Obesity conveys poor outcome in patients with hepatocellular carcinoma treated by transarterial chemoembolization

PURPOSE

The purpose of this retrospective study was to evaluate the impact of obesity on radiologic outcomes in patients with hepatocellular carcinoma (HCC) treated by transarterial chemoembolization (TACE).

MATERIALS AND METHODS

A total of 100 TACE procedures performed in 57 patients (42 men, 15 women) with a mean age of 62 years±8.4 (SD) (range: 39-83 years) were retrospectively reviewed. The 1-2-month follow-up computed tomography or magnetic resonance imaging examinations was assessed for new or residual disease and radiologic response using mRECIST criteria. Patients were categorized into two groups according to body mass index (BMI). Patients with BMI<25kg/m² were further referred as to low BMI patients and those with BMI≥25kg/m² as high BMI patients. Outcomes were compared between the two groups.

RESULTS

Low and high BMI patients were similar in regard to age, gender, HCC etiology and stage, and pre-procedure disease burden. TACE for high BMI, compared to low BMI, patients resulted in lower complete response (39% vs. 66%) and higher progressive disease (21% vs. 5%) rates (P=0.04), and higher rates of residual disease (63% vs. 39%, P=0.02) and new lesions in untreated liver (39% vs. 18%, P=0.04) on 1-2-month follow-up imaging.

CONCLUSIONS

High BMI is associated with significantly more residual disease, new lesions, and progressive disease in patients with HCC treated by TACE.

Chronic thalidomide and chemoembolization for hepatocellular carcinoma

BACKGROUND

Transcatheter arterial chemoembolization (TACE) has been used to curtail tumor vasculature and delay tumor progression in hepatocellular carcinoma (HCC). We conducted a phase I trial to evaluate the efficacy and toxicity of thalidomide when combined with TACE in patients with advanced HCC.

METHODS

Between June 2000 and November 2003, 56 patients with unresectable HCC and amenable to TACE were enrolled. The starting dose of thalidomide was 200 mg/day and was escalated every 2 weeks as tolerated to a maximum dose of 1,000 mg/day. Dose reductions and discontinuation were determined by toxicity. TACE was performed 4 weeks after initiation of thalidomide therapy and repeated as necessary.

RESULTS

Overall, 47 and 55 patients were evaluable for response and toxicity, respectively; the median dose of thalidomide given was 200 mg/day. Three patients (6.38%) patients achieved complete responses, whereas 10 (21.3%) had partial responses, for an overall response rate of 27.7%, and 27 (57.5%) had stable disease. Median progression-free survival was 7 months (95% confidence interval [CI]: 5-10 months), and median OS was 21 months (95% CI: 16-28 months) (Fig. 1). Fatigue and lethargy (49.1%), constipation (47.3%), and nausea (43.6%) were common. Grade 3-4 toxicities consisted mostly of increased aspartate aminotransferase (43.6%) and elevated alanine aminotransferase (38.2%) (Table 1).

CONCLUSION

Thalidomide and TACE were commonly associated with nonhematologic side effects, with fatigue and constipation being prominent. With a lack of clear therapeutic benefit, this combination is unlikely to be pursued for HCC.

Treating hepatocellular carcinoma progression following first-line sorafenib: therapeutic options and clinical observations

Despite the established efficacy of sorafenib in advanced hepatocellular carcinoma (HCC), a significant number of sorafenib-treated patients experience disease progression. Current guidelines recommend either best supportive care or clinical trial enrollment for this population. As such, there remains an unmet need for tolerable, life-prolonging strategies in the second-line setting. New information regarding the molecular pathogenesis of resistance to antiangiogenic therapy and positive post-progression experience with antiangiogenics in other tumor types has led to trials investigating the effect of continued use of sorafenib, alone or combined with other agents. Trials investigating the effect of switching from sorafenib to alternate antiangiogenic agents, phosphatidylinositol 3 kinase/AKT/mammalian target of rapamycin inhibitors, or cMet inhibitors are also underway. As these data emerge, clinicians may consider a new paradigm for managing advanced HCC. This article briefly reviews the mechanisms of disease resistance to antiangiogenic therapy as a vehicle for discussing clinical strategies to prolong survival in patients with advanced HCC that are currently employed at our institutions or are under investigation. Key ongoing trials investigating the use of molecularly targeted therapies in patients with progressive disease are also highlighted.

