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Schmauch B, Elsoukkary SS, Moro A, Raj R, Wehrle CJ, Sasaki K, Calderaro J, Sin-Chan P, Aucejo F, Roberts DE. Combining a deep learning model with clinical data better predicts hepatocellular carcinoma behavior following surgery. J Pathol Inform 2024; 15:100360. [PMID: 38292073 PMCID: PMC10825615 DOI: 10.1016/j.jpi.2023.100360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 12/10/2023] [Accepted: 12/23/2023] [Indexed: 02/01/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is among the most common cancers worldwide, and tumor recurrence following liver resection or transplantation is one of the highest contributors to mortality in HCC patients after surgery. Using artificial intelligence (AI), we developed an interdisciplinary model to predict HCC recurrence and patient survival following surgery. We collected whole-slide H&E images, clinical variables, and follow-up data from 300 patients with HCC who underwent transplant and 169 patients who underwent resection at the Cleveland Clinic. A deep learning model was trained to predict recurrence-free survival (RFS) and disease-specific survival (DSS) from the H&E-stained slides. Repeated cross-validation splits were used to compute robust C-index estimates, and the results were compared to those obtained by fitting a Cox proportional hazard model using only clinical variables. While the deep learning model alone was predictive of recurrence and survival among patients in both cohorts, integrating the clinical and histologic models significantly increased the C-index in each cohort. In every subgroup analyzed, we found that a combined clinical and deep learning model better predicted post-surgical outcome in HCC patients compared to either approach independently.
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Affiliation(s)
| | - Sarah S. Elsoukkary
- Owkin Lab, Owkin, Inc., New York, NY, USA
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Amika Moro
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Roma Raj
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kazunari Sasaki
- Department of Surgery, Stanford University, Palo Alto, CA, USA
| | - Julien Calderaro
- Department of Pathology, Henri Mondor University Hospital, Créteil, France
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Wehrle CJ, Zhang M, Khalil M, Pita A, Modaresi Esfeh J, Diago-Uso T, Kim J, Aucejo F, Kwon DC, Ali K, Cazzaniga B, Miyazaki Y, Liu Q, Fares S, Hong H, Tuul M, Jiao C, Sun K, Fairchild RL, Quintini C, Fujiki M, Pinna AD, Miller C, Hashimoto K, Schlegel A. Impact of Back-to-Base Normothermic Machine Perfusion on Complications and Costs: A Multi-Center, Real-World Risk-Matched Analysis. Ann Surg 2024:00000658-990000000-00830. [PMID: 38557793 DOI: 10.1097/sla.0000000000006291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Assess cost and complication outcomes after liver transplantation (LT) using normothermic machine perfusion (NMP). SUMMARY BACKGROUND DATA End-ischemic NMP is often used to aid logistics, yet its' impact on outcomes after LT remains unclear, as does its' true impact on costs associated with transplantation. METHODS Deceased donor liver recipients at two centers (1/1/2019-6/30/2023) were included. Retransplants, splits and combined grafts were excluded. End-ischemic NMP (OrganOx-Metra®) was implemented 10/2022 for extended-criteria DBDs, all DCDs and logistics. NMP-cases were matched 1:2 with cold storage controls (SCS) using the Balance-of-Risk (DBD-grafts) and UK-DCD Score (DCD-grafts). RESULTS Overall, 803 transplantations were included, 174 (21.7%) receiving NMP. Matching was achieved between 118 NMP-DBDs with 236 SCS; and 37 NMP-DCD with 74 corresponding SCS. For both graft types, median inpatient comprehensive complications index (CCI) values were comparable between groups. DCD-NMP grafts experienced reduced cumulative 90-day CCI (27.6 vs. 41.9, P=0.028). NMP also reduced the need for early relaparotomy and renal-replacement-therapy, with subsequently less-frequent major complications (Clavien-Dindo >IVa). This effect was more pronounced in DCD-transplants. NMP had no protective effect on early biliary complications. Organ acquisition/preservation costs were higher with NMP, yet NMP-treated grafts had lower 90-day pre-transplant costs in context of shorter waiting-list times. Overall costs were comparable for both cohorts. CONCLUSIONS This is the first risk-adjusted outcome and cost analysis comparing NMP and SCS. In addition to logistical benefits, NMP was associated with a reduction in relaparotomy and bleeding in DBD-grafts, and overall complications and post-LT renal-replacement for DCDs. While organ acquisition/preservation was more costly with NMP, overall 90-day-healthcare costs-per-transplantation were comparable.
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Affiliation(s)
| | | | | | | | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, OH
| | - Teresa Diago-Uso
- Cleveland Clinic Abu Dhabi, Department of Liver Transplantation, Cleveland, OH
| | - Jaekeun Kim
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Khaled Ali
- Transplantation Center, Cleveland Clinic, OH
| | | | | | - Qiang Liu
- Transplantation Center, Cleveland Clinic, OH
| | - Sami Fares
- Transplantation Center, Cleveland Clinic, OH
| | - Hanna Hong
- Transplantation Center, Cleveland Clinic, OH
| | | | - Chunbao Jiao
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Keyue Sun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Robert L Fairchild
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Cristiano Quintini
- Cleveland Clinic Abu Dhabi, Department of Liver Transplantation, Cleveland, OH
| | | | | | | | - Koji Hashimoto
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
| | - Andrea Schlegel
- Transplantation Center, Cleveland Clinic, OH
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland, OH
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Wehrle CJ, Woo K, Chang J, Gamaleldin M, DeHaan R, Dahdaleh F, Felder S, Rosen DR, Champagne B, Steele SR, Naffouje SA. Impact of neoadjuvant therapy on nodal harvest in clinical stage III rectal cancer: Establishing optimum cut-offs by disease response. J Surg Oncol 2024; 129:945-952. [PMID: 38221655 DOI: 10.1002/jso.27586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/19/2023] [Accepted: 12/29/2023] [Indexed: 01/16/2024]
Abstract
INTRODUCTION A minimum lymph node harvest (LNH) of 12 is the current standard for appropriate nodal staging in resectable rectal cancer. However, the rise of neoadjuvant chemoradiation (NCRT) and total neoadjuvant therapy (TNT) has been associated with decreasing number of LNH. We hypothesize that as tumor response to neoadjuvant therapy increases, the optimum for LNH to achieve appropriate nodal staging should decrease. METHODS Patients with clinical stage III rectal adenocarcinoma who underwent NCRT/TNT followed by resection were identified from the National Cancer Database. A JoinPoint regression analysis was used to determine the LNH for each tumor regression grade (TRG) category beyond which the rate of positive nodes does not significantly change. RESULTS Thirteen thousand four hundred and twenty-six patients met inclusion criteria. Of these, 2406 (17.9%) achieved TRG 0 or ypT0 and 8210 (61.2%) achieved ypN0. Collectively, 2043 patients (15.2%) were reported to have a pathologic complete response (ypT0 ypN0). Positive pathologic nodes were found in 15%, 23%, 31%, 54%, and 53% as ypT stage increased from ypT0 to ypT4, respectively. Similarly, ypN+ rates were 15%, 36%, 41%, and 55% in TRG 0-3. No JoinPoint was identified for TRG 0, whereas inflection points were found at 6-10 nodes for TRG1 (p = 0.002) and TRG 2 (p = 0.016), and at 11-15 nodes for TRG 3. CONCLUSION The benchmark of retrieving 12 nodes in resectable stage III rectal cancer is not consistently achieved after NCRT/TNT. We demonstrate that the LNH requirement to establish accurate pathologic nodal staging can vary depending on the tumor response to neoadjuvant therapies.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Kimberly Woo
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Jenny Chang
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Maysoon Gamaleldin
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Reece DeHaan
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Elmhurst, Illinois, USA
| | - Seth Felder
- Moffitt Cancer Center, GI Oncology Program, Tampa, Florida, USA
| | - David R Rosen
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Bradley Champagne
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Scott R Steele
- Cleveland Clinic Digestive Diseases and Surgery and Institute, Colorectal Surgery, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Cleveland Clinic, Digestive Diseases and Surgery and Institute, General Surgery, Cleveland, Ohio, USA
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Said SA, Perlmutter BC, Wehrle CJ, Chang J, Hossain MS, Naffouje S, Joyce D, Simon R, Walsh RM, Augustin T. Tumor Size Combined With CA-19 Level Improves Prediction of Survival of Patients With Pancreatic Adenocarcinoma Undergoing Perioperative Chemotherapy and Resection. Am Surg 2024:31348241241738. [PMID: 38513242 DOI: 10.1177/00031348241241738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
BACKGROUND AND OBJECTIVE Five-year survival in pancreatic adenocarcinoma is less than 20%. While previous studies have postulated that a carbohydrate antigen 19-9 (CA19-9) threshold could predict outcome of resection, the role for CA19-9 in decision-making remains unclear. This study aims to assess whether CA19-9 levels combined with tumor size improve prediction of post-resection survival. METHOD A retrospective analysis was conducted on 109 patients with pancreatic adenocarcinoma who underwent perioperative chemotherapy followed by resection. The primary outcome of mortality was, divided into short (<1 year) or prolonged (>2 years). Univariate and multivariable analyses compared the tumor size-adjusted CA19-9 between the outcome groups. RESULTS Twenty-seven (24.78%) and eighty-two (75.23%) patients were in the short survival and prolonged-survival groups, respectively. The mean CA19-9 was significantly greater in the short vs prolonged group (P < .001). Analyzing CA19-9 level by tumor size, the association of high CA19-9 and short survival was significant for small (≤2 cm) and large tumor (>4 cm), but not for intermediate-size tumors (2-4 cm). Adjusting for preoperative variable did not change this association. CONCLUSION CA 19-9 in combination with tumor size better identifies patients with prolonged post-resection survival. This prediction is most accurate in patients with either small (≤2 cms) or large (>4 cms) tumors compared to intermediate-size tumors.
