Successful experiences of ABO-incompatible adult living donor liver transplantation in a single institute: no immunological failure in 10 consecutive cases

ABO-incompatible (ABOi) adult living donor liver transplantation (ALDLT) is a feasible therapeutic option for countries with a scarcity of deceased donors. This report presents our initial experiences in ABOi ALDLT in 10 patients between December 2008 and September 2009. The mean age of recipients was 48.5 ± 5.7 years (range, 40-54 years). The mean Model for End-stage Liver-Disease score was 13.9 ± 4.0 (range, 9-22). All patients were administered preoperative rituximab once and plasma exchanges according to the hemagglutinin titer. The spleen was preserved in all cases. For local infusion therapy, hepatic arterial infusion was performed in 9 patients and portal vein infusion in 1 subject. The 10 patients experienced no in-hospital mortality. At a mean follow-up period of 31.8 ± 2.9 months (range, 4.1-34.9 months), 1 patient has died (postoperative month 4 due to sepsis following a biliary stricture. The 3-month patient and graft survivals were 100%, and 1- and 2-year survivals, 90.0%. There was no episode of antibody-mediated rejection. The promising results of our initial experience may have been due to the use of preoperative rituximab and the good preoperative conditions of the patients.

Avoiding a spanning cluster in percolation models

When dynamics in a system proceeds under suppressive external bias, the system can undergo an abrupt phase transition, as can happen when an epidemic spreads. Recently, an explosive percolation (EP) model was introduced to understand such phenomena. The order of the EP transition has not been clarified in a unified framework covering low-dimensional systems and the mean-field limit. We introduce a stochastic model in which a rule for dynamics is designed to avoid the formation of a spanning cluster through competitive selection in Euclidean space. We use heuristic arguments to show that in the thermodynamic limit and depending on a control parameter, the EP transition can be either continuous or discontinuous if d < d(c) and is always continuous if d ≥ d(c), where d(c) is the spatial dimension and d is the upper critical dimension.

Skin cancer treatment by albumin/5-Fu loaded magnetic nanocomposite spheres in a mouse model

Albumin/drug loaded magnetic nanocomposite spheres were fabricated using an oil-in-oil emulsion/solvent evaporation method, and tested on a mouse model (experimental squamous cell carcinoma) to determine the efficacy of the drug delivery system (DDS) on skin cancer. This novel DDS consists of human serum albumin, poly(lactic-co-glycolic acid) (PLGA), 5-fluorouracil (5-Fu), magnetic nanoparticles (10 nm) and fluorescent labeling molecule (diphenylhexatriene). One of the major purposes of using albumin is that it likely provides internal binding to and retention by the inflammatory tissues to reduce the amount of magnetic nanoparticles needed in the drug loaded microspheres (750–1100 nm). This study is aimed at reducing many negative side effects of conventionally used chemotherapy drugs by localizing the chemotherapy drug, controlling the release of the therapeutic agent and encouraging uptake of the DDS into cancerous cells. A group of mice treated with (1) the magnetic targeted DDS were compared to the other three groups, including, (2) DDS without a magnet, (3) 5-Fu local injection, and (4) untreated groups. The fluorescent tracer was ubiquitously identified inside the tumor tissue, and the DDS/tumor tissue boundary presented a leaky interface. The test results clearly showed that the magnetic targeted DDS exhibited significantly superior therapeutic effects in treating the skin cancer, with the increased efficacy to halt the tumor growth.

Origin of the hub spectral dimension in scale-free networks

The return-to-origin probability and the first-passage-time distribution are essential quantities for understanding transport phenomena in diverse systems. The behaviors of these quantities typically depend on the spectral dimension d(s). However, it was recently revealed that in scale-free networks these quantities show a crossover between two power-law regimes characterized by d(s) and the so-called hub spectral dimension d(s)((hub)) due to the heterogeneity of connectivities of each node. To understand the origin of d(s)((hub)) from a theoretical perspective, we study a random walk problem on hierarchical scale-free networks by using the renormalization group (RG) approach. Under the RG transformation, not only the system size but also the degree of each node changes due to the scale-free nature of the degree distribution. We show that the anomalous behavior of random walks involving the hub spectral dimension d(s)((hub)) is induced by the conservation of the power-law degree distribution under the RG transformation.

