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Sica GS, Sensi B, Siragusa L, Blasi F, Crispino B, Pirozzi B, Angelico R, Biancone L, Khan J. Surgical management of colon cancer in ulcerative colitis patients with orthotopic liver transplant for primary sclerosing cholangitis. A systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106922. [PMID: 37210276 DOI: 10.1016/j.ejso.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/13/2023] [Accepted: 04/27/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Colon cancer in ulcerative colitis patients with liver transplant (UCCOLT) due to primary sclerosing cholangitis carries significant treatment challenges. Aim of this literature search is to review management strategies and provide a framework to facilitate the decisional process in this clinical setting. METHODS PRISMA-compliant systematic search was followed by critical expert commentary of the results and development of a surgical management algorithm. Endpoints included surgical management, operative strategies, functional and survival outcomes. Technical and strategics aspects with particular regard to the choice of reconstruction were evaluated to tentatively develop an integrated algorithm. RESULTS Ten studies reporting treatment of 20 UCCOLT patients were identified after screening. Nine patients underwent proctocolectomy and end-ileostomy (PC) and eleven had restorative ileal pouch-anal anastomosis (IPAA). Reported results for perioperative outcomes, oncological outcomes, and graft loss were comparable for both procedures. There were no reports of subtotal colectomies and ileo-rectal anastomosis (IRA). CONCLUSIONS Literature in the field is scarce and decision-making is particularly complex. PC and IPAA have been reported with good results. Nevertheless, IRA may also be considered in UCCOLT patients in selected cases, reducing the risks of sepsis, OLT and pouch failure; furthermore, in young patients, it has the advantage of preserving fertility or sexual function. The proposed treatment algorithm may represent a valuable support in guiding surgical strategy.
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Affiliation(s)
- G S Sica
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy.
| | - B Sensi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Siragusa
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - F Blasi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Crispino
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - B Pirozzi
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - R Angelico
- Department of Surgical Science, University of Rome Tor Vergata, Rome, Italy
| | - L Biancone
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - J Khan
- Portsmouth Hospitals, NHS Trust, Portsmouth, UK
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Miyagi Y, Kinjo T, Yoshizumi T, Harada N, Arakaki S, Kinjo T, Hokama A, Takatsuki M. Elective staged proctocolectomy and living donor liver transplantation for colon cancer with sclerosing cholangitis-related ulcerative colitis: a case report. Surg Case Rep 2020; 6:278. [PMID: 33130979 PMCID: PMC7604274 DOI: 10.1186/s40792-020-01059-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/22/2020] [Indexed: 11/10/2022] Open
Abstract
Background Primary sclerosing cholangitis (PSC) is a well-known complication of ulcerative colitis (UC), but it is rare to encounter patients requiring both living donor liver transplantation (LDLT) and proctocolectomy. We report a case of elective two-stage surgery involving proctocolectomy performed after LDLT for a patient with early colon cancer concurrent with PSC-related UC. To our knowledge, this is the first report of concurrent cancer successfully treated with both LDLT and proctocolectomy. Case presentation A 32-year-old Japanese man with colon cancer associated with UC underwent restorative proctocolectomy at 3 months after living donor liver transplantation (LDLT) for PSC. He was diagnosed with PSC and UC when he was a teenager. Conservative therapy was initiated to treat both PSC and UC. He had experienced recurrent cholangitis for years; therefore, a biliary stent was placed endoscopically. However, his liver function progressively deteriorated. Colonoscopic surveillance revealed early colon cancer; hence, surgical treatment was considered. PSC progressed to cirrhosis and portal hypertension; hence, LDLT was performed before restorative proctocolectomy. Three months after LDLT, we performed restorative proctocolectomy with ileal pouch–anal anastomosis. The postoperative course was uneventful. The patient was well, with good liver and bowel functions and without tumor recurrence, more than 1 year after proctocolectomy. Conclusions With strict patient selection and careful patient management and follow-up, elective proctocolectomy may be performed safely and effectively after LDLT for concurrent early colon cancer with PSC-related UC. There are no previous reports of the use of both LDLT and proctocolectomy for the successful treatment of PSC-related UC and concurrent cancer.
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Affiliation(s)
- Yoshihiro Miyagi
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0125, Japan.
