Fifteen patients with histology-proven CCA (5 men, 10 women) had received palliative treatment with TACE over a 6-year period. The treatment protocol comprised repeated TACE at a minimum of 8-week intervals. TACE was performed with a mixture of 10 ml Lipiodol and 10 mg mitomycin C injected into the tumor-supplying vessels. Follow-up investigations after 8-10 weeks comprised contrast-enhanced multislice spiral CT and laboratory control. Statistical evaluation included survival analysis using the Kaplan-Meier method. During the investigation period 58 TACEs (3.9 +/- 3.8; 1-15) were performed in 15 patients. Mean tumor size was 10.8 +/- 4.6 cm (range, 2.0-18.0 cm). Unifocal tumor disease was diagnosed in eight patients, and multifocal disease in seven. Mean survival was 21.1 months (95% CI, 9.4-32.5 months). At the end of the investigation period 3 patients are still alive, and 12 patients have died. The 1-, 2-, and 3-year survival rate was 51.3%, 27.5%, and 27.5% respectively. According to RECIST criteria interim best response to therapy was stable disease in 9 of 15 patients, a partial response in 1 of 15 patients, and tumor progression in 4 of 15 patients. No deaths and no acute liver failure occurred under TACE therapy. Major complications were observed in two patients, comprising anaphylactic shock owing to contrast medium administration in one and gastric ulceration due to lipiodol displacement in the second patient. These results demonstrate that TACE is a safe procedure with a moderate number of complications for patients suffering from inoperable CCA. According to recently published data on i.v. chemotherapy we suggest that TACE might be able to prolong survival in selected patients who would succumb under other palliative treatment modalities.

[Single center experience over a 5-year period with sequential transarterial chemoembolization (TACE) in the treatment of hepatocellular carcinoma (HCC)]

PURPOSE

To analyze the course of disease of patients treated with sequential TACE and to evaluate the dependent and independent prognostic factors for patient survival using the Cox Proportional Hazard Model.

MATERIALS AND METHODS

94 patients palliatively treated with TACE. Patients were selected if they had been treated at least 3 times. The TACE procedure was carried out at 8-week intervals using a suspension consisting of a fixed dosage of Mitomycin C (10 mg) and 10 ml Lipiodol. Follow-up investigations included contrast-enhanced multislice CT before and after TACE and assessment of the laboratory test results (i. e., blood count, liver enzymes, and coagulation).

RESULTS

In 66.7 % of the patients, multifocal tumors were found. In 16.0 % of the patients, the tumor load represented more then 50 % of the liver volume. In 23.4 % of the cases, a portal vein thrombosis was found in the initial CT scan. The mean survival for the total cohort was 24.1 months (95 %-CI 20.1 - 28.2). During the investigation period, 72/94 of the patients died. The cumulative 1-year, 2-year, and 3-year survival rates are 71.6 %, 33.9 %, und 17.2 %, respectively. A median of 6.0 +/- 3.1 (range 14, n total = 612 TACE) was performed in each patient. A total of 62.5 % patients died because of tumor progression whereas 18.1 % died due to progressive liver failure. Patients in whom the tumor responded to the TACE treatment and who did not develop ascites or those with Okuda stage I or unifocal tumor growth showed a survival benefit whereas the presence of portal vein thrombosis was associated with a significantly poor outcome (p < 0.05). The Child-Pugh stage was not statistically significant for the disease course; the occurrence of new tumor lesions had no influence with regard to 1-year and 2-year survival but had a significant influence on long-term survival (p < 0.05). Independent prognostic factors are (multivariate analysis; p < 0.05): number of TACE performed, tumor type (i. e., unifocal vs. multifocal), response to TACE (response vs. progression), and Okuda stage.

CONCLUSION

Our results emphasize the value of TACE in the palliative treatment of HCC. Under sequential TACE therapy the course of disease in patients suffering from portal vein thrombosis was not significantly worse. Crucial prognostic factors for the course of the HCC are tumor type and extension, response to TACE, and liver function at the beginning of TACE.