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Affiliation(s)
- Sayf A Said
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Chase J Wehrle
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Samer Naffouje
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
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Wehrle CJ, Chang JH, Gross AR, Woo K, Naples R, Stackhouse KA, Dahdaleh F, Augustin T, Joyce D, Simon R, Walsh RM, Naffouje SA. Comparing oncologic and surgical outcomes of robotic and laparoscopic pancreatoduodenectomy in patients with pancreatic cancer: a propensity-matched analysis. Surg Endosc 2024:10.1007/s00464-024-10783-1. [PMID: 38498210 DOI: 10.1007/s00464-024-10783-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/07/2024] [Indexed: 03/20/2024]
Abstract
INTRODUCTION Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied. METHODS The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles. RESULTS A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9 days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50-0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92-1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68-1.71), 30-day (HR = 0.78, 95% CI = 0.39-1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42-1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92-1.44), nodal harvest (HR = 1.01, 95%CI = 0.94-1.09) or positive margins (HR = 1.19, 95% CI = 0.89-1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033). CONCLUSION LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Jenny H Chang
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Abby R Gross
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kimberly Woo
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Robert Naples
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Naperville, IL, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Wehrle CJ, Maspero M, Pinna AD, Dutkowski P, Miller C, Hashimoto K, Clavien PA, Schlegel A. Age Matters: What Affects the Cumulative Lifespan of a Transplanted Liver? Ann Surg 2024:00000658-990000000-00803. [PMID: 38489660 DOI: 10.1097/sla.0000000000006259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Assess factors affecting the cumulative lifespan of a transplanted liver. SUMMARY BACKGROUND DATA Liver ageing is different from other solid organs. It is unknown how old a liver can actually get after liver transplantation (LT). METHODS Deceased donor liver transplants from 1988-2021 were queried from the United States (US) UNOS registry. Cumulative liver age was calculated as donor age + recipient graft survival. RESULTS In total, 184,515 livers were included. Most were DBD-donors (n=175,343). The percentage of livers achieving >70, 80, 90 and 100years cumulative age was 7.8% (n=14,392), 1.9% (n=3,576), 0.3% (n=528), and 0.01% (n=21), respectively. The youngest donor age contributing to a cumulative liver age >90years was 59years, with post-transplant survival of 34years. In pediatric recipients, 736 (4.4%) and 282 livers (1.7%) survived >50 and 60years overall, respectively. Transplanted livers achieved cumulative age >90years in 2.86-per-1000 and >100years in 0.1-per-1000. The US population at-large has a cumulative "liver age" >90years in 5.35-per-1000 persons, and >100y in 0.2-per-1000. Livers aged>60 years at transplant experienced both improved cumulative survival ( P <0.0001) and interestingly improved survival after transplantation ( P <0.0001). Recipient warm-ischemia-time of >30minutes was most predictive of reduced cumulative liver survival overall (n=184,515, HR=1.126, P <0.001) and excluding patients with mortality in the first 6month (n=151,884, HR=0.973, P <0.001). CONCLUSIONS In summary, transplanted livers frequently get as old as those in the average population despite ischemic-reperfusion-injury and immunosuppression. The presented results justify using older donor livers regardless of donation type, even in sicker recipients with limited options.
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Affiliation(s)
- Chase J Wehrle
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | - Marianna Maspero
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
- Upper GI Surgery and Liver Transplantation Unit, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | | | - Philipp Dutkowski
- Department of Surgery and Transplantation, Swiss HPB Centre, University Hospital Zurich, Switzerland
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
| | | | - Andrea Schlegel
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, Ohio, US
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, Ohio, US
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Wehrle CJ, Raj R, Aykun N, Orabi D, Estfan B, Kamath S, Krishnamurthi S, Fujiki M, Hashimoto K, Quintini C, Kwon DCH, Diago-Uso T, Sasaki K, Aucejo FN. Correction to "Liquid Biopsy by ctDNA in Liver Transplantation for Colorectal Cancer Liver Metastasis" [J Gastrointest Surg. 2023;27(7):1498-509]. J Gastrointest Surg 2024; 28:336. [PMID: 38445929 DOI: 10.1016/j.gassur.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Chase J Wehrle
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States.
| | - Roma Raj
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Nihal Aykun
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Danny Orabi
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Bassam Estfan
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Suneel Kamath
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Smitha Krishnamurthi
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Masato Fujiki
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Koji Hashimoto
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Cristiano Quintini
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - David Choon Hyuck Kwon
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Teresa Diago-Uso
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
| | - Kazunari Sasaki
- Department of Surgery - Abdominal Transplantation, Stanford Hospital and Clinics, Palo Alto, California, United States
| | - Federico N Aucejo
- Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States
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Wehrle CJ, Perlmutter B, Hong H, Chang J, Stackhouse KA, Naples R, Shanaz Hossain M, Joyce D, Simon R, Kim J, Naffouje SA, Aucejo F, Kwon DCH, Walsh RM, Augustin T. Impact of autotransfusion on recurrence of colorectal cancer liver metastasis: Long-term follow-up of patients undergoing curative intent hepatectomy. J Surg Oncol 2024; 129:793-801. [PMID: 38151831 DOI: 10.1002/jso.27569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Colorectal cancer liver metastasis (CRLM) occurs in upto 50% of cases and drives patient outcomes. Up-front liver resection is the treatment of choice in resectable cases. There is no consensus yet established as to the safety of intraoperative autotransfusion in liver resection for CRLM. METHODS Patients undergoing curative-intent hepatectomy for CRLM at a single quaternary-care institution from 1999 to 2016 were included. Demographics, surgical variables, Fong Clinical Risk Score (FCRS), use of intraoperative auto and/or allotransfusion, and survival data were analyzed. Propensity score matching (PSM) was performed accounting for allotransfusion, extent of hepatectomy, FCRS, and systemic treatment regimens. RESULTS Three-hundred sixteen patients were included. The median follow-up was 10.4 years (7.8-14.1 years). The median recurrence-free survival (RFS) and overall survival (OS) in all patients were 1.6 years (interquartile range: 0.63-6.6 years) and 4.4 years (2.1-8.7), respectively. Before PSM, there was a significantly reduced RFS in the autotransfusion group (0.96 vs. 1.73 years, p = 0.20). There was no difference in OS (4.11 vs. 4.44 years, p = 0.118). Patients in groups of FCRS 0-2 and 3-5 both had reduced RFS when autotransfusion was used (p = 0.005). This reduction in RFS was further found when comparing autotransfusion versus no autotransfusion within the FCRS 0-2 group and within the FCRS 3-5 group (p = 0.027). On Cox-regression analysis, autotransfusion (hazard ratio = 1.423, 1.028-2.182, p = 0.015) remained predictive of RFS. After PSM, there were no differences in FCRS (p = 0.601), preoperative hemoglobin (p = 0.880), allotransfusion (p = 0.130), adjuvant chemotherapy (p = 1.000), immunotherapy (p = 0.172), tumor grade (p = 1.000), use of platinum-based chemotherapy (p = 0.548), or type of hepatic resection (p = 0.967). After matching, there was a higher rate of recurrence with autotransfusion (69.0% vs. 47.6%, p = 0.046). There was also a reduced time to recurrence in the autotransfusion group compared with the group without (p = 0.006). There was no difference in OS after PSM (p = 0.262). CONCLUSION Autotransfusion may adversely affect recurrence in liver resection for CRLM. Until further studies clarify this risk profile, the use of intraoperative autotransfusion should be critically assessed on a case-by-case basis only when other resuscitation options are not available.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Breanna Perlmutter
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hanna Hong
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rob Naples
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - M Shanaz Hossain
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jaekeun Kim
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David C H Kwon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Wehrle CJ, Prabhu AS, Thompson R, Petro CC, Miller BT, Krpata DM, Rosen MJ, Huang LC, Beffa LR. Mesh versus suture repair of incisional hernias 2 cm or less: Is mesh necessary? A propensity score-matched analysis of the abdominal core health quality collaborative. Surgery 2024; 175:799-805. [PMID: 37716868 DOI: 10.1016/j.surg.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/13/2023] [Accepted: 08/08/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Mesh has been the acceptable standard for incisional hernia repair regardless of hernia size. It is not clear whether there is a size of incisional hernias in whom repair would be best performed without mesh. This study aims to compare outcomes of mesh versus suture repairs for incisional hernias <2 cm in size. METHODS Incisional hernia repairs from 2012 to 2021 for hernias ≤2 cm in width were queried from the Abdominal Core Health Quality Collaborative. Those with 1-year follow up were considered. Hernia recurrence was defined using composite hernia recurrence, which combines both clinical and patient reported outcomes. Propensity score matching was performed between mesh and non-mesh using body mass index, smoking, diabetes, and drains as covariates. RESULTS A total of 352 patients met inclusion criteria. After propensity score matching, there were 132 repairs with mesh and 71 without. There was no difference in recurrence rates at 1 year between mesh and non-mesh repairs (15% vs 24%, P = .12). Mesh was associated with a higher rate of 30-day postoperative complications (11% vs 1%, P = .017). There were no differences in 1-year quality of life scores. CONCLUSION The repair of incisional hernias ≤2 cm without mesh results in similar recurrence rates, similar quality of life scores, and lower postoperative early complications compared with repairs with mesh. Our findings suggest that there may be select patients with small incisional hernias that could reasonably undergo incisional hernia repair without mesh. Longer-term follow-up is needed to confirm ideal candidates and durability of these repairs.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH.
