Liver transplantation as an alternative for the treatment of intrahepatic cholangiocarcinoma: Past, present, and future directions

Intrahepatic cholangiocarcinoma (iCCA) is a rare biliary tract cancer with high mortality rate. Complete resection of the iCCA lesion is the first choice of treatment, with good prognosis after margin-negative resection. Unfortunately, only 12%-40% of patients are eligible for resection at presentation due to cirrhosis, portal hypertension, or large tumor size. Liver transplantation (LT) offers margin-negative iCCA extirpation for patients with unresectable tumors. Initially, iCCA was a contraindication for LT until size-based selection criteria were introduced to identify patients with satisfied post-LT outcomes. Recent studies have shown that tumor biology-based selection can yield high post-LT survival in patients with locally advanced iCCA. Another selection criterion is the tumor response to neoadjuvant therapy. Patients with response to neoadjuvant therapy have better outcomes after LT compared with those without tumor response to neoadjuvant therapy. Another index that helps predict the treatment outcome is the biomarker. Improved survival outcomes have also opened the door for living donor LT for iCCA. Patients undergoing LT for iCCA now have statistically similar survival rates as patients undergoing resection. The combination of surgery and locoregional and systemic therapies improves the prognosis of iCCA patients.

Evaluation of the occurrence of venous thromboembolic events in COVID-19 outpatients

Introduction

Thrombotic events are present at higher rates among COVID-19 patients. Prophylactic use of parenteral anticoagulants during hospitalisation is recommended to reduce the risk of complications. In this context, the Tunisian Anticoagulation Survey in COVID-19 patient General Practice experience (TASC-GP) was conducted.

Objective

The evaluation of the incidence of venous thromboembolic events (VTE) and bleedings in COVID-19 patients treated in ambulatory.

Method

The TASC-GP is an observational, multicenter study included 3,383 patients from July to October 2021. The following up of patients was done 35 days after inclusion date with investigation of VTE and bleeding events. The four main enrolment criteria were: 1) age ≥ 18 years; 2) confirmed COVID-19 infection; 3) treated as an outpatient; 4) initiation of Rivaroxaban 10 mg/d. Patients were excluded if any of the following criteria applied: 1) the use of anticoagulant or thrombolytic drugs other than Rivaroxaban on admission or within days of admission; 2) the use of any dosage other than that specified in the study protocol.

Results

The mean age of the population was 51.6 ± 15.5 years with a sex ratio of 0.67, 30.7% of the population had hypertension, 23.4% were diabetic and 34.9% were obese. At least one cardiovascular comorbidity was observed in 40% of cases and 9.5% had chronic respiratory disease. The mean IMPROVE and IMPROVE DDimer scores were 0.65 ± 0.9 and 1.4 ± 1.4, respectively. The mean Improve bleeding score was 1.4 ± 1.5. A VTE was reported during follow-up in 39 patients (1.15%). Diabetes and chronic respiratory disease were independent factors for the occurrence of VTE with an odd ratio of 2.2 [95% CI 1.1–4.2] (P = 0.017) and 3.2 [95% CI 1.5–6.4] (P = 0.002) respectively. IMPROVE and IMPROVE DDimer scores were comparable in patients with and without VTE. There was no statistically significant increase in the rate of major bleeding (0.001%). The IMPROVE Bleeding score was comparable in the bleeding and non-bleeding groups at follow-up. There were no predictive factors for bleeding.

Conclusion

Our study is in agreement with the literature concerning a decrease in the rate of thrombembolic complications when using prophylactic anticoagulation versus placebo. Other VTE estimation scores including chronic respiratory disease and diabetes can be proposed. The use of Rivaroxaban in this population was not associated with increased bleeding.

[Primary breast sarcomas: About 30 cases treated at Salah-Azaiez institute in Tunisia]

PURPOSE

To identify retrospectively prognostic factors of primary breast sarcoma and review its treatment modalities.

MATERIALS AND METHODS

This is a descriptive study on 30 cases of primary breast sarcoma. We carried out a univariate and multivariate analysis correlating clinical, pathological and therapeutic parameters with disease-free survival and overall survival.

RESULTS

The mean age was 46.8 years. The mean tumour size was 10cm. The 30 cases were 18 phyllodes sarcomas, eight angiosarcomas, three liposarcomas and a case of granulocytic sarcoma. Sixteen patients had adjuvant radiotherapy and only seven patients received adjuvant chemotherapy. The median follow-up was 64 months. Overall survival rates at 3 and 5 years were 49.1% and 33.7%. Disease-free survival rates at 3 and 5 years were 22.8% and 15.2% respectively. The analytical study of the following parameters: tumour size and presence or absence of node or distant metastases, showed no correlation with overall survival nor with disease-free survival. Furthermore, adjuvant radiotherapy did not improve overall survival (P=0.298; hazard ratio [HR]=1 [0.982-1.04]) nor disease-free survival (P=0.61; HR=0.942 [0.862-1.029]). By univariate analyses, we identified a correlation between overall survival, surgical margins (>1cm) (P=0005; HR=3.4 [1.217-9.919]) and tumour necrosis (P=0.028; HR=0.099 [0.014-0.682]). We did not find any independent prognostic factor by multivariate analysis.

CONCLUSION

The prognosis of primary breast sarcoma seems to depend essentially on optimal surgical excision (margin over 1cm). The only potential histological parameter correlated with the prognosis is the presence of tumour necrosis. The histological subtype should not be considered as a prognostic marker for overall or disease-free survival in patients with primary breast sarcoma.

Iron deficiency in Yemeni patients with sickle-cell disease

Despite the general view that patients with sickle-cell disease (SCD) have iron overload, there are reports of iron deficiency in a proportion of these patients. We studied Yemeni patients aged 1-30 years with homozygous SCD to determine their iron status using a set of 4 criteria (low serum iron, low transferrin saturation, high total iron binding capacity and low mean corpuscular volume for age). Of the 75 patients, 44 had never been transfused while 31 patients had received blood transfusions but not during the 3-month period prior to the study. Of the patients, 10 (13.3%) met the criteria for iron deficiency, 9 of whom were from the non-transfused patients (20.5%). The sensitivity and specificity were 40% and 98% respectively for reticulocyte count and 80% and 90% respectively for reticulocyte index. We recommend screening non-transfused SCD patients for iron deficiency.