| | - Tatsuya Kinjo
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0125, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shingo Arakaki
- Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tetsu Kinjo
- Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Okinawa, Japan
| | - Akira Hokama
- Department of Infectious, Respiratory, and Digestive Medicine, University of the Ryukyus, Okinawa, Japan
| | - Mitsuhisa Takatsuki
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0125, Japan
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Rao BB, Lashner B, Kowdley KV. Reviewing the Risk of Colorectal Cancer in Inflammatory Bowel Disease After Liver Transplantation for Primary Sclerosing Cholangitis. Inflamm Bowel Dis 2018; 24:269-276. [PMID: 29361103 DOI: 10.1093/ibd/izx056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Indexed: 02/07/2023]
Abstract
The presence of concomitant primary sclerosing cholangitis (PSC) with inflammatory bowel disease (IBD) represents a distinct disease phenotype that carries a higher risk of colorectal cancer (CRC) than the average IBD patient. Given that liver transplantation (LT) is the only treatment that offers a survival benefit in PSC patients with hepatic dysfunction, management decisions in IBD patients' post-LT for PSC are frequently encountered. One such consideration is the risk of CRC in this immunosuppressed cohort. With most studies showing an increased risk of CRC post-LT in these IBD patients, a closer look at the associated risk factors of CRC and the adopted surveillance strategies in this subset of patients is warranted. Low-dose ursodeoxycholic acid has shown a potential chemopreventive effect in PSC-IBD patients pre-LT; however, a favorable effect remains to be seen in post-LT group. Also, further studies are necessary to assess the benefit of 5 aminosalicylate therapy. Annual surveillance colonoscopy in the post-LT period is recommended for PSC-IBD patients subset given their high risk for CRC.
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Affiliation(s)
- Bhavana Bhagya Rao
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Bret Lashner
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Kris V Kowdley
- Liver Care Network and Organ Care Research, Swedish Medical Center, Seattle, Washington
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Liu G, Lin J, Xie H, Shen B, Stocchi L, Liu X. Histomorphological features and prognosis of colitis-associated colorectal cancer in patients with primary sclerosing cholangitis. Scand J Gastroenterol 2016; 50:1389-96. [PMID: 26061393 DOI: 10.3109/00365521.2015.1052094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Histomorphology of colitis-associated colorectal cancer (CAC) in patients with primary sclerosing cholangitis (PSC) remains to be systemically characterized and prognosis in these patient needs to be further defined. AIM To examine the impact of PSC on histomorphology and to assess prognosis of CAC-PSC patients. METHODS A cohort of CAC patients were identified from the Pathology Database (1994-2010) at Cleveland Clinic; histomorphological features and other relevant data were collected by retrospective review of pathology slides and medical records. RESULTS A total of 87 CAC patients were included, with 11 patients having PSC (the study group) and 76 patients without PSC (the control group). The overall median follow up was 6 (range: 0-20) years. The patients in the study group had a longer median duration of inflammatory bowel disease prior to CAC diagnosis (p = 0.046). In study group, seven (63.6%) patients had right-sided CAC (vs. 36.8% in the control group, p = 0.11). Background high-grade dysplasia was noted less (9.1% vs. 44.7%), while low-grade dysplasia was detected more in the study group (72.7% vs. 28.9%) (p = 0.02). All histomorphological features were comparable between groups. The overall survival (OS) and progression-free survival (PFS) showed no statistical difference between CAC patients with or without PSC. After excluding TNM stage IV patients, patients with PSC showed a trend toward shorter OS and PFS (p = 0.07 and p = 0.1). CONCLUSION In CAC, histomorphology appeared to be independent of PSC. PSC is associated with a trend toward shorter OS and PFS in CAC patients with stage I-III diseases.
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Affiliation(s)
- Ganglei Liu
- Department of Geriatric Surgery, the Second Xiangya Hospital, Central South University , Changsha , China
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Kekilli M, Tunc B, Beyazit Y, Kurt M, Onal IK, Ulker A, Haznedaroglu IC. Circulating CD4+CD25+ regulatory T cells in the pathobiology of ulcerative colitis and concurrent primary sclerosing cholangitis. Dig Dis Sci 2013; 58:1250-5. [PMID: 23306841 PMCID: PMC3661043 DOI: 10.1007/s10620-012-2511-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 12/01/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Immunopathogenetic features of primary sclerosing cholangitis (PSC) in ulcerative colitis (UC) still remains unclear. Peripheral blood CD4+CD25+ regulatory T cells have a key role in the induction and maintenance of peripheral self-tolerance and inhibit several organ-specific autoimmune diseases. Therefore, CD4+CD25+ T cells are believed to play an essential role in autoimmune diseases. The aim of the present study is to analyze the role of CD4+CD25+ T cells in the pathogenesis of UC-associated PSC. METHODS This study evaluated the levels of CD4+CD25+ T cells in peripheral blood mononuclear cells (PBMC) of 27 UC patients with PSC and 20 UC patients as controls. CD4+CD25+ T cells were isolated from PBMC with a direct immunofluorescence technique, using mice monoclonal antibodies namely FITC-labeled anti-CD4 and PE-labeled anti-CD25. In each patient, CD4+CD25+ T cells percentage in PBMC were studied by flow cytometry, and then the number of CD4+CD25+ T cells were calculated. RESULTS Twenty-seven UC patients with PSC and 20 UC patients without PSC as controls were enrolled in the present study. The percentage of CD4+CD25+ regulatory T cells among PBMC were significantly elevated in UC + PSC patients compared with UC patients without PSC (p = 0.04). CONCLUSIONS CD4+CD25+ T cells were found to be elevated in UC patients with PSC suggesting a partial role of activated T cell response in the disease pathophysiology. Our findings imply that CD4+CD25+ regulatory T cells may play a key role in the immunopathogenesis of UC-associated PSC and may affect the therapeutic management of these diseases.
