Comparison of the sixth and the seventh editions of the UICC classification for intrahepatic cholangiocarcinoma

Background

The current seventh edition of the TNM classification for intrahepatic cholangiocarcinoma (ICC) includes tumor number, vascular invasion, lymph node involvement but no longer the tumor size as compared to the sixth edition. The impact of the seventh edition on stage-based prognostic prediction for patients with ICC was evaluated.

Methods

Between 03/2001 and 02/2013, 98 patients with the diagnosis of an ICC were surgically treated at our center. Median survival times were calculated for these patients after separate classification by both sixth and seventh editions.

Results

Median overall survival was increased in patients classified to the lower tumor stages I and II using the seventh as compared to the sixth edition: stage I (54.9 vs. 47.3 months), stage II (19.9 vs. 18.9 months), stage III (17.2 vs. 19.9 months), and stage IV (23.2 vs. 15.3 months), respectively. The seventh edition definition of the T category resulted in an increased median survival regarding the T1 (50.4 vs. 47.3 months) as well as the T2 category (19.9 vs. 15.6 months) and revealed a reduced median survival of patients within the T3 (21.6 vs. 24.8 months) as well as the T4 category (19.9 vs. 27.0 months).

Conclusions

The UICC seventh edition TNM classification for ICC improves separation of patients with intermediate stage tumors as compared to the sixth edition. The prognostic value of the UICC staging system has been improved by the seventh edition.

Trial registration The data for this study have been retrospectively registered and the study has been approved by the ethic committee of the medical faculty of the University Hospital of Essen, Germany (license number 15-6353-BO).

[Left-Lateral Living Related Liver Donation - The Essen Experience]

Background: The international organ shortage for liver transplantation exists particularly in paediatric transplantation. Therefore left-lateral living related liver donation (LLRLD) plays a major role in this field. The aim of the present study was to analyse all procedures of LLRLD in terms of donor safety from December 2008 to October 2012 at the University Hospital of Essen, Germany. Methods: All procedures of LLRLD from December 2008 to October 2012 at the University Hospital of Essen were included in the present study. All operations were carried out via an open narrowed median longitudinal laparotomy. General donor data were analysed. Complications were recorded and classified in accordance to their relevance. Results: 35 LLRLD were performed between December 2008 and October 2012 at the University Hospital of Essen, Germany. Mean age of the donors was 31.9 (23.4-61.7) years and 60 % were female. Past medical histories of the donors showed no relevant diagnoses. Mean length of the surgical procedure was 180 (± 89) minutes. Survival rate was 100 %. Minor complications were seen in 1 of 35 patients. Laboratory data showed a peak of the transaminases on the first postoperative day which resolved during the further course. Median postoperative hospital stay was 7 (5-11) days. Conclusion: LLRLD can be performed safely for the donors after adequate donor selection. The organ pool for paediatric recipients can be expanded by this procedure at suitable transplant centres.

Polo-like kinase 3 is associated with improved overall survival in cholangiocarcinoma

BACKGROUND & AIMS

Cholangiocarcinomas (CCA) paradoxically express the death ligand TRAIL and thus, are dependent on effective survival signals to circumvent apoptosis. Hedgehog signalling exerts major survival signals in CCA by regulating serine/threonine kinase polo-like kinase (PLK)2. We here aimed to examine the role of PLK1/2/3 expression for CCA tumour biology.

METHODS

We employed CCA samples from 73 patients and human HUCCT-1/Mz-CHA1/KMCH-1 CCA cells. Immunohistochemistry for PLK1/2/3 was performed using tissue microarrays from representative tumour areas.

RESULTS

PLK1/2/3-immunoreactive cancer cells were present in most of the CCA samples. However, only PLK1 and especially PLK3 were expressed in higher amounts within CCA cells as compared to normal liver. Given that fibroblast growth factor (FGF) can induce PLK3 expression and also is present in CCA, we examined the effect of FGF on PLK3 in vitro. Indeed, rhFGF rapidly increased PLK3 mRNA expression all three CCA cell lines giving an explanation for the abundant PLK3 presence in the tissue samples. Clinicopathologically, PLK3 expression was associated with decreased tumour cell migration and lymph/blood vessel infiltration whereas higher levels of PLK1 were correlated with larger tumour sizes. Moreover, strong PLK3 expression was associated with prolonged overall survival.

CONCLUSIONS

The results suggest that PLK3 predominantly is expressed in CCA cells and that high PLK3 expression correlates with prolonged overall survival. These observations might have implications for prognosis prediction of human CCA as well as the potential therapeutic use of polo-like kinase inhibitors (i.e., PLK1/2 specifity).