Transmission of anaplastic large cell lymphoma via organ donation after cardiac death

Recently, donation after cardiac death (DCD) has been encouraged in order to expand the donor pool. We present a case of anaplastic T-cell lymphoma transmitted to four recipients of solid organ transplants from a DCD donor suspected of having bacterial meningitis. On brain biopsy, the donor was found to have anaplastic central nervous system T-cell lymphoma, and the recipient of the donor's pancreas, liver and kidneys were found to have involvement of T-cell lymphoma. The transplanted kidneys and pancreas were excised from the respective recipients, and the kidney and pancreas recipients responded well to chemotherapy. The liver recipient underwent three cycles of chemotherapy, but later died due to complications of severe tumor burden. We recommend transplanting organs from donors with suspected bacterial meningitis only after identification of the infectious organism. In cases of lymphoma transmission, excision of the graft may be the only chance at long-term survival.

Non-Hodgkin's lymphoma presenting as a breast mass in patients with HIV infection: a report of three cases

Breast involvement with non-Hodgkin's lymphoma (NHL) is rare. Patients with AIDS have an increased incidence of NHL, often with high-grade histology, extranodal presentation and aggressive clinical course. Lymphoma of the breast in patients with HIV-1 infection has not been reported. We reviewed our tumor registry database of all AIDS-associated NHL and report on the clinical presentation and long-term outcome of 3 patients with AIDS who presented with lymphomatous involvement of the breast.

Transplantation for hepatocellular carcinoma and cirrhosis: sensitivity of magnetic resonance imaging

The sensitivity of magnetic resonance imaging (MRI) in patients who undergo transplantation for hepatocellular carcinoma (HCC) and cirrhosis is not known. We prospectively evaluated 24 patients with known HCC who underwent MRI and subsequent transplantation within 60 days (mean, 20 days). Using a phased-array coil at 1.5T, breath-hold turbo STIR and T2-weighted MR images were performed. Dynamic gadolinium-enhanced MRI was performed using a two- or three-dimensional gradient echo pulse sequence with images obtained in the hepatic arterial, portal venous, and equilibrium phases. The prospective interpretation of the MR study was directly compared with thin-section pathology evaluation of the explanted livers. All 24 patients had at least one HCC, and MR diagnosed tumor in 21 (88%) of these patients. On a lesion-by-lesion basis, MRI depicted 39 of 118 HCC for an overall sensitivity of 33%. MRI detected five (100%) of five lesions >5 cm, 20 (100%) of 20 lesions >2 cm but not exceeding 5 cm, 11 (52%) of 21 lesions between 1 and 2 cm, and three (4%) of 72 lesions <1 cm. Of the nine patients with carcinomatosis (innumerable lesions less than 1 cm), MR detected three lesions in one patient. Of the 15 dysplastic nodules found at pathology, MRI depicted a single 1.8-cm high-grade lesion, for a sensitivity of 7%. In conclusion, MRI is sensitive for the detection of HCC measuring at least 2 cm in diameter but is insensitive for the diagnosis of small HCC (<2 cm) and carcinomatosis.