Flow and Pressure during Liver Preservation under ex situ and in situ Perfusion with University of Wisconsin Solution and Histidine-Tryptophan-Ketoglutarate Solution

Effective preservation of liver grafts is the first essential step for successful liver transplantation. Insufficient perfusion leads to ischemic-type biliary lesions after transplantation. Perfusion of the graft can be performed either in situ or ex situ, with gravity flow or pressure-controlled. Mainly University of Wisconsin (UW) and histidine-tryptophan-ketoglutarate (HTK) solutions are used widespread in clinical liver transplantation. Due to a persistent lack of data, we performed this systematic investigation of in situ and ex situ perfusion of liver grafts with HTK (low-viscous) and UW (high-viscous) solutions at different pressure steps on the perfusion solution (gravity flow, 50, 100, 150, and 200 mm Hg). End points were perfusion flow and pressure in the hepatic artery. A pig model was used with n = 8 pigs randomized to each (HTK and UW) group. In situ perfusion was ineffective for both solutions at any pressure on the perfusate bag. Ex situ perfusion showed significantly improved flow and pressure in the hepatic artery and, therefore, was highly effective. No major differences between HTK and UW solutions could be detected. Therefore, an additional ex situ perfusion of the hepatic artery should be mandatory in every liver procurement.

Transarterial Chemoembolization Before Liver Transplantation in 60 Patients With Hepatocellular Carcinoma

Tumor recurrence is a major problem after orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC). In 60 patients OLT was performed for HCC after pretreatment by repeated transarterial chemoembolization (TACE). Forty-four recipients exceeded the Milan criteria. Recurrence-free 5-year survival was 65.2% and 5-year freedom from recurrence was 73.2%. During the waiting time, 14 patients experienced minimal change, which did not fulfill the definition of tumor progression according to official oncological criteria. Five-year freedom from recurrence among patients with stable compared with progressive disease was 93.3% versus 28.1%, respectively (P = .0001). A strict TACE pretreatment protocol may select patients with obviously biologically less aggressive tumors, who are suitable for OLT even if the HCC exceeds the commonly accepted listing criteria.

Fimbrial lectins influence the chemokine repertoire in the urinary tract mucosa

The defense against mucosal infections relies on chemokines that recruit inflammatory cells to the mucosa. This study examined if the chemokine response to uro-pathogenic Escherichia coli is influenced by fimbrial expression. The CXC (CXCL1, CXCL5, CXCL8, CXCL9, CXCL10) and CC chemokines (CCL2, CCL3, CCL5) were quantified after in vitro infection of uro-epithelial cells with a fimbriated E. coli pyelonephritis isolate, or with P or type 1 fimbriated transformants of an avirulent E. coli K-12 strain. The response profile was shown to vary with the fimbrial type. Type 1 fimbriated E. coli elicited mainly CXCL1 and CXCL8, whereas P fimbriated E. coli stimulated CCL2 and CCL5 and class II were more potent chemokine inducers than class III P fimbriae. Chemokines were also quantified in urine samples from 73 patients with febrile urinary tract infection, and analyzed as a function of disease severity and fimbrial expression by the strain infecting each patient. A complex CXC and CC chemokine response was detected in patient urine, with a significant influence of the fimbrial type. The results show that virulence factors like fimbriae may modify the mucosal chemokine response. This mechanism may allow the host to adjust the inflammatory cell infiltrate to fit the infecting strain.

Einstellungen zur postmortalen Organspende - Ergebnisse einer Repräsentativerhebung der deutschen Bevölkerung

The increasing deficit of organs causes a drastic decline in the quality of life and survival of numerous patients in need of a transplantation. The purpose of this representative community study was to survey attitudes toward transplantation in the German population and to identify underlying determinants. Unlike previous surveys, fears and concerns were elicited based on a concrete case vignette. Among the 1,002 participants, 90 % were in favour of organ donation in general; 21 % reported having signed an organ donor card. Consent to organ donation was associated with younger age and higher social class; the same was true for the possession of an organ donor card. In the virtual decision situation, the majority (77 %) voted in favour of an organ donation based on saving lives, consolation for bereaved and the absence of disadvantages for the donor. Common (up to 50 %), however, were also fears and concerns regarding determination of the time of death, displacement of medical concern from the donor to the recipient of the organ, utilisation of organs for other purposes, or explantation before death. The knowledge of the determinants identified, of existing fears and concerns are helpful not only for informing the public, but also for the dialogue with the next of kin of potential donors. Here, it may be helpful not only to address arguments pro organ donation, but also to address potential fears and concerns.