Safely expanding the donor pool: brain dead donors with history of temporary cardiac arrest

BACKGROUND & AIMS

Cardiac arrest (CA) in deceased organ donors can potentially be associated with ischaemic organ injury, resulting in allograft dysfunction after liver transplantation (LT). The aim of this study was to analyse the influence of cardiac arrest in liver donors.

METHODS

We evaluated 884 consecutive adult patients undergoing LT at our Institution from September 2003 to December 2011. Uni- and multivariable analyses was performed to identify predictive factors of outcome and survival for organs from donors with (CA donor) and without (no CA donor) a history of cardiac arrest.

RESULTS

We identified 77 (8.7%) CA donors. Median resuscitation time was 16.5 (1-150) minutes. Allografts from CA donors had prolonged CIT (p = 0.016), were obtained from younger individuals (p < 0.001), and had higher terminal preprocurement AST and ALT (p < 0.001) than those of no CA donors. 3-month, 1-year and 5-year survival for recipients of CA donor grafts was 79%, 76% and 57% and 72.1%, 65.1% and 53% for no CA donor grafts (log rank p = 0.435). Peak AST after LT was significantly lower in CA donor organs than in no CA donor ones (886U/l vs 1321U/l; p = 0.031). Multivariable analysis identified CIT as a risk factor for both patient and graft survival in CA donors.

CONCLUSION

This analysis represents the largest cohort of liver donors with a history of cardiac arrest. Reasonable selection of these donors constitutes a safe approach to the expansion of the donor pool. Rapid allocation and implantation with diminution of CIT may further improve the outcomes of livers from CA donors.

Vitamin D counteracts fibrogenic TGF-β signalling in human hepatic stellate cells both receptor-dependently and independently

OBJECTIVE

Non-alcoholic fatty liver disease (NAFLD) is closely linked to obesity and constitutes part of the metabolic syndrome, which have been associated with low serum vitamin D (VD). Due to known crosstalk between VD and transforming growth factor (TGF)-β signalling, VD has been proposed as an antifibrotic treatment.

DESIGN

We evaluated the association between VD, the vitamin D receptor (VDR) and liver fibrosis in primary human hepatic stellate cells (phHSC) and 106 morbidly obese patients with NAFLD.

RESULTS

Treating phHSC with VD ameliorated TGF-β-induced fibrogenesis via both VDR-dependent and VDR-independent mechanisms. Reduction of fibrogenic response was abolished in cells homozygous for GG at the A1012G single nucleotide polymorphisms within the VDR gene. Compared with healthy livers, NAFLD livers expressed higher levels of VDR mRNA and VDR fragments. VDR mRNA was lower in patients homozygous for GG at A1012G and expression of pro-fibrogenic genes was higher in patients carrying the G allele.

CONCLUSIONS

VD may be an antifibrotic treatment option early in the onset of fibrosis in specific genotypes for VDR. Known polymorphisms of the VDR may influence the response to VD treatment.

Donor information based prediction of early allograft dysfunction and outcome in liver transplantation

BACKGROUND & AIMS

Poor initial graft function was recently newly defined as early allograft dysfunction (EAD) [Olthoff KM, Kulik L, Samstein B, et al. Validation of a current definition of early allograft dysfunction in liver transplant recipients and analysis of risk factors. Liver Transpl 2010; 16: 943]. Aim of this analysis was to evaluate predictive donor information for development of EAD.

METHODS

Six hundred and seventy-eight consecutive adult patients (mean age 51.6 years; 60.3% men) who received a primary liver transplantation (LT) (09/2003-12/2011) were included. Standard donor data were correlated with EAD and outcome by univariable/multivariable logistic regression and Cox proportional hazards to identify prognostic donor factors after adjustment for recipient confounders. Estimates of relevant factors were utilized for construction of a new continuous risk index to develop EAD.

RESULTS

38.7% patients developed EAD. 30-day survival of grafts with and without EAD was 59.8% and 89.7% (P < 0.0001). 30-day survival of patients with and without EAD was 68.5% and 93.1% (P < 0.0001) respectively. Donor body mass index (P = 0.0112), gGT (P = 0.0471), macrosteatosis (P = 0.0006) and cold ischaemia time (CIT) (P = 0.0031) were predictors of EAD. Internal cross validation showed a high predictive value (c-index = 0.622).

CONCLUSIONS

Early allograft dysfunction correlates with early results of LT and can be predicted by donor data only. The newly introduced risk index potentially optimizes individual decisions to accept/decline high risk organs. Outcome of these organs might be improved by shortening CIT.

[Orthotopic liver transplantation for polycystic liver disease with massive hepatomegaly]

HISTORY

A 51-year-old man (126 kg, 192 cm) with massive hepatomegaly causing cardiopulmonary symptoms was referred to our transplant center 14 years after initial diagnosis of polycystic liver disease.