Clinical experience with a new specimen capturing bone marrow biopsy needle

The SNARECOIL needle is a specimen capturing bone marrow biopsy needle that incorporates a tiny internal capturing coil. It was developed to minimize postinsertion needle manipulation and to facilitate specimen recovery. Forty-four patients underwent 50 bone marrow biopsy procedures with the SNARECOIL needle for a variety of hematologic indications. Second and third procedures were done for follow-up or staging. Each procedure retrieved a specimen with an average length of 2.1 cm. Fifty-two percent of the specimens were > or =2.0 cm in length. The majority of specimens demonstrated intact marrow architecture enabling a pathologic diagnosis in every case. Delicate cores of nontrabeculated marrow were recovered in three cases. The SNARECOIL bone marrow biopsy needle reliably retrieves intact bone marrow core specimens for pathologic interpretation.

MEIS1 and HOXA7 genes in human acute myeloid leukemia

Co-activation of Meisl with Hoxa7 or Hoxa9 homeobox genes by retroviral gene insertion has recently been reported to be leukemogenic in murine myeloid leukemia. In this study we determined their expression in human leukemia. Most human myeloid leukemia cell lines co-expressed MEIS1 with HOXA7 and HOXA9. Among patients with acute leukemia, 50% of AML patients expressed MEIS1, while the majority of ALL patients were negative. A total of 89.5% of patients expressing MEIS1 co-expressed HOXA7. In unadjusted models, poorer response to chemotherapy was associated with expression of HOXA7 regardless of MEIS1 status and older patients were more likely to express either gene.

Bone-marrow biopsy needle incorporating a snare-coil specimen-capturing device: description and preclinical studies

A tissue biopsy needle maximizes adequate specimen retrieval and minimizes patient pain and tissue disruption. The proposed biopsy needle incorporates an internal snare-coil for capturing specimens. The snare-coil device is described along with needle durability and performance testing. Sharply cut, nonfragmented, cored specimens were retrieved from a resin-based foam. In clinical practice, the snare-coil technology may minimize post-insertion needle manipulations and patient pain. Further studies are required to determine the impact of snare-coil needles on the retrieval of adequate specimens from patients.

Transient diplopia as a result of block injections. Mandibular and posterior superior alveolar

Anesthetic "accidents" can and do happen as a result of maxillary and/or mandibular injections. The family practitioner has little or no control now. The anatomical pathways are discussed, but are not clear.

The dental referral process. New insights

Doctor-patient, doctor-doctor dental relationships are discussed. The dental referral process is a triad of patient, general practitioner and specialist and, in many ways, is dependent upon Freud's concept of transference-countertransference. The unconscious distortions of this process may affect the patient's treatment, as well as interpersonal and intraprofessional relationships.

Central venous catheter placement in patients with disorders of hemostasis

OBJECTIVE

To define the incidence of bleeding complications from central venous access procedures performed by a critical care service in patients with disorders of hemostasis.

DESIGN

Prospective, consecutive sample, collection of clinical data.

SETTING

University teaching hospital.

PATIENTS

Seventy-six consecutive patients with disorders of hemostasis who required central venous access for clinical management between October 1992 and October 1993.

MEASUREMENTS

Age, sex, clinical diagnosis, most recent platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) were recorded from the medical record of patients with known coagulation or platelet abnormalities. The site of central venous catheter placement, the number of needle passes necessary to complete the procedure, and the occurrence of complications were reported by the critical care attending physician performing or supervising the procedure.

RESULTS

One hundred four central venous access procedures were performed on 76 patients with disorders of hemostasis. Seventy-three percent of catheters were placed in patients with platelet counts less than 100,000/mL and 40% of catheters were placed in patients with abnormalities of PT, aPTT, or both. Thirteen percent of patients had abnormalities of both platelets and coagulation profile. There were no serious complications. Bleeding complicated 7 (6.5% of the procedures; 5 patients had bleeding from the skin (from the suture sites in four), and 2 patients developed small periosteal hematomas. All patients with bleeding complications had thrombocytopenia with mean platelet counts of 22,000/mL and a range of 6,000 to 37,000/mL. Most patients with platelet counts in this range did not have clinically evident bleeding.