[Surgical approach in hilar cholangiocarcinoma]

Surgery is the decisive life-prolonging treatment in patients with hilar cholangiocarcinoma. Surgery is mainly based on empiric data. Since patients without surgery have only about 6 months to survive, to achieve a high resection rate is crucial for these patients. During diagnostic workup, percutaneous transhepatic cholangiography results in the most reliable assessment of longitudinal tumor growth. The extent of the tumor is frequently overestimated leading to the consequence of excluding the patients from surgery. En-bloc resection of the tumor and the adjacent liver should be the preferred surgical approach. So far, surgical radicality (right trisegmentectomy, extended lymphadenectomy and vascular resection) has not been demonstrated to prolong survival. In our experience with 117 patients, median survival of patients following resection was 813 days, whereas patients not amenable to resection survived for 214 days only. Resection rate and the rate of curative resections were 71 and 72 %, respectively, operative mortality was 7 %. In the multivariate analysis, lymph node involvement proved to be the only prognostic marker.

TACE: Therapie des HCC vor Lebertransplantation - Erfahrungen

PURPOSE

Analysis of the course of disease in patients with histologically proven HCC before and after orthotopic liver transplantation (LTx) who received transarterial chemoembolization (TACE).

MATERIAL AND METHODS

Thirty-five of a total collective of 363 patients with histologically proven HCC underwent LTx. Before LTx, all patients were treated with sequential TACE. According to treatment pattern, TACE should be performed every 6 weeks, using a suspension consisting of max. 10 mg Mitomycin C as well as 10 - 30 ml iodized oil (Lipiodol). Patients were classified according to the Milano criteria. Criteria were called exceeded if the tumor size was > 5 cm and/or > 3 tumors larger than 3 cm were found. Therapy success and liver function were examined by means of spiral CT and laboratory controls. Investigation parameters included the number of tumor knots as well as the maximum tumor size. Additionally, the Lipiodol accumulation, the patency of the portal vein and the occurrence of complications were checked.

RESULTS

Altogether, 184 TACE procedures were accomplished (5.3 +/- 3.3, range 1 - 14). The waiting period up to the transplantation amounted to 366 +/- 255 days (range 44 - 1137). The average number of tumor knots for each patient was 3.1 +/- 2.2 before and 2.9 +/- 2.2 after TACE (p = 0.887). The average tumor size was 4.2 +/- 2.5 before and 2.8 +/- 1.4 after TACE. The Milano criteria to LTx crossed 17/35 patients. Patients with exceeded Milan criteria showed a highly significant size reduction of the tumor after TACE (p = 0.001); in 9/17 cases the transplantation criteria were secondarily fulfilled through downstaging. A successful LTx was accomplished in 35/35 cases. Follow up after LTx was 769 +/- 509 days. The tumor recurrence in patients with exceeded vs. fulfilled transplantation criteria was 11.1 % vs. 11.8 % (p = 0.99). The recurrence free survival was 93.3 %, 82.5 % and 82.5 % at 1, 3 and 5 years, respectively. There were no relevant differences between patients with exceeded vs. fulfilled transplantation criteria (p = 0.99).

CONCLUSION

The sequential TACE is an effective method for the therapy of the HCC before LTx in selected patients. A relevant downsizing could be achieved by TACE in patients with advanced HCC. Patients with larger tumors showed a significantly stronger size reduction after TACE. The recurrence rate and the survival rate for patients with advanced or small tumors do not differ.

[Ambulatory management of hepatitis B before and after liver transplantation]

HISTORY AND CLINICAL FINDINGS

A 48-year-old patient from Pakistan was referred with scleral icterus, ascites and lower limb edema.

DIAGNOSIS

The patient was suffering from post-hepatitis liver cirrhosis, CHILD stage B, with underlying chronic hepatitis B and C coinfection.

