Alpha-Fetoprotein Response after First Transarterial Chemoembolization (TACE) and Complete Pathologic Response in Patients with Hepatocellular Cancer

Transarterial chemoembolization (TACE) is used as a bridging treatment in liver transplant candidates with hepatocellular carcinoma (HCC). Alpha-fetoprotein (AFP) is the main tumor marker used for HCC surveillance. The aim of this study was to assess the potential of using the AFP change after the first TACE in the prediction of complete tumor necrosis. The study comprised 101 patients with HCC who underwent liver transplantation (LT) after TACE in the period between January 2011 and December 2020. The ΔAFP was defined as the difference between the AFP value before the first TACE and AFP either before the second TACE or the LT. The receiver operator characteristics (ROC) curves were used to identify an optimal cut-off value. Complete tumor necrosis was found in 26.1% (18 of 69) and 6.3% (2 of 32) of patients with an initial AFP level under and over 100 ng/mL, respectively (p = 0.020). The optimal cut-off value of ΔAFP for the prediction of complete necrosis was a decline of ≥10.2 ng/mL and ≥340.5 ng/mL in the corresponding subgroups. Complete tumor necrosis rates were: 62.5% (5 of 8) in patients with an initial AFP < 100 ng/mL and decline of ≥10.2 ng/mL; 21.3% (13 of 61) in patients with an initial AFP < 100 ng/mL and decline of <10.2 ng/mL; 16.7% (2 of 12) in patients with an initial AFP > 100 ng/mL and decline of ≥340.5 ng/mL; and null in 20 patients with an initial AFP > 100 ng/mL and decline of <340.5 ng/mL, respectively (p = 0.003). The simple scoring system, based on the initial AFP and AFP decline after the first treatment, distinguished between a high, intermediate and low probability of complete necrosis, with an area under the ROC curve of 0.699 (95% confidence intervals 0.577 to 0.821, p = 0.001). Combining the initial AFP with its change after the first treatment enables early identification of the efficacy of TACE.

Can Color Doppler Ultrasound Be Effectively Used as the Follow-Up Modality in Patients Undergoing Splenic Artery Aneurysm Embolization? A Correlational Study between Doppler Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography

Splenic artery aneurysm (SAAs) rupture is associated with a high mortality rate. Regular surveillance with imaging before and after intervention is crucial to guide best evidence treatment. The following study aimed to determine the efficacy of color Doppler ultrasound imaging (DUS) compared to digital subtraction angiography (DSA) and magnetic resonance angiography (MRA) as a follow-up modality after selective coil embolization of true SAAs. We analyzed data from 20 patients, 15 females (48.1 ± 16.1 years) undergoing selective SAA coil embolization using detachable fibered embolization coils. Imaging using DUS, MRA, and DSA was performed 3 months after the initial embolization or the consequent re-embolization procedure. Primary clinical success, defined as Class I aneurysm occlusion, on 3-month follow-up was seen in 16 (80.0%) patients. DUS had a sensitivity of 94.4% and a specificity of 42.9% when compared to DSA and 92.3% and 30%, respectively, when compared to MRA in identifying Class I aneurysm occlusion. The positive predictive value (PPV) of DUS in identifying the need for re-embolization was 75.0%, while the NPV of DUS in these terms was 90.5%. DUS showed a high sensitivity in detecting aneurysm occlusion and clinical success, simultaneously exhibiting poor specificity. Still, with caution, this follow-up modality could be used for monitoring select low-risk patients after selective embolization of SAAs. DUS could provide a higher cost-to-benefit ratio, enabling more systematic post-procedural follow-up, as it is far more commonly used compared to MRA and non-invasive compared to DSA.

Impact of muscle mass on survival of patients with hepatocellular carcinoma after liver transplantation beyond the Milan criteria

BACKGROUND

Access to the liver transplant waitlist for patients with hepatocellular carcinoma (HCC) depends on tumour presentation, biology, and response to treatments. The Milan Criteria (MC) represent the benchmark for expanded criteria that incorporate additional prognostic factors. The purpose of this study was to determine the added value of skeletal muscle index (SMI) in HCC patients beyond the MC.

METHOD

Patients with HCC that were transplanted beyond the MC were included in this retrospective multicentre study. SMI was quantified using the Computed Tomography (CT) within 3 months prior to transplantation. Cox regression models were used to identify predictors of overall survival (OS). The discriminative performance of SMI extended Metroticket 2.0 and AFP models was also assessed.