Abstract P1-01-13: Patterns of definitive axillary management in the era prior to reporting ACOSOG Z0011: comparison between NCCN Centers and hospitals in Michigan

Background: The results of the ACOSOG- Z0011 trial have had potential practice changing implications for the management of patients with positive sentinel lymph node (SLN) undergoing lumpectomy and radiation for breast cancer. However, some evidence suggests a shift in axillary management even prior to the initial report of data supporting sentinel lymph node biopsy (SLNB) alone in mid-2010. We analyzed data in the National Comprehensive Cancer Network (NCCN) outcomes database from NCCN centers and the Michigan Breast Oncology Quality Initiative (MiBOQI) hospitals to examine institutional practice patterns with respect to use of completion axillary dissection (CALND) for SLN positive breast cancer in the years leading up to publication of these trial results. We hypothesized that CALND would be omitted more frequently in women treated at NCCN centers compared to those treated at MiBOQI programs.

Methods: We identified 2,172 women with clinical T1/T2 N0 breast cancer who underwent breast surgery and SLNB and had a positive SLN from 2007 through 2010 at one of 12 participating NCCN centers or 12 MiBOQI sites. Patient and tumor characteristics, definitive breast procedure, year of diagnosis, and institutional affiliation were analyzed as predictors of use of SLNB alone in univariate Chi-Square and multivariable logistic regression models.

Results: CALND was omitted in 314 (14.5%) of the 2,172 patients. Over time, there was a dramatic increase in the use of SLNB alone (12% in 2007 to 23% in 2010). In the univariate analyses, increased patient age, later year of diagnosis, lower T stage, and lower pathologic N stage were significant predictors of use of SLNB alone (all p &lt; .0001). There was no association between definitive breast surgery type, hormone receptor status, Her-2 Neu status, or institutional affiliation and use of SLNB alone. In the multivariable model, older age at diagnosis, later year of diagnosis, and lower pathologic N stage remained significant independent predictors of SLNB alone. There were no significant differences in rates of omission of CALND between NCCN and MIBOQI sites.

Abstract P4-13-06: Association of Age, Obesity and Incident Breast Cancer Phenotypes

Background: Obesity has been shown to be associated with increased risk of breast cancer in postmenopausal women. However, it is unclear whether this risk is isolated to a specific phenotype. We hypothesized that the increased levels of insulin, IGF-1 and estrogens associated with obesity preferentially drive an increased proportion of the luminal A phenotype of breast cancer.

Methods: Between 2008 and 2011, 1001 women were diagnosed with invasive breast cancer at Duke University Medical Center and had weight and height recorded at the time of diagnosis. Tumor phenotypes were based on hormone receptor (HR: ER− and/or PR-positive) and Her2 testing with subtypes defined as follows: Luminal A: HR(+), Her2(−); Luminal B: HR(+), Her2(−); Her2: HR(−), Her2(+); triple negative: HR(−), Her2(−).

Results: Median age of the cohort was 55.7 years; median BMI was 27.7. As expected, increasing BMI was associated with older age, with BMI almost evenly distributed between three groups: ≤ 25, 25–30, and &gt;30. In the overall group, proportion of luminal B, Her2, and triple negative subtypes did not differ by BMI; however the proportion of patients with luminal A cancer increased from 65% for the lowest BMI group to 70% for the highest BMI group. Analysis stratified by age ≤ 40, 40 to 59, and ≥60 years showed a lower proportion of the triple-negative (19% vs. 6% vs. 4%, p &lt; 0.001) and higher proportion of the luminal A (11% vs. 23% vs. 32%; p &lt; 0.001) phenotype with older age group. This finding was limited to women with higher BMI only.

Conclusions: Although there were no trends observed between BMI and incident phenotype in the overall cohort, age stratified analysis revealed striking correlations. High BMI was associated with triple negative phenotype in the youngest age group and luminal A phenotype in older age groups. These results suggest that obesity likely exerts different effects on tumor progression based on patient age and/or menopausal status.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-13-06.