TREATMENT AND COURSE

One year after diagnosis, orthotopic liver transplantation (OLT) was performed. To avoid recurrence of the hepatitis B in the transplant, the patient was given a treatment with lamivudine preoperatively. A prophylaxis with a combination of lamivudine and hepatitis B immunoglobulin peri- and postoperatively has been given for more than 5 years.

CONCLUSION

The use of lamivudine and hepatitis B immunoglobulin improves transplant survival in patients who have undergone OLT on the basis of post-hepatitis liver cirrhosis secondary to chronic hepatitis B. Costs are reduced by administering the hepatitis B immunoglobulin intramuscularly and by managing the preoperative and aftercare of the patient on an outpatient basis.

[Diagnostic imaging of hilar cholangiocarcinoma: preoperative evaluation of ERC, MRC and PTC in comparison with histopathology]

PURPOSE

To compare the results of the preoperative workup consisting of endoscopic retrograde cholangiography (ERC), magnetic resonance cholangiography (MRC), and percutaneous resonance cholangiography (PTC) with the tumor extent of the surgical specimen in patients with hilar cholangiocarcinoma (hilCC).

MATERIALS AND METHODS

Between 9/1997 and 12/2002, 59 patients with hilCC tumor underwent surgical resection. Preoperative ERC, MRC, and PTC were analyzed, blinded for the identity of the patient, and compared with the surgical specimen. For this retrospective analysis, 55 of the initial 59 ERCs, 39 of the initial 40 MRCs and 32 of the initial 38 PTCs were available. Most of the ERCs and MRCs had been performed at referring institutions by various investigators. In 20 patients, all three imaging modalities were available for direct comparison.

RESULTS

The mean scores of the visualization of the bile ducts and tumor differ considerably for ERC, MRC and PTC, with PTC visualizing the bile ducts better than ERC (p < 0.001) and MRC (p = 0.019). The tumor classification according to Bismuth and Corlette was correctly predicted by ERC in 29 %, by MRC in 36 % and by PTC in 53 %. The tumor extent was overestimated in 40 % (ERC), 41 % (MRC) and 31 % (PTC) and underestimated in less than 10 % for all modalities. Twenty patients, who underwent all three imaging modalities, were included in an additional analysis for a direct comparison of ERC, MRC and PTC. PTC provided correct or acceptable information on tumor extent in 19 of 20 patients, MRC in 15 of 20 patients, and ERC in only 11 of 20 patients. The statistical analysis revealed a significant superiority of PTC to ERC (McNemar test: p < 0.01) but not to MRC (p = 0.22).

DISCUSSION

The management of patients with hilar cholangiocarcinoma requires a high degree of expertise in diagnostic imaging techniques. Cholangiography should not only define the location but also visualize the uppermost extent of the tumor to determine resectability. In contrast to most reports in the literature, ERC and MRC were found to be of limited reliability regarding the assessment of the tumor extent. ERC may be more and more reserved for patients considered for nonsurgical intervention or palliation. PTC proved to be the most reliable approach. MRC represents a noninvasive diagnostic tool for the evaluation of malignant perihilar biliary obstructions, but should be performed at highest quality using state-of-the-art MRI techniques. The most common mistake of each diagnostic modality was an overestimated tumor extent, which may exclude patients from potentially curative surgery.

CT-Angiographie an einem 16-Schicht-CT zur perioperativen Evaluation der Leberarterien im Vergleich zur MR-Angiographie

PURPOSE

To evaluate the efficiency of CT angiography (CTA) with 16-row MSCT compared with MR angiography (MRA) in analyzing the arterial anatomy in patients undergoing liver surgery.

MATERIALS AND METHODS

In 30 patients, MRA and CTA studies of the abdominal vessels were reviewed. CT parameters: slice thickness 3 mm; collimation 1.5; reconstruction interval 2 mm (Philips MX 8000 IDT); 120 ml contrast media (400 mg/ml) at a rate of 4 ml/sec; acquisition of arterial-phase scans. The anatomy of the hepatic artery was evaluated from axial and reconstructed maximum-intensity-projection (MIP) images ("Slab-Viewer", Philips). MR parameters: contrast-enhanced coronal FLASH-3D sequences; slice thickness 1.4 mm; TR 3.47, TE 1.3; 1.5 T scanner (Siemens Somatom). Image quality was rated with a scoring system. Contrast enhancement of the hepatic artery and the liver parenchyma was measured.