RESULTS

Out of 889 patients transplanted outside the MC, 528 had a CT scan within 3 months prior to liver transplantation (LT), of whom 176 (33%) were classified as sarcopenic. The median time between assessment of the SMI and LT was 1.8 months (IQR: 0.77-2.67). The median follow-up period was 5.1 95% CI [4.7-5.5] years, with a total of 177 recorded deaths from any cause. In a linear regression model with SMI as the dependent variable, only male gender (8.55 95% CI [6.51-10.59], P < 0.001) and body mass index (0.74 95% CI [0.59-0.89], P < 0.001) were significant. Univariable survival analysis of patients with sarcopenia versus patients without sarcopenia showed a significant difference in OS (HR 1.44 95% CI [1.07 - 1.94], P = 0.018). Also the SMI was significant (HR 0.98 95% CI [0.96-0.99], P = 0.014). The survival difference between the lowest SMI quartile versus the highest SMI quartile was significant (log-rank: P = 0.005) with 5 year OS of 57% and 71%, respectively. Data from 423 patients, describing 139 deaths, was used for multivariate analysis. Both sarcopenia (HR 1.45 95% CI [1.02 - 2.05], P = 0.036) and SMI were (HR 0.98 95% CI [0.95-0.99], P = 0.035) significant. On the survival scale this translates to a 5 year OS difference of 11% between sarcopenia and no sarcopenia. Whereas for SMI, this translates to a survival difference of 8% between first and third quartiles for both genders.

CONCLUSIONS

Overall, we can conclude that higher muscle mass contributes to a better long-term survival. However, for individual patients, low muscle mass should not be considered an absolute contra-indication for LT as its discriminatory performance was limited.

Performance of initial LI-RADS 2018 treatment response in predicting survival of patients with hepatocellular carcinoma following TACE: a retrospective, single-center cohort study

Purpose

Treatment response following transarterial chemoembolization (TACE) is frequently evaluated with Liver Imaging Reporting and Data System Treatment Response (LR-TR) algorithm, but its association with patients’ outcomes is not supported in the literature. The purpose of this study was to provide such data.

Methods

A retrospective analysis of 99 TACE patients with stage A/B hepatocellular carcinoma according to Barcelona-Clinic Liver Cancer staging system was performed. Two radiologists assessed LR-TR, while a third radiologist re-assessed divergent results. Overall survival (OS) and time to disease progression (TTP) were the primary endpoints of the study, while the Cox proportional hazard model was used for outcome analyses.

Results

Interobserver agreement was substantial between the two readers with κ = 0.69 (95% CI 0.58–0.81). The median OS in viable, equivocal, and non-viable groups were 27, 27, and 73 months, respectively (p < 0.001). However, after adjustment for confounding factors, there was no significant association between initial viable response and OS (HR 0.98 [95% CI 0.37–2.63], p = 0.97), while equivocal response remained statistically significant (HR 3.52. [95% CI 1.27–9.71], p = 0.015). No significant association was noted when viable and equivocal groups were analyzed in aggregate (HR 1.03 [95% CI 0.4–2.4], p = 0.96). The median TTP did not differ between non-viable and viable groups (23 vs 18 months, respectively; p = 0.98). None of the analyzed predictors was associated with TTP.

Conclusion

Initial LR-TR response was not an independent predictor for OS nor TTP. The preliminary results suggest the necessity for more aggressive management of equivocal patients.

Selective occlusion of splenic artery aneurysms with the coil packing technique: the impact of packing density on aneurysm reperfusion correlated between contrast-enhanced MR angiography and digital subtraction angiography

PURPOSE

The aim was to evaluate the relationship between coil packing densities after splenic artery aneurysm (SAA) treatment using detachable microcoils and rates of SAA reperfusion and to suggest a post-treatment surveillance protocol using contrast-enhanced MRA.

MATERIALS AND METHODS

Evaluated were 16 patients (4 men; mean age 46.7), who underwent true SAA embolization using detachable microcoils (Concerto, Medtronic). SAAs were treated by selective coil packing (CP) or stent-assisted coil exclusion (SAC). Contrast-enhanced magnetic resonance angiography (CE-MRA) and digital subtraction angiography (DSA) were performed at 3 months post-procedure and correlated.