Abstract P3-06-07: Ki67 as a Predictive Marker of Response to Neoadjuvant Chemotherapy in Patients with Early-Stage Breast Cancer (ESBC): A Systematic Review and Evidence Summary

Background: Immunohistochemical (IHC) assessment of the proportion of cells staining for the KI67 nuclear antigen is being increasing utilized in the management of patients with early-stage breast cancer (ESBC). A comprehensive systematic review and evidence synthesis of biomarkers potentially predictive of response to systemic therapy was initiated as a part of an NCI-funded comparative effectiveness research program.

Methods: Studies of chemotherapy response prediction based on baseline IHC assessment of Ki67 in patients with ESBC receiving neoadjuvant systemic therapy were identified. Response was specified as pathologic complete response (pCR) or clinical response (ClinR). Assay predictive performance for response was assessed on the basis of sensitivity, specificity, predictive value and predictive odds ratio (POR±95%CLs) utilizing mixed effects models. Study results were fitted in an ROC analysis based on the method of DerSimonian and Laird. Publication bias was evaluated on the basis of funnel plot asymmetry assessed by Egger's regression intercept and Begg and Mazumdar's rank correlation.

Results: Of 469 potentially eligible studies, dual blind full text review identified 42 eligible studies reporting 44 independent cohorts with 6,716 patients (21–979). While Ki67 cutpoints varied considerably, they were most commonly between 10%–30% (median 20%, range 1–50%). The analysis prsented here is limited to the 30 studies of ESBC patients (N = 3,343) receiving neoadjuvant therapy of which 14 reported fewer than 100 patients. The proportion of patients with elevated Ki67 across studies ranged from 0.20–0.92 (median = 0.54). Sensitivity and specificity for treatment response in patients with high vs. low baseline Ki67 was 0.65 [0.61, 0.68] and 0.52 [0.50, 0.54], respectively. Estimated response rates across studies in patients with high vs. low Ki67 were 31% [29%, 34%] and 19% [17%, 21%], respectively. The estimated POR for response across studies was 2.82 [2.14, 3.72; P &lt; .001].

Abstract P4-01-13: Practice patterns of MRI utilization for breast cancer treatment within the University of California system as part of the Athena initiative

Background: The appropriate utilization of Breast MRI in breast cancer care remains controversial. As part of a quality improvement initiative for breast cancer screening and treatment, we sent out a survey to physicians who treat breast cancer patients. All respondents are participants in the ATHENA initiative, a program which unites physicians, researchers, and patients at the five University of California medical centers.

Objective: To use the ATHENA infrastructure to perform a qualitative analysis of variations in breast cancer care.

Methods: Surveys were sent to 50 physicians in the ATHENA network whose practices are focused on breast cancer. Respondents were presented with clinical scenarios, and asked whether they would recommend MRI always/usually or sometimes/never. Differences were compared by Chi square.

Results: 39 physicians completed the survey (78% response rate). Of these physicians 29% were surgeons, 26% radiation oncologists and 45% medical oncologists. Athena physicians were more likely to order MRI for high risk screening of mutation carriers than not (85% yes vs. 15% no, p &lt; 0.003) but not based on breast density alone or previous history of breast cancer. They were also more likely to order it for monitoring neo-adjuvant chemotherapy (70% yes vs. 30% no, p &lt; 0.03). Although the majority answered that they would order a Breast MRI for new breast cancer the difference between responses was not significantly different (56% yes vs. 44%, p = 0.07).

Conclusion: Athena physicians follow established published guidelines which demonstrate a benefit for Breast MRI screening for BRCA mutation carriers but not based on density or previous history of breast cancer. The Athena network allows a forum for new practice guidelines to be implemented as data becomes available to improve patient outcomes and utilize the best evidence for patient care, where both the patterns of MRI use as well as the outcomes of practice patterns will be evaluated prospectively.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-01-13.