| | - Ajita S Prabhu
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Reid Thompson
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Clayton C Petro
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Benjamin T Miller
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - David M Krpata
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Michael J Rosen
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH
| | - Li-Ching Huang
- Vanderbilt University Medical Center, Department of Biostatistics, Nashville, TN
| | - Lucas R Beffa
- Cleveland Clinic Foundation Center for Abdominal Core Health, Cleveland, OH. https://twitter.com/BeffaLukeMD
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10
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Hong H, Wehrle CJ, Zhang M, Fares S, Stitzel H, Garib D, Estfan B, Kamath S, Krishnamurthi S, Ma WW, Kuzmanovic T, Azzato E, Yilmaz E, Modaresi Esfeh J, Linganna MW, Khalil M, Pita A, Schlegel A, Kim J, Walsh RM, Miller C, Hashimoto K, Kwon DCH, Aucejo F. Circulating Tumor DNA Profiling in Liver Transplant for Hepatocellular Carcinoma, Cholangiocarcinoma, and Colorectal Liver Metastases: A Programmatic Proof of Concept. Cancers (Basel) 2024; 16:927. [PMID: 38473290 DOI: 10.3390/cancers16050927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/15/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Circulating tumor DNA (ctDNA) is emerging as a promising, non-invasive diagnostic and surveillance biomarker in solid organ malignancy. However, its utility before and after liver transplant (LT) for patients with primary and secondary liver cancers is still underexplored. METHODS Patients undergoing LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), and colorectal liver metastases (CRLM) with ctDNA testing were included. CtDNA testing was conducted pre-transplant, post-transplant, or both (sequential) from 11/2019 to 09/2023 using Guardant360, Guardant Reveal, and Guardant360 CDx. RESULTS 21 patients with HCC (n = 9, 43%), CRLM (n = 8, 38%), CCA (n = 3, 14%), and mixed HCC/CCA (n = 1, 5%) were included in the study. The median follow-up time was 15 months (range: 1-124). The median time from pre-operative testing to surgery was 3 months (IQR: 1-4; range: 0-5), and from surgery to post-operative testing, it was 9 months (IQR: 2-22; range: 0.4-112). A total of 13 (62%) patients had pre-transplant testing, with 8 (62%) having ctDNA detected (ctDNA+) and 5 (32%) not having ctDNA detected (ctDNA-). A total of 18 (86%) patients had post-transplant testing, 11 (61%) of whom were ctDNA+ and 7 (33%) of whom were ctDNA-. The absolute recurrence rates were 50% (n = 5) in those who were ctDNA+ vs. 25% (n = 1) in those who were ctDNA- in the post-transplant setting, though this difference was not statistically significant (p = 0.367). Six (29%) patients (HCC = 3, CCA = 1, CRLM = 2) experienced recurrence with a median recurrence-free survival of 14 (IQR: 6-40) months. Four of these patients had positive post-transplant ctDNA collected following diagnosis of recurrence, while one patient had positive post-transplant ctDNA collected preceding recurrence. A total of 10 (48%) patients had sequential ctDNA testing, of whom n = 5 (50%) achieved ctDNA clearance (+/-). The remainder were ctDNA+/+ (n = 3, 30%), ctDNA-/- (n = 1, 10%), and ctDNA-/+ (n = 1, 11%). Three (30%) patients showed the acquisition of new genomic alterations following transplant, all without recurrence. Overall, the median tumor mutation burden (TMB) decreased from 1.23 mut/Mb pre-transplant to 0.00 mut/Mb post-transplant. CONCLUSIONS Patients with ctDNA positivity experienced recurrence at a higher rate than the ctDNA- patients, indicating the potential role of ctDNA in predicting recurrence after curative-intent transplant. Based on sequential testing, LT has the potential to clear ctDNA, demonstrating the capability of LT in the treatment of systemic disease. Transplant providers should be aware of the potential of donor-derived cell-free DNA and improved approaches are necessary to address such concerns.
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Affiliation(s)
- Hanna Hong
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Chase J Wehrle
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mingyi Zhang
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Sami Fares
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Henry Stitzel
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - David Garib
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Bassam Estfan
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Suneel Kamath
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Smitha Krishnamurthi
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Wen Wee Ma
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Teodora Kuzmanovic
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Elizabeth Azzato
- Molecular Pathology and Cytogenomics, Pathology and Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Emrullah Yilmaz
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Maureen Whitsett Linganna
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Mazhar Khalil
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Alejandro Pita
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Andrea Schlegel
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Jaekeun Kim
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - R Matthew Walsh
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Charles Miller
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Koji Hashimoto
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - David Choon Hyuck Kwon
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Federico Aucejo
- Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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11
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Wehrle CJ, Fujiki M, Schlegel A, Whitsett Linganna M, Pita A, Kim JK, Kwon DCH, Miller C, Hashimoto K, Dueland S, Sasaki K, Sapisochin G, Line PD, Hernandez-Alejandro R, Aucejo F. Update to 'A Contemporary Systematic Review on Liver Transplantation for Unresectable Liver Metastasis of Colorectal Cancer'. Ann Surg Oncol 2024; 31:697-700. [PMID: 37996635 DOI: 10.1245/s10434-023-14611-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
Colorectal cancer is the second most common cause of cancer-related death worldwide, and half of patients present with colorectal liver metastasis (CRLM). Liver transplant (LT) has emerged as a treatment modality for otherwise unresectable CRLM. Since the publication of the Lebeck-Lee systematic review in 2022, additional evidence has come to light supporting LT for CRLM in highly selected patients. This includes reports of >10-year follow-up with over 80% survival rates in low-risk patients. As these updated reports have significantly changed our collective knowledge, this article is intended to serve as an update to the 2022 systematic review to include the most up-to-date evidence on the subject.
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Affiliation(s)
- Chase J Wehrle
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Masato Fujiki
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Andrea Schlegel
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Alejandro Pita
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jae-Keun Kim
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David C H Kwon
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Charles Miller
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Koji Hashimoto
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Svein Dueland
- Department of Transplantation, Oslo University Hospital, Oslo, Norway
| | - Kazunari Sasaki
- Department of Abdominal Transplantation, Stanford University, Palo Alto, CA, USA
| | - Gonzalo Sapisochin
- Department of Abdominal Transplant and HPB Surgical Oncology, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Pal-Dag Line
- Department of Transplantation, Oslo University Hospital, Oslo, Norway
| | | | - Federico Aucejo
- Department of Liver Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
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12
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Wehrle CJ, Raj R, Maspero M, Satish S, Eghtesad B, Pita A, Kim J, Khalil M, Calderon E, Orabi D, Zervos B, Modaresi Esfeh J, Whitsett Linganna M, Diago-Uso T, Fujiki M, Quintini C, Kwon CD, Miller C, Pinna A, Aucejo F, Hashimoto K, Schlegel A. Risk assessment in liver transplantation for hepatocellular carcinoma: long-term follow-up of a two-center experience. Int J Surg 2024:01279778-990000000-01005. [PMID: 38241354 DOI: 10.1097/js9.0000000000001104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 01/21/2024]
Abstract
BACKGROUND Liver transplantation (LT) is a well-established treatment for hepatocellular carcinoma (HCC), but there are ongoing debates regarding outcomes and selection. This study examines the experience of LT for HCC at a high-volume center. METHODS A prospectively maintained database was used to identify HCC patients undergoing LT from 2000-2020 with>3 years follow-up. Data was obtained from the center database and electronic medical records. The Metroticket 2.0 HCC-specific five-year survival scale was calculated for each patient. Kaplan-Meier and Cox-regression analyses were employed assessing survival between groups based on Metroticket score and individual donor and recipient risk factors. RESULTS 569 patients met criteria. Median follow-up was 96.2 months (8.12 y; IQR 59.9-147.8). Three-year recurrence-free (RFS) and overall survival (OS) were 88.6% (n=504) and 86.6% (n=493). Five-year RFS and OS were 78.9% (n=449) and 79.1% (n=450). Median Metroticket 2.0 score was 0.9 (IQR 0.9-0.95). Tumor size>3 cm (P=0.012), increasing tumor number on imaging (P=0.001) and explant pathology (P<0.001) was associated with recurrence. Transplant within Milan (P<0.001) or UCSF-criteria (P<0.001) had lower recurrence rates. Increasing AFP-values were associated with more HCC-recurrence (P<0.001) and reduced OS (P=0.008). Chemoembolization was predictive of recurrence in the overall population (P=0.043) and in those outside Milan criteria (P=0.038). A receiver-operator curve using Metroticket 2.0 identified an optimal cut-off of projected survival>87.5% for predicting recurrence. This cut-off was able to predict RFS (P<0.001) in the total cohort and predict both, RFS (P=0.007) and OS (P=0.016) outside-Milan. Receipt of donation after brain death (DBD) grafts (55/478, 13%) or living-donor grafts (3/22, 13.6%) experienced better survival rates compared to donation after cardiac death (DCD) grafts (n=15/58, 25.6%, P=0.009). Donor age was associated with a higher HCC-recurrence (P=0.006). Both total ischemia time (TIT)>6hours (P=0.016) and increasing TIT correlated with higher HCC-recurrence (P=0.027). The use of DCD-grafts for outside-Milan candidates was associated with increased recurrence (P=0.039) and reduced survival (P=0.033). CONCLUSION This large two-center analysis confirms favorable outcomes after LT for HCC. Tumor size and number, pre-transplant AFP, and Milan criteria remain important recipient HCC-risk factors. A higher donor risk (i.e., donor age, DCD-grafts, ischemia time) was associated with poorer outcomes.