RESULTS

Primary CP was used in 13 patients, while SAC was used in three patients. On follow-up, complete aneurysm occlusion was seen in seven patients (43.8%). Sac reperfusion occurred in nine patients (56.2%) and was demonstrated in all CE-MRA and six DSA studies. Mean aneurysm packing density was 20.10 ± 8.05% for the CP group and 32.90 ± 11.95% for the SAC group (p = 0.038). There was a significant difference in the incidence of aneurysm sac reperfusion on CE-MRA study between CP and SAC (9 vs. 0). No sac reperfusion was seen in aneurysms with packing densities ≥ 29%, irrespective of either embolization method.

CONCLUSION

Favorable midterm results for coil packing of SAAs seem to depend on the coil packing density with a coil volume approximately a quarter of the aneurysm volume being most effective. Follow-up should involve the use of CE-MRA as this modality has been shown to be superior over DSA in detecting aneurysm reperfusion and coil compaction.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Justification and Indifference: Diverse Permissive Attitudes Toward Witnessed Violence Against the Elderly and Disabled

The violence against the elderly and disabled is widespread. This means that many people who witness acts of violence against elders and the disabled do not react. Instead, they are rather inclined to develop permissive attitudes. The presented article distinguishes two permissive attitudes toward witnessed violence against the elderly and disabled: justification and indifference. The rationale for such differentiation is justified with reference to differences concerning (a) the strength of their relationship, (b) their frequency distribution in the population, and (c) the disparate influence of the underlying predictors. A survey study carried out on a nationwide representative sample of 1,000 adult Poles was the empirical basis for answering research questions. The study showed that domestic violence against elders and the disabled is a noticeable phenomenon in the population of Poland. Around 50% of respondents claimed that they came in touch with physical, economic, or psychological violence against the elderly. More than 30% reported the same in the case of disabled persons. Based on this study, it was found that justification of and indifference to violence were actually unrelated phenomena. Moreover, justification was much less widespread in the population than indifference. It seems easier to accept excuses for passivity in the face of violence than to find justifications for violence. Both permissive attitudes turned out to have a disparate pattern of predictors: Justification turned out to be mainly a function of environmental exposure to violence, whereas indifference was mainly a matter of worldview based on materialism and the imperative of self-interest.

Promoting False-Lumen Thrombosis after Thoracic Endovascular Aneurysm Repair in Type B Aortic Dissection by Selectively Excluding False-Lumen Distal Entry Tears

PURPOSE

To evaluate the efficacy and clinical outcomes of ancillary endovascular procedures in promoting false-lumen (FL) thrombosis (FLT) and preventing aortic expansion in patients after thoracic endografting for type B dissections.

MATERIALS AND METHODS

This retrospective review included 15 patients (12 men and 3 women; mean age, 59.6 y). Mean aortic diameter at the time of ancillary treatment was 47.4 mm. Different techniques were used as single procedures or sequentially: covered stent occlusion of detached visceral artery entry tears, occlusion of single entry tears with vascular plugs, or aortic endograft occlusion of multiple FL entry tears. FL embolization with ethylene vinyl alcohol copolymer was performed when selective occlusion was considered insufficient to close distal entry tears. Apart from endovascular aneurysm repair, all procedures were performed percutaneously under local anesthesia. If FL diameter increase persisted after 6-month follow-up computed tomographic (CT) angiography, another intervention was planned; otherwise, yearly follow-up was performed.

RESULTS

Mean clinical follow-up duration was 43.8 months (range, 8 d to 86.8 mo), with no in-hospital mortality. Estimated overall survival rates were 93.3%, 86.6%, and 77% at 12, 24, and 48 months, respectively. Three late deaths occurred, one of which was dissection-related at 40 months. Eight surviving patients (53%) had total FLT and 3 had partial FLT with stable aortic diameter on follow-up CT angiography. FL diameter increased in one patient, requiring further intervention.

CONCLUSIONS

Selective exclusion of new distal entry tears remaining after thoracic endovascular aneurysm repair can stabilize abdominal aortic expansion and promote FLT.

Sexually transmitted diseases among Polish soldiers serving in the U.N. peace missions in Lebanon and Cambodia

The results are presented of a survey conducted on the incidence of sexually transmitted diseases (STD) among Polish military personnel of the United Nations Forces in Lebanon (UNIFIL) in 1993-2000, and Cambodia (UNTAC) in 1992-1993. The analysis was based on the medical documentation of the patients treated in the UNIFIL Hospital in years 1993-2000. The most frequently recorded cases of sexually transmitted diseases in Cambodia were those of gonorrhoea. The results showed that sexually transmitted diseases did not present a serious health problem among soldiers in Lebanon, but were a problem in Cambodia. Specific living conditions and social norms characteristic for these countries were taken into consideration in presenting the results of the survey.