Bacillus-derived poly-γ-glutamic acid reciprocally regulates the differentiation of T helper 17 and regulatory T cells and attenuates experimental autoimmune encephalomyelitis

Forkhead box protein 3 (FoxP3(+)) regulatory T (T(reg)) cells and interleukin (IL)-17-producing T helper 17 (Th17) cells have opposing effects on autoimmunity, as the former are crucial for maintaining self-tolerance while the latter play a key role in precipitating inflammatory autoimmune diseases. Here we report that Bacillus-derived poly-γ-glutamic acid (γ-PGA) signals naive CD4(+) T cells to promote the selective differentiation of T(reg) cells and to suppress the differentiation of Th17 cells. The γ-PGA inducibility of FoxP3 expression was due partially to transforming growth factor (TGF)-β induction through a Toll-like receptor (TLR)-4/myeloid differentiating factor 88 (MyD88)-dependent pathway. However, this pathway was dispensable for γ-PGA suppression of Th17 differentiation. γ-PGA inhibited IL-6-driven induction of Th17-specific factors including signal transducer and activator of transcription-3 (STAT-3) and retinoic acid-related orphan receptor γt (RORγt) while up-regulating the STAT-3 inhibitor suppressor of cytokine signalling 3 (SOCS3). Importantly, in vivo administration of γ-PGA attenuated the symptoms of experimental autoimmune encephalomyelitis and at the same time reduced Th17 cell infiltrates in the central nervous system. Thus, we have identified the microbe-associated molecular pattern, γ-PGA, as a novel regulator of autoimmune responses, capable of promoting the differentiation of anti-inflammatory T(reg) cells and suppressing the differentiation of proinflammatory Th17 cells. These findings draw attention to the potential of γ-PGA for treating Th17 cell-mediated autoimmune diseases.

Reproducibility and clinical correlations of post-treatment changes on CT of prostate cancer bone metastases treated with chemotherapy

OBJECTIVES

The objective of this study was to determine whether, in patients with prostate cancer (PCa) bone metastases receiving chemotherapy, early post-treatment changes on CT are reproducible and associated with clinical outcomes.

METHODS

Blinded to outcomes, two radiologists with 1 year and 5 years of experience independently reviewed CTs obtained before and 3 months after chemotherapy initiation in 38 patients with bone metastases from castration-resistant PCa, recording the size, matrix and attenuation of ≤5 lesions; presence of new lesions, extraosseous components, periosteal reactions and cortical thickening; and overall CT assessment (improved, no change or worse). Kappa statistics were used to assess inter-reader agreement; the Kruskal-Wallis test and Cox regression model were used to evaluate associations.

RESULTS

Inter-reader agreement was low/fair for size change (concordance correlation coefficient=0.013), overall assessment and extraosseous involvement (κ=0.3), moderate for periosteal reaction and cortical thickening (κ=0.4-0.5), and substantial for CT attenuation (κ=0.7). Most metastases were blastic (Reader 1, 58%; Reader 2, 67%) or mixed lytic-blastic (Reader 1, 42%; Reader 2, 34%). No individual CT features correlated with survival. Readers 1 and 2 called the disease improved in 26% and 5% of patients, unchanged in 11% and 21%, and worse in 63% and 74%, respectively, with 64% interreader agreement. Overall CT assessment did not correlate with percentage change in prostate-specific antigen level. For the more experienced reader (Reader 2), patients with improved or unchanged disease had significantly longer median survival (p=0.036).

CONCLUSIONS

In PCa bone metastases, interreader agreement is low in overall CT post-treatment assessment and varies widely for individual CT features. Improved or stable disease identified by an experienced reader is statistically associated with longer survival.

First passage time for random walks in heterogeneous networks

The first passage time (FPT) for random walks is a key indicator of how fast information diffuses in a given system. Despite the role of FPT as a fundamental feature in transport phenomena, its behavior, particularly in heterogeneous networks, is not yet fully understood. Here, we study, both analytically and numerically, the scaling behavior of the FPT distribution to a given target node, averaged over all starting nodes. We find that random walks arrive quickly at a local hub, and therefore, the FPT distribution shows a crossover with respect to time from fast decay behavior (induced from the attractive effect to the hub) to slow decay behavior (caused by the exploring of the entire system). Moreover, the mean FPT is independent of the degree of the target node in the case of compact exploration. These theoretical results justify the necessity of using a random jump protocol (empirically used in search engines) and provide guidelines for designing an effective network to make information quickly accessible.

Right gastroepiploic artery is the first alternative inflow source for hepatic arterial reconstruction in living donor liver transplantation

BACKGROUND

Sufficient arterial flow after living donor liver transplantation (LDLT) is closely related to graft survival and prevention of postoperative complications. However, some unfavorable hepatic arterial conditions in recipients preclude reconstruction, requiring alternative stumps. We have used the right gastroepiploic artery (RGEA) as a first alternative for hepatic inflow.