RESULTS

The image quality of CTA was rated as excellent in 18 (MRA 5); good in 8 (MRA 22); satisfactory in 4 patients (MRA 3), and non-diagnostic in 0 patient (MRA 1). Compared to MRA, the image quality of CTA was better in 15/30 patients; equal for both in 13 and worse in 2 patients. CTA provided a better depiction of the segmental branches of the hepatic arteries in 15/30 patients and revealed important anatomic variations of the hepatic artery in 8/30 patients. These variations were not be seen in MRA: e. g., MRA missed a left gastric arterial supply to the left liver. The ratio of contrast enhancement in liver parenchyma and hepatic artery was 4.7 in CTA and 4.5 in MRA.

CONCLUSION

CTA with multislice scanners delivers better image quality and depiction of the hepatic arteries than MRA. Thus, MRI of the hepatic arteries can be replaced by routine CT, which is already part of the preoperative evaluation for liver transplantation.

[Hilar cholangiocarcinoma -- results of en bloc resection of tumor and liver]

The increasingly performed en bloc resection of liver and hilar tumor has contributed to the improvement of long-term survival in patients with hilar cholangiocarcinoma. Based on preoperative definition of operative strategy we tried to avoid any traumatization of the hilar region. Between September 1997 and September 2002, 82 patients with hilar cholangiocarcinoma were treated at our department. Three patients were excluded from any surgery. The resection rate was 75% (59 of 79); 79% (38 of 48) of en bloc resections of the hilar tumor and adjacent liver were formally curative. The hospital mortality was 7%. The 1- and 3-year survival rates of patients after explorative laparotomy, palliative and curative resection was 27 and 7%, 67 and 26%, 89 and 45% ( p<0.001), respectively. The 1- and 3-year survival rates of patients after en bloc resection were 78 and 49%, respectively. In patients with formally curative en bloc resection ( n=38), the 3-year survival rate was 63%; in patients with N0/R0 resection ( n=31) it was 71%. Lymph node involvement proved to be the only independent prognostic marker if patients who underwent hilar and en bloc resection were included in the multivariate analysis. The R situation was the only significant predictor for patients after en bloc resection. These data justify the extended diagnostic work-up and the principal liver resection in hilar cholangiocarcinoma.

Preoperative imaging of hilar cholangiocarcinoma: surgical evaluation of standard practises

It was the goal of this study to compare the results of the preoperative diagnostic workup (ERC, MRC, and PTC) with the tumor extent of the surgical specimen in patients with hilar cholangiocarcinoma (hilCC).

PATIENTS AND METHODS

Between 9/97 and 12/2002 82 patients with hilCC were treated at our institution. In 59 patients tumor resection was feasible. Preoperative ERC, MRC and PTC - blinded for the idendity of the patients - were analysed retrospectively and compared with the surgical specimen.

RESULTS

PTC resulted in significantly superior visualization of the bile ducts including the hilar lesion compared to ERC and MRC (p < 0.01). ERC, MRC and PTC were correct in predicting tumor extent in 29, 36 and 53 % of cases, respectively. The extent of the tumor was overestimated in 42 % (ERC), 41 % (MRC) and 31 % (PTC). Underestimation or wrong assessment or no decision at all occurred in 31, 23 and 16 %, respectively. In 20 patients results of all three diagnostic methods were available allowing a statistical comparison regarding the resection to be performed: PTC was superior to ERC (McNemar test:p < 0.01), but not to MRC. In the patients with overestimated tumor extent both the rate of curative resections and survival were similar to the other resected patients.

DISCUSSION

In contrast to most reports in the literature, ERC and MRC were found to be of limited reliability regarding the assessment of tumor extent. PTC proved to be the most reliable approach. Overestimation of the tumor extent, which may lead to exclude the patient from potentially curative surgery, was the most common mistake in each diagnostic modality.