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Affiliation(s)
- Chase J Wehrle
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Roma Raj
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Marianna Maspero
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Sangeeta Satish
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Bijan Eghtesad
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Alejandro Pita
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Jaekeun Kim
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Mazhar Khalil
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Esteban Calderon
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Danny Orabi
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Bobby Zervos
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL
| | | | | | - Teresa Diago-Uso
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Masato Fujiki
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Cristiano Quintini
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Choon David Kwon
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Charles Miller
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Antonio Pinna
- Cleveland Clinic Weston Hospital, Department of Liver Transplantation, Weston, FL
| | - Federico Aucejo
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Koji Hashimoto
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
| | - Andrea Schlegel
- Transplantation Center, Department of Surgery, Digestive Disease Institute, Cleveland Clinic, OH
- Department of Immunology, Lerner Research Institute, Cleveland Clinic, OH
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13
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Wehrle CJ, Schlegel A, Khalil M, Rotroff D, Del Prete L, Maspero M, Raj R, Frankel WC, Eghtesad B, Aucejo F, Fujiki M, Kwon CD, Kim J, Tong MZY, Unai S, Cywinski J, Modaresi Esfeh J, Fares M, Pita A, Miller C, Quintini C, Hashimoto K, Diago-Uso T. Combined Liver Transplant and Cardiac Surgery: Long-Term Outcomes and Predictors of Success. Ann Surg 2023:00000658-990000000-00710. [PMID: 38050733 DOI: 10.1097/sla.0000000000006171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
OBJECTIVE We aim to report our institutional outcomes of single-staged combined liver transplantation (LT) and cardiac surgery (CS). SUMMARY BACKGROUND DATA Concurrent LT and CS is a potential treatment for combined cardiac dysfunction and end-stage liver disease, yet only 54 cases have been previously reported in the literature. Thus, the outcomes of this approach are relatively unknown, and this approach has been previously regarded as extremely risky. METHODS Thirty-one patients at our institution underwent combined cardiac surgery and liver transplant. Patients with at least one-year follow-up were included. The Leave-One-Out Cross-Validation (LOOCV) machine-learning approach was used to generate a model for mortality. RESULTS Median follow-up was 8.2 years (IQR 4.6-13.6 y). One- and five-year survival was 74.2% (N=23) and 55% (N=17), respectively. Negative predictive factors of survival included recipient age>60 years (P=0.036), NASH-cirrhosis (P=0.031), Coronary Artery Bypass-Graft (CABG)-based CS (P=0.046) and pre-operative renal dysfunction (P=0.024). The final model demonstrated that renal dysfunction had a relative weighted impact of 3.2 versus CABG (1.7), age ≥60y (1.7) or NASH (1.3). Elevated LT+CS risk score was associated with an increased five-year mortality after surgery (AUC=0.731, P=<0.001). Conversely, the widely accepted STS-PROM calculator was unable to successfully stratify patients according to 1- (P>0.99) or 5-year (P=0.695) survival rates. CONCLUSIONS This is the largest series describing combined LT+CS, with joint surgical management appearing feasible in highly selected patients. CABG and pre-operative renal dysfunction are important negative predictors of mortality. The four-variable LT+CS score may help predict patients at high risk for post-operative mortality.
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Affiliation(s)
- Chase J Wehrle
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Andrea Schlegel
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Mazhar Khalil
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Daniel Rotroff
- Quantitative Health Sciences, Cleveland Clinic, Cleveland OH
| | - Luca Del Prete
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | | | - Roma Raj
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - William C Frankel
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Bijan Eghtesad
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Federico Aucejo
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Masato Fujiki
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | | | - Jaekeun Kim
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Michael Z Y Tong
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Shinya Unai
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | | | | | - Maan Fares
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Alejandro Pita
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | - Charles Miller
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
| | | | - Koji Hashimoto
- Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
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14
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Wehrle CJ, Seavey CN, Chang J, Stackhouse K, Woo K, Augustin T, Joyce D, Simon R, Walsh RM, Naffouje SA. ASO Visual Abstract: Neoadjuvant Gastric Score-How Response to Neoadjuvant Chemotherapy Affects Overall Survival and Adjuvant Benefit. Ann Surg Oncol 2023; 30:8607-8608. [PMID: 37743456 DOI: 10.1245/s10434-023-14323-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Caleb N Seavey
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Kimberly Woo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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15
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Wehrle CJ, Seavey CN, Chang J, Stackhouse K, Woo K, Augustin T, Joyce D, Simon R, Walsh RM, Naffouje SA. Neoadjuvant Gastric Score: How Response to Neoadjuvant Chemotherapy Affects Overall Survival and Adjuvant Benefit. Ann Surg Oncol 2023; 30:7240-7250. [PMID: 37659978 DOI: 10.1245/s10434-023-14259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/22/2023] [Indexed: 09/04/2023]
Abstract
INTRODUCTION The Neoadjuvant Rectal score (NAR) was developed as a short-term surrogate for 5-year overall survival (OS) prediction in locally advanced rectal cancer on the basis of response to neoadjuvant therapy. We aim to assess whether this score can be repurposed for locally advanced gastric adenocarcinoma treated with neoadjuvant chemotherapy followed by surgical resection. METHODS Patients with gastric adenocarcinoma treated with neoadjuvant systemic therapy followed by surgical resection were extracted from the National Cancer Database. Neoadjuvant Gastric (NAG) scores were calculated, and patients were stratified into low-, intermediate-, and high-score categories, with low scores predicting longer survival. Patients were propensity-matched 1:1:1 between the groups for OS comparison. We also matched patients within each group 1:1 per receipt of adjuvant therapy and compared 5-year OS. RESULTS There were 2,970 patients identified. NAG classified patients into low- (n = 396, 13.3%), intermediate-(n = 756, 25.5%), and high (n = 1818, 61.2%) groups. After propensity matching, 5-year OS was significantly different between the matched groups (low-NAG 82%, intermediate-NAG 73%, and high-NAG 39%; p < 0.001). NAG score grouping also predicted OS benefit of adjuvant therapy; low- and intermediate-NAG patients had no OS benefit with adjuvant therapy (86% vs. 84%; p = 0.492, and 77% vs. 74%; p = 0.382, respectively), whereas patients with high-NAG score had a 5-year OS benefit with adjuvant therapy (39% vs. 29%; p = 0.024). CONCLUSION NAR score may be repurposed to generate a prognostic tool in gastric adenocarcinoma to predict 5-year OS and has the potential to guide decision-making regarding allocation of adjuvant therapy. Further studies should prospectively validate these findings to confirm clinical utility.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Caleb N Seavey
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Kimberly Woo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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16
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Wehrle CJ, Quinones PM, Smith HT, Fox ED, Holsten SB, Lawson A. Assessing the Impact of Hands-Free Georgia on Serious Motor Vehicle Accidents. Am Surg 2023; 89:4789-4792. [PMID: 36284492 DOI: 10.1177/00031348221136575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
BACKGROUND Hands-Free Georgia Law (HB673) was designed to prevent motor vehicle collisions (MVCs) by banning drivers from using their hands for non-driving-related activities, including cell phone use. We investigate HB673 effect on trauma activations secondary to MVCs in Georgia. METHODS The Georgia Trauma Registry (GTR) was queried for MVCs from 2017 to 2019, representing the 18 months prior and following implementation of HB673. The number of MVCs for each period and severity of MVC designated by the average injury severity score (ISS) for each trauma activation were collected. RESULTS Prior to implementation, a total of 43 080 traumas were recorded in GTR, 11 111 (25.8%) were attributed to an MVC. Following implementation, 12 130 (23.6%) occurred secondary to MVCs. Statewide MVC-related traumas per 1000 residents increased from 1.07 to 1.14 with increased mortality rate and unchanged median ISS per MVC. CONCLUSIONS The Hands-Free Georgia Law seems to have not had a major reduction in mortality in its early implementation.