METHODS

From January 2006 to December 2008, we performed 754 LDLTs including 28 cases of RGEA among hepatic arterial anastomoses. The arterial anastomosis was performed by an single surgeon under 859 a microscope using an end-to-end interrupted suture technique. RGEA was mobilized over 15 cm from the greater curvature of stomach and greater omentum.

RESULTS

The indications for RGEA use included severe hepatic arterial injury from previous transarterial chemoembolization (n=14), need for additional arterial flow in dual-grafts LDLT (n=13), poor blood flow from the recipient hepatic artery (n=3), and arterial injury during hilar dissection (n=3). The mean diameter of the isolated RGEA was 2.0±0.2 mm (range: 1.0-2.5). Most hepatic arterial anastomoses were performed with a significant size discrepancy of more than twofold. All reconstructed hepatic arterial flowes showed good; no complication was identified during the mean follow-up period of 56 months to date.

CONCLUSIONS

Using RGEA as an alternative arterial inflow is a simple, reliable procedure for situations of inadequate recipient hepatic or multiple graft arteries.

Standardization of modified right lobe grafts to minimize vascular outflow complications for adult living donor liver transplantation

BACKGROUND

After >2000 adult living donor liver transplants (LDLTs), we observed minimization of the complication rate using case-by-case modification of venous outflow reconstruction in right liver graft (RLG), standardization seeking intend to provide a hemodynamic- based, regeneration-compliant hepatic outflow reconstruction.

METHODS

We retrospectively examined 100 consecutive adult LDLT using modified RLG before and after application of RLG standardization to compare the 6-month incidences of vascular outflow complications.

RESULT

The right hepatic vein stenting rate for first 6 months was 5% in the customized group and 1% in the standardized group (P=.212). The middle hepatic vein stenting rate for first 6 months was 9% in the customized group and 4% in the standardized group (P=.373). The inferior right hepatic vein stenting rate for first 6 months was 12.8% in the customized group and 7.1% in the standardized group (P=.472). The overall 6-month patient survival rate was 94% in the customized group and 95% in the standardized group (P=.867). The overall incidence of significant RLG venous outflow complications was 19% in the customized group and 8% in the standardized group (P=.023).

CONCLUSION

Standardization as a universal graft model seemed to be more effective and feasible than conventional graft customization requiring individualized case-by-case modification.

De novo malignancies after liver transplantation: incidence comparison with the Korean cancer registry

PURPOSE

De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population.

METHODS

Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed.

RESULTS

Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population.

CONCLUSIONS

OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

Frequency of adverse reactions to first- and second-line anti-tuberculosis chemotherapy in a Korean cohort

OBJECTIVE

To determine the frequency of and risk factors for major adverse drug reactions (MADRs) associated with anti-tuberculosis treatment at a tuberculosis (TB) referral hospital in the Republic of Korea.

METHODS

Data from an ongoing natural history cohort study were analyzed for permanent regimen changes due to adverse drug reactions and confirmed by chart review.

RESULTS

Among 655 subjects, there were 132 MADRs in 112 (17%) subjects. The most common MADRs were gastrointestinal (n = 53), musculoskeletal (n = 22), psychiatric (n = 10), visual (n = 9) and peripheral neuropathic (n = 8). MADRs were more frequent in subjects being treated with second-line regimens (16%) compared to first-line regimens (2.5%). Drugs frequently associated with MADRs were amikacin (3/10, 30%), linezolid (8/29, 28%), para-aminosalicylic acid (47/192, 24%), pyrazinamide (31/528, 5.8%), macrolides (2/44, 4.5%) and cycloserine (12/272, 4.4%). Fluoroquinolones accounted for a single MADR (1/377, 0.003%), despite widespread usage. In multivariate analysis, infection with multi- or extensively drug-resistant disease and previous history of anti-tuberculosis treatment were risk factors for MADR, with adjusted hazard ratios of respectively 2.2 (P = 0.02) and 1.6 (P = 0.04).

CONCLUSION

MADRs are common during anti-tuberculosis chemotherapy in this population, occurring in more than one in six subjects. New and less toxic agents to treat drug-resistant TB are urgently needed.