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Affiliation(s)
- Murat Kekilli
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
| | - Bilge Tunc
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
| | - Yavuz Beyazit
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
| | - Mevlut Kurt
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
| | - Ibrahim Koral Onal
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
| | - Aysel Ulker
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Training and Research Hospital, Kızılay Sok. No: 2, 06100 Sıhhıye, Ankara, Turkey
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Antoniou E, Mantas D, Paraskeva P, Dimitroulis D, Smyrnis A, Nikitakis N, Labadariou A, Tsavaris N, Vernicos P, Kostakis A. How can we treat a patient with liver cirrhosis (hepatitis C virus), hepatocellular carcinoma, and synchronous colon cancer? Transplant Proc 2012; 44:2745-7. [PMID: 23146511 DOI: 10.1016/j.transproceed.2012.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION The coexistence of liver cirrhosis with hepatocellular carcinoma (HCC) and colon cancer (Ca), which is a rare clinical condition, was treated in a liver transplant recipient. PATIENTS AND METHODS A 46-year-old man, diagnosed incidentally during an ultrasound (US) examination with a 3.5-cm HCC in segment VII related to chronic hepatitis C virus (HCV), was referred for liver resection. He underwent a laparoscopic protocol evaluation for liver cirrhosis. Liver appearance and biopsy of the left lobe showed Child B/C liver cirrhosis. Because he fulfilled the Milan criteria, we suggested an orthotopic liver transplantation (OLT). During protocol colonoscopy, we discovered an ulcerative sigmoid colon Ca. Three weeks after completing the pre-OLT assessment he underwent an OLT and was discharged home on day 9 on an immunosuppressive regimen of Everolimus, Myfortic, and Prezolone. Two months after transplantation, the patient underwent a sigmoidectomy and for nearly 1 month thereafter received chemotherapy for colon Ca (6 cycles of FOLFOX:Folinic Acid+Fluorouracil+Oxaliplatin). One and a half years after OLT, patient was in good condition but presented with an increased alpha fetoprotein (a-FP) without other findings. A couple of months later we discovered a colon Ca recurrence and 3 small liver metastases. Patient underwent a bowel resection with Hartmann's procedure. Almost immediately after the last operation, he was found to suffer multiple myeloma. He underwent chemotherapy for both malignancies with good responses, but a few months later died of severe sepsis. DISCUSSION The relevant literature regarding treatment of liver cirrhosis complicated with HCC and synchronous colon Ca reveals poor and controversial outcomes. Our patient underwent chemotherapy immediately after colon resection in the presence of with a good functioning liver. Although his condition was satisfactory after OLT, the optimal treatment of such complicated patients is as yet uncertain.
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Affiliation(s)
- E Antoniou
- 2nd Department of Propaedutic Surgery, School of Medicine, University of Athens, "Laikon" Hospital, Athens, Greece.
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Okita Y, Miki C, Yoshiyama S, Otake K, Araki T, Uchida K, Kusunoki M. Neutrophil dysfunction in steroid-overdosed patients with ulcerative colitis: potential relevance of macrophage migration inhibitory factor to increased postoperative morbidity. Surg Today 2011; 41:1504-11. [PMID: 21969153 DOI: 10.1007/s00595-010-4505-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2010] [Accepted: 08/24/2010] [Indexed: 12/15/2022]
Abstract
PURPOSE We studied macrophage migration inhibitory factor (MIF)-related neutrophil dysfunction in patients with ulcerative colitis (UC), under conditions of surgical stress, focusing in particular on total preoperative steroid dosages. METHODS Neutrophils were isolated from peripheral blood samples obtained from 21 UC patients soon after radical surgery for UC. The patients were divided into two subgroups according to their total preoperative prednisolone dosages. The neutrophil phagocytosis, viable cell, and cell necrosis rates after exposure to Escherichia coli were evaluated by flow cytometry. The supernatant concentrations of mediators after exposure to E. coli were evaluated by enzyme-linked immunosorbent assay. RESULTS There was a significant positive correlation between the levels of MIF and the total preoperative dosage of prednisolone. More viable neutrophils from the high-dosage steroid group patients than from the low-dosage steroid group patients tended to undergo necrosis, followed by the release of neutrophil elastase after exposure to E. coli. The levels of anti-inflammatory cytokines were not enhanced after E. coli stimulation, but the levels of proinflammatory cytokines in the supernatants of neutrophils from the high-dosage steroid group patients were increased significantly. CONCLUSION Steroid-overdosed UC patients with MIF-related neutrophil dysfunction may be at increased risk of destructive local inflammation following surgery.
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Affiliation(s)
- Yoshiki Okita
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative Medicine, Institute of Life Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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