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Affiliation(s)
- Chase J Wehrle
- Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | | | - Hallie T Smith
- Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Elizabeth D Fox
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Steven B Holsten
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
| | - Andrew Lawson
- Department of Surgery, Medical College of Georgiaat Augusta University, Augusta, GA, USA
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Wehrle CJ, Woo K, Raj R, Chang J, Stackhouse KA, Dahdaleh F, Augustin T, Joyce D, Simon R, Kim J, Aucejo F, Walsh RM, Kwon DCH, Pawlik TM, Naffouje SA. Comparing Outcomes of Minimally Invasive and Open Hepatectomy for Primary Liver Malignancies in Patients with Low-MELD Cirrhosis. J Gastrointest Surg 2023; 27:2424-2433. [PMID: 37620660 DOI: 10.1007/s11605-023-05817-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Cirrhotic patients with primary liver cancer may undergo curative-intent resection when selected appropriately. Patients with T1 tumors and low-MELD are generally referred for resection. We aim to evaluate whether minimally invasive hepatectomy (MIH) is associated with improved outcomes versus open hepatectomy (OH). METHODS NSQIP hepatectomy database 2014-2021 was used to select patients with T1 Hepatocellular Carcinoma (HCC) or Intra-hepatic Cholangiocarcionoma (IHCC) and low-MELD cirrhosis (MELD ≤ 10) who underwent partial hepatectomy. Propensity score matching was applied between OH and MIH patients, and 30-day postoperative outcomes were compared. Multivariable regression was used to identify predictors of post-hepatectomy liver failure (PHLF) in the selected population. RESULTS There were 922 patients: 494 (53.6%) OH, 372 (40.3%) MIH, and 56 (6.1%) began MIH converted to OH (analyzed with the OH cohort). We matched 354 pairs of patients with an adequate balance between the groups. MIH was associated with lower rates of bile leak (HR 0.37 [0.19-0.72)], PHLF (HR 0.36 [0.15-0.86]), collections requiring drainage (HR 0.30 [0.15-0.63]), postoperative transfusion (HR 0.36 [0.21-0.61]), major (HR 0.45 [0.27-0.77]), and overall morbidity (HR 0.44 [0.31-0.63]), and a two-day shorter median hospitalization (3 vs. 5 days; HR 0.61 [0.45-0.82]). No difference was noted in operative time, wound, respiratory, and septic complications, or mortality. Regression analysis identified ascites, prior portal vein embolization (PVE), additional hepatectomies, Pringle's maneuver, and OH (vs. MIH) as independent predictors of PHLF. CONCLUSION MIH for early-stage HCC/IHCC in low-MELD cirrhotic patients was associated with improved postoperative outcomes over OH. These findings suggest that MIH should be considered an acceptable approach in this population of patients.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Kimberly Woo
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Roma Raj
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Fadi Dahdaleh
- Department of Surgical Oncology, Edward-Elmhurst Health, Elmhurst, IL, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Jaekeun Kim
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David C H Kwon
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Timothy M Pawlik
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
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Raj R, Wehrle CJ, Aykun N, Stitzel H, Ma WW, Krishnamurthi S, Estfan B, Kamath S, Kwon DCH, Aucejo F. Immunotherapy Plus Locoregional Therapy Leading to Curative-Intent Hepatectomy in HCC: Proof of Concept Producing Durable Survival Benefits Detectable with Liquid Biopsy. Cancers (Basel) 2023; 15:5220. [PMID: 37958394 PMCID: PMC10650763 DOI: 10.3390/cancers15215220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Immunotherapy has emerged as an improved systemic treatment for select patients with advanced unresectable HCC. Objective response is reported in 30% of patients, yet complete response (pCR) allowing for curative-intent resection is rare. Locoregional therapies (LRTs) seem to show synergistic effects with immunotherapy, though this effect has not been scientifically reported. We report a cohort of patients showing pCR to immunotherapy + LRT as a proof of concept for the proposed treatment approach for locally unresectable HCC. METHODS Patients with unresectable HCC treated with immunotherapy as an intended destination therapy from 2016 to 2023 were included. The electronic health record was queried for oncologic information, locoregional therapies, surgical interventions, and long-term outcomes. Circulating tumor DNA (ctDNA) testing was obtained using Guardant360, and tumor mutational burden (TMB) was defined as the number of somatic mutations per megabase. RESULTS Ninety-six patients with advanced HCC received immunotherapy + LRT as a destination therapy. In total, 11 of 96 patients showed a complete response according to mRECIST criteria. Four of these (36.4%) ultimately underwent curative-intent resection. The median follow-up was 24.9 (IQR 15.6-38.3) months. Overall survival rates in those with complete response at 1, 3, and 5 years were 100%, 91%, and 81.8%, respectively, which were significantly improved compared to those of the cohort not achieving pCR (p < 0.001). All four patients undergoing immunotherapy + LRT followed by curative-intent hepatectomy have no evidence of disease (NED). Of those undergoing surgery, ctDNA was cleared in 75% (n = 3), providing an additional objective measurement of complete response. All four patients were TMB+ before beginning this treatment course, with three being TMB-, indicating stable and complete disease response. CONCLUSIONS Immunotherapy + locoregional therapy can help downstage a significant proportion of patients with initially unresectable HCC, allowing for curative-intent surgery. The survival benefit associated with complete response seems durable up to 3 years after achieving this response. ctDNA measurement was converted from positive to negative in this cohort, providing additional indication of response.
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Affiliation(s)
- Roma Raj
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
| | - Chase J. Wehrle
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
| | - Nihal Aykun
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
| | - Henry Stitzel
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
| | - Wen Wee Ma
- Cleveland Clinic Foundation, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH 44195, USA; (W.W.M.); (S.K.); (B.E.); (S.K.)
| | - Smitha Krishnamurthi
- Cleveland Clinic Foundation, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH 44195, USA; (W.W.M.); (S.K.); (B.E.); (S.K.)
| | - Bassam Estfan
- Cleveland Clinic Foundation, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH 44195, USA; (W.W.M.); (S.K.); (B.E.); (S.K.)
| | - Suneel Kamath
- Cleveland Clinic Foundation, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland, OH 44195, USA; (W.W.M.); (S.K.); (B.E.); (S.K.)
| | - David C. H. Kwon
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
| | - Federico Aucejo
- Cleveland Clinic Foundation, Department of Hepato-Pancreato-Biliary & Liver Transplant Surgery, Digestive Diseases and Surgery Institute, Cleveland, OH 44195, USA; (R.R.); (N.A.); (H.S.); (D.C.H.K.); (F.A.)
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Raj R, Aykun N, Wehrle CJ, Maspero M, Krishnamurthi S, Estfan B, Kamath S, Aucejo F. Immunotherapy for Advanced Hepatocellular Carcinoma-a Large Tertiary Center Experience. J Gastrointest Surg 2023; 27:2126-2134. [PMID: 37464142 DOI: 10.1007/s11605-023-05783-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/01/2023] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Combination of immune-checkpoint inhibitor (ICI) and vascular endothelial growth factor (VEGF) antagonist has become the first line systemic treatment for advanced hepatocellular carcinoma (HCC). However, two-thirds of patients do not respond to ICI-based treatments and biomarkers for response remain elusive. METHODS Patients with advanced HCC who received Atezolizumab/Bevacizumab combination or Nivolumab during 2016-2022 were identified in our Liver Cancer Database. Retrospective review of their clinical data was performed to investigate parameters that could be predictive of immunotherapy response. RESULTS 96 patients received Atezolizumab/Bevacizumab (n=60) or Nivolumab (n=36). Median age at diagnosis was 67.1 years. 70 patients had received treatment and 26 patients were treatment naïve before starting immunotherapy. Mean pre-treatment AFP was 9780.7 (±32035) ng/mL. Confirmed objective response (complete or partial) was seen in 29% of the population (n=27). Disease remained stable in 12% (n=11) and progressed in 60% (n=56). On univariate analysis, pre-treatment AFP>400 ng/mL was associated with objective response (OR=4.5, 95% CI:1.7-11.9, p=0.0015), while white race (OR=0.35, 95% CI:0.13-0.92, p=0.030) and prior radiotherapy (OR=0.14, 95% CI:0.01-1.1, p=0.033) or systemic therapy with TKIs (OR=0.25, 95% CI:0.08-0.81, p=0.017) were associated with poor response. On multivariate analysis only AFP>400 ng/mL remained associated with response (OR=3.7, 95% CI:1.3-10.5, p=0.014). Overall survival (OS) at one and three years was 86% and 43% in responders, and 45% and 29% in non-responders, respectively. CONCLUSION In our institutional experience, treatment naivety and pre-treatment AFP>400 ng/mL were associated with objective response. Prospective studies aimed at identifying factors associated with response to immunotherapy will aide patient selection.
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Affiliation(s)
- Roma Raj
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, OH, Cleveland, USA.
| | - Nihal Aykun
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, OH, Cleveland, USA
| | - Chase J Wehrle
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, OH, Cleveland, USA
| | - Marianna Maspero
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, OH, Cleveland, USA
| | - Smitha Krishnamurthi
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH, USA
| | - Bassam Estfan
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH, USA
| | - Suneel Kamath
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH, USA
| | - Federico Aucejo
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, OH, Cleveland, USA.
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Wehrle CJ, Stackhouse KA, Chang J, Hossain MS, McMichael J, Roy M, Augustin T, Naffouje S, Joyce D, Simon R, Walsh RM. Evaluating approaches to diagnosis and management of idiopathic acute pancreatitis. HPB (Oxford) 2023; 25:1187-1194. [PMID: 37211463 DOI: 10.1016/j.hpb.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/18/2023] [Accepted: 04/27/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence. METHODS Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines. RESULTS A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence. CONCLUSION Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jenny Chang
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mir S Hossain
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John McMichael
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mayank Roy
- Department of General Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Toms Augustin
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samer Naffouje
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Joyce
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Simon
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - R Matthew Walsh
- Department of General Surgery, Section of Hepatobiliary Pancreatic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Wehrle CJ, Raj R, Aykun N, Orabi D, Stackhouse K, Chang J, Estfan B, Kamath S, Krishnamurthi S, Walsh RM, Kwon DCH, Aucejo F. Circulating Tumor DNA in Colorectal Cancer Liver Metastasis: Analysis of Patients Receiving Liver Resection and Transplant. JCO Clin Cancer Inform 2023; 7:e2300111. [PMID: 37820293 DOI: 10.1200/cci.23.00111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/13/2023] [Accepted: 08/29/2023] [Indexed: 10/13/2023] Open
Abstract
PURPOSE Liver metastases occur in about 50% of colorectal cancer cases and drive patient outcomes. Circulating tumor DNA (ctDNA) is emerging as a diagnostic, surveillance, and tumor mutational information tool. METHODS Patients with colorectal cancer liver metastasis (CCLM) seen in a multidisciplinary liver tumor clinic from January to August 2022 received ctDNA testing on each visit. ctDNA was obtained using the Guardant360 platform. Tumor mutational burden (TMB) is defined as the number of identified mutations per megabase of genome analyzed. RESULTS Fifty-two patients had available ctDNA, with 34 (65%) tested preoperatively and 18 (35%) postoperatively; nine patients had sequential pre- and postoperative testing. The median time to test result was 12 days (IQR, 10-13.5). There were a greater number of somatic mutations identified preoperatively (n = 29 v n = 11) and a greater genomic heterogeneity (P = .0069). The mean TMB score was 12.77 in those without pathologic response to cytotoxic therapy and 6.0 in those with pathologic response (P = .10). All nine patients with sequential testing were positive preoperatively, compared with just three (33.3%) postoperatively (P = .0090). Positive postoperative ctDNA was associated with the increased likelihood of disease recurrence after resection (57%) versus negative ctDNA (0%, P = .0419). CONCLUSION Routine ctDNA screening in patients with CCLM is logistically feasible. Liver resection and/or transplant may be associated with clearance of detectable ctDNA and a reduction in TMB or genomic heterogeneity. Persistence of ctDNA alterations postresection appears predictive of disease recurrence. Further studies are necessary to confirm these findings, and longitudinal ctDNA testing is needed to monitor changing tumor biology.