CONCLUSIONS

Central venous access procedures can be done safely in patients with disorders of hemostasis by skilled physicians who frequently perform these procedures. Patients most likely to experience bleeding from these procedures are patients with severe thrombocytopenia. In this series, only a single patient, with a platelet count of 6,000/mL, required therapeutic blood product administration.

B-cell lymphoma presenting as infiltrative renal disease

Acute renal failure is rarely the presenting manifestation of non-Hodgkin's lymphoma. Of the reported cases of renal insufficiency secondary to diffuse renal infiltration with lymphoma, few have presented with acute renal failure. We present a patient with acute renal failure secondary to diffuse bilateral renal infiltration by a B-cell non-Hodgkin's lymphoma. The findings of an elevated serum lactate dehydrogenase (LDH), lymphopenia, and homogenous bilateral renal enlargement on computed tomographic (CT) imaging were important in suggesting the diagnosis of primary renal lymphoma. Renal biopsy with immunohistochemical and ultrastructural analysis was instrumental in confirming this diagnosis.

Transient diplopia from a posterior alveolar injection

Several anatomical vascular pathways have been proposed to explain oculomotor disturbances observed after injection of local dental anesthetics. The author suggests another possible pathway to account for the unusual clinical observations described in this report.

Phase II study of CHIP chemotherapy in advanced adenocarcinomas of the upper gastrointestinal tract

Iproplatin (CHIP) is a second generation cisplatin analogue which has completed its Phase I trials. We studied the efficacy and toxicity of CHIP in 36 previously untreated patients with advanced upper gastrointestinal tract adenocarcinomas (GE junction, cardia, antrum and body of the stomach). The starting dose was 275 mg/m2; course were repeated on an every four week schedule. Thirty-five patients were evaluable for response. Three partial remissions (8.5%) [95% confidence limits 2.5-15%] were seen. Toxicity was tolerable and included mild myelosuppression and mild nausea and vomiting. Although well tolerated, in patients with gastric and GE junction adenocarcinomas, CHIP chemotherapy was not more and probably slightly less, effective than the parent analogue cisplatin.

Extrapulmonary Pneumocystis carinii infection in AIDS: CT findings

Clinical and computed tomographic (CT) findings in three cases of extrapulmonary Pneumocystis carinii infection in patients with acquired immunodeficiency syndrome (AIDS) were reviewed. Proved sites of involvement included the spleen (n = 2), bone marrow (n = 1), liver (n = 1), and peritoneal and pleural fluid (n = 1). CT findings included focal low-attenuation splenic lesions that became progressively calcified in rimlike or punctate fashion; punctate calcifications in the liver, renal cortices, and adrenal glands; calcification of lymph nodes; and pleural and peritoneal effusions with subsequent calcifications of the pleural and peritoneal surfaces. Although rare both before and since the onset of the AIDS epidemic, extrapulmonary P carinii infection in AIDS patients has been reported with increasing frequency in recent years, and more cases with radiologic manifestations should be expected.

Expression of transforming growth factor alpha and epidermal growth factor receptor messenger RNA in neoplastic and nonneoplastic human kidney tissue

Using Northern blot analysis, we have demonstrated that mRNA for transforming growth factor alpha (TGF-alpha) was expressed in five malignant kidney tissue specimens but was not detected in their autologous nonneoplastic homologues. In addition, the expression of epidermal growth factor (EGF) receptor mRNA in these malignant tissues was 2- to 3-fold greater than in nontransformed tissues. In two cases examined using immunohistochemistry, we were able to correlate the increased expression of the mRNA with an increase in protein expression. Since TGF-alpha is known to bind to the EGF receptor, the finding of an increased expression of both TGF-alpha and EGF receptor mRNA in kidney tumor tissue suggests that interaction between TGF-alpha and the EGF receptor may play a role in promoting transformation and/or proliferation of kidney neoplasms, perhaps by an autocrine mechanism.