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Affiliation(s)
- Chase J Wehrle
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Roma Raj
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Nihal Aykun
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Danny Orabi
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Kathryn Stackhouse
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Jenny Chang
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Bassam Estfan
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH
| | - Suneel Kamath
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH
| | - Smitha Krishnamurthi
- Cleveland Clinic Foundation, Taussig Cancer Institute, Department of Hematology and Oncology, Cleveland, OH
| | - R Matthew Walsh
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - David Choon Hyuck Kwon
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
| | - Federico Aucejo
- Cleveland Clinic Foundation, Digestive Diseases and Surgery Institute, Department of Hepato-pancreato-biliary & Liver Transplant Surgery, Cleveland, OH
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Wehrle CJ, Raj R, Aykun N, Orabi D, Estfan B, Kamath S, Krishnamurthi S, Fujiki M, Hashimoto K, Quintini C, Kwon DCH, Diago-Uso T, Sasaki K, Aucejo FN. Liquid Biopsy by ctDNA in Liver Transplantation for Colorectal Cancer Liver Metastasis. J Gastrointest Surg 2023; 27:1498-1509. [PMID: 37273078 DOI: 10.1007/s11605-023-05723-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/20/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Colorectal cancer is a leading cause of cancer-related death worldwide. Metastatic liver disease develops in 50% of cases and drives patient outcomes. Although the ideal treatment for colorectal cancer liver metastases (CRLM) is resection, only a third of patients are suitable for this approach. Reports of liver transplantation in selected patients with unresectable CRLM have shown encouraging results compared to conventional forms of therapy. No study to date has examined the utility of liquid biopsy circulating tumor DNA (ctDNA) for evaluation of residual disease in this cohort of patients. We report a small series of liver transplantation in patients with CRLM in whom ctDNA was assessed peri-operatively. METHODS Five patients underwent liver transplantation for unresectable CRLM or liver failure following CRLM treatment from 2018 to 2022. Clinical data, cross-sectional imaging, and serum biomarkers including peri-operative ctDNA were reviewed from electronic medical records. RESULTS All patients are alive without radiologic evidence of disease at time of this publication. Median time of follow-up was 32 months (IQR 6.6-40 months). ctDNA was assessed before (4 patients) and after transplant (6 patients). One patient experienced a pulmonary recurrence that was resected, for whom pre-recurrence ctDNA was not available; the remaining patients have not experienced recurrence. Four patients are without evidence of ctDNA following transplant, and two demonstrate persistent ctDNA positivity post-transplant. Three of four patients with positive pre-transplant ctDNA remain ctDNA-negative post-transplant. CONCLUSIONS Liver transplantation for liver-confined unresectable CRLM is emerging as a valid surgical option in selected patients. The significance of liquid biopsy in this population remains elusive due to lack of data. The clearance of ctDNA after transplant in these patients with metastatic disease and despite their immunosuppression is notable. The significance and usefulness of liquid biopsy in patient selection, surveillance, and as an indication for treatment warrant further investigation.
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Affiliation(s)
- Chase J Wehrle
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | - Roma Raj
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nihal Aykun
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Danny Orabi
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bassam Estfan
- Department of Hematology and Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH, USA
| | - Suneel Kamath
- Department of Hematology and Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH, USA
| | - Smitha Krishnamurthi
- Department of Hematology and Oncology, Cleveland Clinic Foundation, Taussig Cancer Institute, Cleveland, OH, USA
| | - Masato Fujiki
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Koji Hashimoto
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Cristiano Quintini
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Choon Hyuck Kwon
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Teresa Diago-Uso
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kazunari Sasaki
- Department of Surgery - Abdominal Transplantation, Stanford Hospital and Clinics, Palo Alto, CA, 94035, USA
| | - Federico N Aucejo
- Digestive Diseases and Surgery Institute, Department of Hepato-Pancreato-Biliary/Liver Transplant Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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Ruiz TL, Sellers B, Devarakonda A, Wehrle CJ, Arora TK. A Novel Mock Oral Curriculum for Senior Surgery Residents: Results of a Pilot Study. J Surg Res 2022; 277:92-99. [DOI: 10.1016/j.jss.2022.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 02/20/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
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Joshi A, Abdelsattar J, Castro-Varela A, Wehrle CJ, Cullen C, Pei K, Arora TK, Dechert TA, Kauffmann R. Incorporating mass casualty incidents training in surgical education program. Global Surg Educ 2022; 1:17. [PMID: 38625271 PMCID: PMC9009279 DOI: 10.1007/s44186-022-00018-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/02/2022] [Accepted: 04/02/2022] [Indexed: 12/21/2022]
Affiliation(s)
- Anip Joshi
- Chief Consultant Surgeon and Associate Professor of Surgery, Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
- Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - Jad Abdelsattar
- University of Southern California Keck School of Medicine, Los Angeles, USA
| | | | | | - Christian Cullen
- Medical College of Georgia at Augusta University, Augusta, GA USA
| | - Kevin Pei
- Department of Surgery, Division of Robotic Surgery and Trauma and Acute Care Surgery, Parkview Health, Fort Wayne, IN USA
| | - Tania K. Arora
- Associate Professor of Surgery, Augusta University Medical Center, Augusta, USA
| | - Tracey A. Dechert
- Associate Professor of Surgery, Boston University School of Medicine, Boston, USA
| | - Rondi Kauffmann
- Department of Surgery, Division of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Nashville, TN USA
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25
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Pierce JL, Sharma AK, Roberts RL, Yu K, Irsik DL, Choudhary V, Dorn JS, Bensreti H, Benson RD, Kaiser H, Khayrullin A, Davis C, Wehrle CJ, Johnson MH, Bollag WB, Hamrick MW, Shi X, Isales CM, McGee-Lawrence ME. The Glucocorticoid Receptor in Osterix-Expressing Cells Regulates Bone Mass, Bone Marrow Adipose Tissue, and Systemic Metabolism in Female Mice During Aging. J Bone Miner Res 2022; 37:285-302. [PMID: 34747055 PMCID: PMC9976194 DOI: 10.1002/jbmr.4468] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 09/23/2021] [Accepted: 10/17/2021] [Indexed: 12/18/2022]
Abstract
Hallmarks of aging-associated osteoporosis include bone loss, bone marrow adipose tissue (BMAT) expansion, and impaired osteoblast function. Endogenous glucocorticoid levels increase with age, and elevated glucocorticoid signaling, associated with chronic stress and dysregulated metabolism, can have a deleterious effect on bone mass. Canonical glucocorticoid signaling through the glucocorticoid receptor (GR) was recently investigated as a mediator of osteoporosis during the stress of chronic caloric restriction. To address the role of the GR in an aging-associated osteoporotic phenotype, the current study utilized female GR conditional knockout (GR-CKO; GRfl/fl :Osx-Cre+) mice and control littermates on the C57BL/6 background aged to 21 months and studied in comparison to young (3- and 6-month-old) mice. GR deficiency in Osx-expressing cells led to low bone mass and BMAT accumulation that persisted with aging. Surprisingly, however, GR-CKO mice also exhibited alterations in muscle mass (reduced % lean mass and soleus fiber size), accompanied by reduced voluntary physical activity, and also exhibited higher whole-body metabolic rate and elevated blood pressure. Moreover, increased lipid storage was observed in GR-CKO osteoblastic cultures in a glucocorticoid-dependent fashion despite genetic deletion of the GR, and could be reversed via pharmacological inhibition of the mineralocorticoid receptor (MR). These findings provide evidence of a role for the GR (and possibly the MR) in facilitating healthy bone maintenance with aging in females. The effects of GR-deficient bone on whole-body physiology also demonstrate the importance of bone as an endocrine organ and suggest evidence for compensatory mechanisms that facilitate glucocorticoid signaling in the absence of osteoblastic GR function; these represent new avenues of research that may improve understanding of glucocorticoid signaling in bone toward the development of novel osteogenic agents. © 2021 American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Jessica L Pierce
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Anuj K Sharma
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Rachel L Roberts
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Kanglun Yu
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Debra L Irsik
- Department of Neuroscience and Regenerative Medicine, Augusta University, Augusta, GA, USA.,Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Vivek Choudhary
- Department of Physiology, Augusta University, Augusta, GA, USA
| | - Jennifer S Dorn
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Husam Bensreti
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Reginald D Benson
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Helen Kaiser
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Andrew Khayrullin
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Colleen Davis
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Chase J Wehrle
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Maribeth H Johnson
- Department of Neuroscience and Regenerative Medicine, Augusta University, Augusta, GA, USA
| | - Wendy B Bollag
- Charlie Norwood VA Medical Center, Augusta, GA, USA.,Department of Physiology, Augusta University, Augusta, GA, USA
| | - Mark W Hamrick
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA
| | - Xingming Shi
- Department of Neuroscience and Regenerative Medicine, Augusta University, Augusta, GA, USA
| | - Carlos M Isales
- Department of Neuroscience and Regenerative Medicine, Augusta University, Augusta, GA, USA
| | - Meghan E McGee-Lawrence
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA, USA.,Department of Orthopaedic Surgery, Augusta University, Augusta, GA, USA
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26
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Cox JS, Wehrle CJ, Mejias C, Devarakonda AK, McKenzie JA, Arora TK. General Surgery Twitter during COVID-19: Tweets, Trends, and Implications for Recruitment Strategies. Am Surg 2021:31348211060414. [PMID: 34937400 DOI: 10.1177/00031348211060414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The COVID-19 pandemic has disrupted traditional resident recruitment practices, requiring virtual interviews and new forms of outreach. Social media, such as Twitter, is one tool programs can use to connect with applicants. This study sought to assess changes in Twitter use during the COVID-19 pandemic among general surgery programs. METHODS Twitter and residency program websites were queried for public Twitter accounts related to general surgery residency programs. Publicly available tweets for available accounts were reviewed for all posts for the period March 15, 2019-November 25, 2020. Thematic analysis of each tweet was performed, and engagement was determined by likes and retweets on each tweet. RESULTS The number of programs with active Twitter accounts increased after the onset of COVID-19 pandemic, as did the number of tweets, likes-, and retweets-per-tweet. There was a significant increase in the number of tweets regarding resident promotion, program promotion, and virtual event promotion. Tweets received more likes-per-tweet if the subject was program promotion and resident promotion than tweets regarding virtual events. All results were statistically significant (P < .05). DISCUSSION Twitter use and engagement with residency programs have increased significantly since pandemic onset. Engagement is highest for tweets regarding program and resident promotion as measured by likes-per-tweet and highest for program promotion and virtual events as measured by retweets-per-tweet. Given the nearly nationwide increase in Twitter engagement after pandemic onset, programs should consider the impact of Twitter as a means of communication with applicants and program branding.
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Affiliation(s)
- James Shell Cox
- 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Chase J Wehrle
- 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | | | | | | | - Tania K Arora
- Department of Surgical Oncology, 1421Medical College of Georgia at Augusta University, Augusta GA, USA
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27
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Wehrle CJ, Lee SW, Devarakonda AK, Arora TK. Patient and Physician Attitudes Toward Telemedicine in Cancer Clinics Following the COVID-19 Pandemic. JCO Clin Cancer Inform 2021; 5:394-400. [PMID: 33822651 DOI: 10.1200/cci.20.00183] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE COVID-19 has infected more than 94 million people worldwide and caused more than 2 million deaths. Patients with cancer are at significantly increased risk compared with the general population. Telemedicine represents a common strategy to prevent viral spread. We sought to evaluate patient with cancer and physician perceptions of telemedicine during the COVID-19 pandemic. METHODS A 16-question survey was e-mailed to 1,843 active e-mails of patients presenting to one of the six cancer clinics at a comprehensive cancer care center from January 1, 2020, to June 1, 2020. A six-question survey was e-mailed to attending physicians of those clinics. Specialties included Medical Oncology, Hematology-Oncology, Surgical Oncology, Urological Oncology, and Gynecologic Oncology. RESULTS Three hundred seventy-four patients (20.3%) and 14 physicians (66.7%) responded. Most (68.2%) currently prefer in-person visits, and 80.4% prefer in-person visits following pandemic resolution. More than half (52.2%) of patients preferring virtual visits do so because of convenience. Most (63.1%) patients with cancer are comfortable with a complete physical examination. Surgical patients are more likely to prefer a complete examination (P = .0476). Physicians prefer in-person visits (64.2%) and believe that virtual visits maybe or probably do not provide comparable care (64.2%). 71.4% believe that virtual visits help prevent the spread of infectious disease. CONCLUSION Given preferences for in-person visits, cancer care teams should be prepared to continue providing in-person visits for many of their patients. The discrepancy between patient and provider concern for spread of infectious disease represents an area where patients may benefit from increased education. Providers should feel comfortable performing physical examinations at their own discretion.
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Affiliation(s)
- Chase J Wehrle
- Medical College of Georgia, Augusta University, Augusta, GA
| | - Sang W Lee
- Medical College of Georgia, Augusta University, Augusta, GA
| | | | - Tania K Arora
- Medical College of Georgia, Augusta University, Augusta, GA
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28
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Wehrle CJ, Talukder A, Tien L, Parikh S, Devarakonda A, Holsten SB, Fox ED, Lawson A. The Accuracy of Point-of-Care Ultrasound in the Diagnosis of Acute Cholecystitis. Am Surg 2021; 88:267-272. [PMID: 33517707 DOI: 10.1177/0003134821989057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
PURPOSE Acute cholecystitis (AC) affects 50-200 000 patients per year. Early surgery is the treatment of choice for AC. Therefore, timely diagnosis is important to begin proper management. Recently, emergency departments have adopted point-of-care ultrasound (POCUS) for the initial evaluation of AC. The accuracy of POCUS for AC has not been well studied. METHODS Patients receiving POCUS for evaluation of AC in the emergency department at our tertiary care institution for 2 years were considered. Patients with previous biliary diagnoses were excluded. Patients were deemed to have AC from a recorded POCUS result or 2/3 of the following POCUS findings: pericholecystic fluid, gallbladder wall hyperemia, and sonographic Murphy's sign. Formal ultrasound and final diagnosis from surgical and pathology reports were used as gold standards for comparison. RESULTS In total, 147 patients met inclusion criteria. POCUS had a sensitivity and specificity of .4 (95% CI: .1216-.7376) and .99 (.9483-.9982), respectively, when compared to a final diagnosis and .33 (.0749-.7007) and .94 (.8134-.9932) when compared to formal US. The modified Tokyo guidelines for suspicion of AC had a sensitivity of .2 (.0252-.5561) and specificity of .88 (.8173-.931) compared to the final diagnosis. CONCLUSION Point-of-care ultrasound was not a better screening test than the modified Tokyo guidelines. We recommend a simplified screening approach for AC using clinical findings and laboratory data, followed by confirmatory formal imaging. This strategy could prevent unnecessary delays in surgical management and use of physician resources.
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Affiliation(s)
- Chase J Wehrle
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Asif Talukder
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Lillie Tien
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Soham Parikh
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Aditya Devarakonda
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Steven B Holsten
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Elizabeth D Fox
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Andrew Lawson
- Department of Surgery, 1421Medical College of Georgia at Augusta University, Augusta, GA, USA
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29
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Wehrle CJ, Walker M, Worthey A, Jones CE, Lewis F, Arora TK. Barriers to Accurate Fluid Measurement in Perioperative Patients: A Mixed Methods Approach. J Surg Res 2020; 260:95-103. [PMID: 33333385 DOI: 10.1016/j.jss.2020.11.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/07/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Surgeons depend on fluid intake and output (I/O) measurements for assessment of resuscitation and fluid balance during the perioperative period. Frequently, these measurements are taken by Registered Nurses (RNs) and/or Patient Care Technicians (PCTs). There is variability in the accuracy and consistency of these measurements across nursing units. The goal of this study is to establish what barriers exist in obtaining accurate fluid measurements and potential solutions. MATERIALS AND METHODS A mixed-method, sequential study design was utilized. First, a survey was conducted at a tertiary care institution of 8 nonintensive care nursing units assessing the perceptions of RNs (n = 85) and PCTs (n = 38) regarding fluid intake and output measurements for surgical patients. Four focus groups were then conducted to expand upon the results of the survey. Fourteen participants (10 RNs and 4 PCTs) were interviewed, and transcripts were analyzed by three reviewers. Qualitative data were manually coded by reviewers using a hierarchical methodology. RESULTS Survey response rate was 40.6%. The strongest barriers in the survey were patient load and staff time limitations. About half (49%) of the respondents acknowledged that fluid measurements were inaccurate half of the time. PCTs spend more time collecting and charting I/Os and have higher patient loads (P < 0.001) than RNs. PCTs noted more difficulty with complex patients (P = 0.017) and devices for outputs (P = 0.004). PCT's (94%) handwrite data prior to electronic entry. One-third of nurses reported direct electronic entry (P < 0.001). Overall, 71% would prefer to chart in patient's rooms. Most (80%) of respondents received <5 h of fluids-related training at the time they were hired. Cronbach's alpha for three focus group reviewers was 0.84 (95% CI 0.693-0.923). Themes included understaffing, lack of training, a high percentage of traveling nurses, and poor communication regarding new orders. Recommended solutions to improve I/Os included in-room kiosks for electronic entry and relief of staffing burdens. CONCLUSIONS Fluid I/O measurement accuracy and efficiency may be improved by increased staffing, educational programs, and computer access, streamlining of order sets, simplicity of EMR data entry, and a standardized process for measuring, recording, and charting I/Os.
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Affiliation(s)
- Chase J Wehrle
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia.
| | - Morgan Walker
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Ayana Worthey
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Caitlin E Jones
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Frank Lewis
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
| | - Tania K Arora
- Medical College of Georgia at Augusta University, Department of Surgery, Augusta, Georgia
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Abstract
BACKGROUND Over 28 million confirmed cases of COVID-19 have been reported to date, resulting in over 900 000 deaths. With an increase in awareness regarding the virus, the behavior of general population has changed dramatically. As activities such as driving and hospital presentation patterns have changed, our study aimed to assess the differences in trauma case variables before and during the COVID-19 pandemic. METHODS Trauma data for the period of March 1st-June 15th were compared for the years 2015-2019 (pre-COVID) and 2020 (COVID). The data were analyzed across the following categories: injury severity score, injury mechanism, motor vehicle crashes (MVCs) vs. other blunt injuries, alcohol involvement, and length of hospital stay. RESULTS The median injury severity score pre-COVID and during COVID was 9, representing no change. There was no difference in overall distribution of mechanism of injury; however, there was a significant decrease in the percentage of MVCs pre-COVID (36.39%) vs. COVID (29.6%, P < .05). Alcohol was significantly more likely to be involved in trauma during COVID-19 (P < .05). The mean hospital stay increased from 3.87-5.4 days during COVID-19 (P < .05). DISCUSSION We saw similar results to prior studies in terms of there being no change in trauma severity. Our observation that motor vehicle collisions have decreased is consistent with current data showing decreased use of motor vehicles during the pandemic. We also observed an increase in alcohol-related cases which are consistent with the reported changes in alcohol consumption since the pandemic began.
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Affiliation(s)
- Aditya K. Devarakonda
- Medical College of Georgia at Augusta
University, Augusta, GA, USA
- Aditya K. Devarakonda, BS, Medical College
of Georgia, 1120 15th Street, Augusta 30912-0004, GA, USA.
| | - Chase J. Wehrle
- Medical College of Georgia at Augusta
University, Augusta, GA, USA
| | | | - Peter D. Drevets
- Department of Surgery,
Medical
College of Georgia, Augusta, GA,
USA
| | - Elizabeth D. Fox
- Department of Surgery,
Medical
College of Georgia, Augusta, GA,
USA
| | - Andrew G. Lawson
- Department of Surgery,
Medical
College of Georgia, Augusta, GA,
USA
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31
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Wehrle CJ, Sinkler MA, Brown JJ, Ritter EF. Facial nerve transfer for facial reanimation with parotidoplasty approach. Microsurgery 2020; 40:868-873. [PMID: 33085134 DOI: 10.1002/micr.30674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/17/2020] [Accepted: 10/09/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Facial paralysis has a profound impact on quality of life in affected individuals, primarily through loss of verbal and nonverbal communication. Common facial nerve reanimation techniques include coaptation to the masseteric or hypoglossal nerve. Most techniques require nerve grafts to achieve a tension-free neurorrhaphy. Our report aims to show a surgical adaption to current facial reanimation procedures using a partial parotidoplasty approach in order to avoid challenges caused by interpositional nerve grafts through primary neurorrhaphy. PATIENTS AND METHODS The modified surgical approach was performed on four patients, aged 30-67. Length of paralysis ranged from 6 to 13 months. Cause of paralysis included one patient with Bell's palsy in one patient, prior surgery in two patients, and traumatic fracture in the remaining patient. A modified Blair approach is used to expose the parotid capsule. The facial nerve is dissected proximally toward the stylomastoid foramen and distally toward the masseter. The parotid gland substance is sectioned overlying each branch of the facial nerve using ultrasonic dissection or hemostatic scalpel, allowing mobilization of the proximal segment and upper and lower divisions of the facial nerve. The superficial lobe of the parotid is preserved in most cases. The House-Brackmann (H-B) functional scale was used to assess facial nerve function pre- and post-operatively. RESULTS All patients showed H-B score V or greater prior to reanimation. Follow-up was conducted at 3-, 6-, and 12-months in all patients with resultant improvement of H-B scores of I in three patients and II in the remaining patient. Only one complication was noted, with one patient developing a right postauricular hematoma that was adequately managed without sequelae. All remaining patients experienced an uncomplicated post-operative course. CONCLUSION Our modified approach to facial nerve reanimation works well with a planned parotidoplasty allowing for successful reanimation outcomes without the need for interpositional grafting. This technique may be considered in masseteric and hemi-hypoglossal nerve transfers for the reinnervation of facial muscles.
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Affiliation(s)
| | | | - Jimmy J Brown
- Department of Otolaryngology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Edmond F Ritter
- Department of Plastic Surgery, Medical College of Georgia, Augusta, Georgia, USA
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32
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Wehrle CJ, Ullah A, Sinkler MA, Heneidi SG, Klaassen Z, Biddinger P, Kruse EJ, Wallace G, Nichols F, Patel N. Paraneoplastic Limbic Encephalitis in a Patient with Primary Well-differentiated Teratoma and Metastatic Poorly Differentiated Embryonal Carcinoma. Yale J Biol Med 2020; 93:495-500. [PMID: 33005114 PMCID: PMC7513443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Testicular tumors account for 1-2% of all tumors in men, with 95% of these being germ cell tumors. Paraneoplastic limbic encephalitis is a rare sequela of testicular tumors associated with anti-Ma2 and KLH11 antibodies. The most effective treatment for paraneoplastic limbic encephalitis is treatment of the primary malignancy. We report a 41-year-old male that presented to the emergency department with episodic alteration of consciousness and memory disturbances. Negative neurologic evaluation and imaging led to concern for a paraneoplastic process from a distant malignancy. CT imaging revealed an enlarged, necrotic para-aortic lymph node and subsequent ultrasound demonstrated a right-sided testicular mass. Right radical orchiectomy was performed. Microscopically, the mass consisted of mixed respiratory epithelium, gastrointestinal glands, and squamous epithelium with keratinization consistent with a post-pubertal testicular teratoma with associated in situ germ cell neoplasia. Resection of the para-aortic mass revealed large anaplastic cells with epithelioid features, nuclear pleomorphism and frequent mitoses. Immunostaining was positive for Pan-Keratin and OCT4, consistent with poorly differentiated embryonal carcinoma. Resection of the primary and metastatic disease, as well as treatment with corticosteroids, resulted in resolution of the encephalitis. This presentation of severe neurological disturbances in the setting of a metastatic mixed non-seminomatous germ cell tumor represents a rare presentation of paraneoplastic limbic encephalitis.
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Affiliation(s)
- Chase J. Wehrle
- Medical College of Georgia, Augusta, GA,To whom all correspondence should be addressed:
Chase J. Wehrle, Medical College of Georgia, Augusta, GA;
, ORCID iD: https://orcid.org/0000-0002-9275-4744
| | - Asad Ullah
- Department of Pathology, Medical College of Georgia,
Augusta, GA
| | | | - Saleh G. Heneidi
- Department of Pathology, Medical College of Georgia,
Augusta, GA
| | | | - Paul Biddinger
- Department of Pathology, Medical College of Georgia,
Augusta, GA
| | - Edward J. Kruse
- Department of Surgical Oncology, Medical College of
Georgia, Augusta, GA
| | - Gerald Wallace
- Department of Neurology, Medical College of Georgia,
Augusta, GA
| | - Fenwick Nichols
- Department of Neurology, Medical College of Georgia,
Augusta, GA
| | - Nikhil Patel
- Department of Pathology, Medical College of Georgia,
Augusta, GA
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Sinkler MA, Ullah A, Wehrle CJ, Ibrahim MA, White J. Primary Pleural Epithelioid Angiosarcoma With Extensive and Rapid Metastasis to Brain and Bilateral Adrenal Glands. Cureus 2020; 12:e9982. [PMID: 32983683 PMCID: PMC7511080 DOI: 10.7759/cureus.9982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 64-year-old male presents with shoulder pain, arm pain, and a chronic cough. CT imaging of the thorax shows a large 8.0 x 6.7 cm mass with central necrosis in the left upper lung lobe with invasion into the chest wall with partial destruction of the second and third ribs, and left axillary adenopathy. Bilateral adrenal nodules are identified via CT imaging and subsequently biopsied. Histologically, the mass reveals sheets of atypical epithelioid cells with round nuclei and abundant eosinophilic cytoplasm. Immunostaining is positive for CD31, CD34, FLI-1, AE1/AE3, and CK7, diagnostic of primary epithelioid angiosarcoma. The patient developed symptoms of confusion, dizziness, and ataxia. An MRI showed metastatic brain lesions. One month later, the patient had worsening symptoms. Repeat imaging demonstrates enlargement of the bilateral adrenal masses, a new lesion posterior to the left kidney, and doubling of the size of the brain lesions. This case illustrates the metastatic potential and pattern of the spread of an aggressive primary pleural angiosarcoma that is not described elsewhere in current literature. It also highlights the importance of timely intervention based on the rapid metastatic progression of this neoplasm.
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Affiliation(s)
- Margaret A Sinkler
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Asad Ullah
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Chase J Wehrle
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Muaz A Ibrahim
- Radiology, Medical College of Georgia - Augusta University, Augusta, USA
| | - Joseph White
- Pathology, Medical College of Georgia - Augusta University, Augusta, USA
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Abstract
Atypical spindle cell lipomatous neoplasm, also known as well-differentiated spindle cell liposarcoma, represents a newly discovered entity of adipocytic tumors. Recent research has shown this tumor variant to be more related to spindle cell lipoma, rather than the originally hypothesized atypical lipomatous tumor spectrum. Here we present a case of a 58-year-old man with a history of chronic lymphocytic leukemia with an enlarging mass on the posterior left shoulder, initially hypothesized to be a benign lipoma. However, magnetic resonance imaging showed a large, multiseptated, heterogeneous mass concerning for soft tissue sarcoma. After resection, pathologic analysis showed cells closely resembling spindle cell lipoma, with additional cellular and fascicular zones containing lipoblasts and mitotic figures. Molecular analysis showed no MDM2 amplification. This lack of amplification indicates this tumor is distinctly different from an atypical lipomatous tumor, which characteristically displays MDM2 amplification. However, tumor expression of RB1 was normal. The majority of atypical spindle cell lipomatous neoplasms are associated with RB1 deletions. We conclude that we have a unique example of an atypical spindle cell lipomatous tumor.
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Affiliation(s)
- Chase J Wehrle
- 1421 Department of General Surgery, Medical College of Georgia at Augusta University, GA, USA
| | - J Will Daigle
- 1421 Department of General Surgery, Medical College of Georgia at Augusta University, GA, USA
| | - Asad Ullah
- 1421 Department of Pathology, Medical College of Georgia at Augusta University, GA, USA
| | - Suash Sharma
- 1421 Department of Pathology, Medical College of Georgia at Augusta University, GA, USA
| | - Edmond F Ritter
- 1421 Department of Plastic Surgery, Medical College of Georgia at Augusta University, GA, USA
| | - Edward J Kruse
- 1421 Department of Surgical Oncology, Medical College of Georgia at Augusta University, GA, USA
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