TREATMENT AND COURSE

Uneventful hepatectomy was followed by orthotopic liver transplantation using caval replacement. Donor liver came from a 73-year-old woman (extended criteria donor organ offer). A portocaval shunting was not established during transplantation although the explanted liver weighed 22 kg. 18 months after transplantation liver function is stable and the patient enjoys normal quality of life.

CONCLUSION

This case report demonstrates the value and success of transplantation for patients suffering from enormous hepatomegaly due to polycystic liver disease.

[Relevance of Ablation Therapies for HCC: "A Real Bridging" for Liver Transplantation?]

BACKGROUND

The utilisation of interventional ablation procedures in the context of bridging and downstaging plans for hepatocellular carcinomas before liver transplantation is increasing. The aim of the present study was to summarise current data for the application of bridging and downstaging procedures before liver transplantation.

METHODS

The present study is based on an extensive investigation of the literature in PubMed. RESULTS of controlled trials, cohort studies, meta-analyses and reviews were included.

RESULTS

Recommendations for the usage of bridging procedures for hepatocellular carcinomas within the Milan criteria and an expected waiting time of more than 6 months until transplantation depend on the size of the lesions and have a low level of evidence. After successful downstaging of hepatocellular carcinomas beyond the Milan criteria into the range of the Milan criteria liver transplantation is recommended with a low level of evidence, as well.

CONCLUSION

Randomised controlled trials, clearly proving the success of bridging and downstaging procedures, are not available at the time and are not awaited for ethical reasons. Due to the uncomplicated application and low risk for therapy-associated complications, interventional procedures for bridging and downstaging are accepted and recommended.

Liver transplantation for hepatocellular carcinoma using extended criteria donor grafts

BACKGROUND

Liver transplantation (OLT) represents the treatment of choice for small hepatocellular carcinomas (HCC) in patients with end-stage liver disease. However, because of organ scarcity, alternative options must be explored, such as the use of extended criteria donor (ECD) grafts.

PATIENTS AND METHODS

We reviewed data of transplanted HCC patients using ECD grafts. Statistical analysis included uni- and multivariate Cox proportional hazards regression and survival analysis using the Kaplan-Meier method with the log-rank test.

RESULTS

Over a 6-year period, we transplanted 53 HCC patients with ECD grafts. The 38 men and 15 women showed a mean age of 56.3 ± 8.26 years. Thirty-four patients underwent a bridging treatment before OLT. Thirty-eight patients (72%) were outside the Milan criteria. The median value for alpha fetoprotein (AFP) level was 30.7 ng/dL. Pathologic tumor grade was G1 (n = 4), G2 (n = 32), G3 (n = 6), or Gx (n = 11). Median follow-up time was 23 months (range, 9-75). Overall 3- and 5- year patient survivals were 79% and 74%, respectively. The 5-year survivals for patients within or outside the Milan criteria were 87% versus 69%, respectively (P = .3728). Donor transaminases and post-OLT hemodialysis were prognostic factors for patient survival upon mutivariate regression analysis (P = .0043 and P = .0003, respectively).

CONCLUSION

OLT with ECD grafts constitutes an additional option for patients with HCC and cirrhosis, particularly subjects outside the Milan criteria. The risk- benefit ratio in these instances should be evaluated on a case-by-case basis.

Liver transplantation in nonalcoholic steatohepatitis is associated with high mortality and post-transplant complications: a single-center experience

BACKGROUND/AIMS

Non-alcoholic fatty liver disease (NAFLD) with its progressive form nonalcoholic steatohepatitis (NASH) is the most common chronic liver disease in western countries which is associated with end-stage liver disease and hepatocellular carcinoma (HCC). This entity is a consistently increasing indication for transplantation. However, data about postsurgery outcome and complications are still limited.

PATIENTS AND METHODS

Records of 432 consecutive transplanted patients between October 2007 and January 2011 were investigated retrospectively. Forty transplants were performed due to NASH-induced cirrhosis. Perioperative courses and short- and long-term outcomes were analyzed.

RESULTS

The NAFLD population consisted of 16 women and 24 men with a mean age of 55 years. The median MELD score was 27 at the time of liver transplantion. BMI before surgery ranged from 21 to 45 (mean 31). Sixteen of the initial 40 patients are still alive. Patients with sustained obesity and features of the metabolic syndrome had a worse 1-year mortality rate of 42%.

CONCLUSIONS

A significant number of liver transplantations in our center was performed due to NASH; transplantation in this cohort was associated with high mortality and postoperative complications, most likely due to associated obesity and diabetes. Weight reduction prior to surgery may lead to a better outcome.

An ex vivo perfusion system emulating in vivo conditions in noncirrhotic and cirrhotic human liver

Various models are used for investigating human liver diseases and testing new drugs. However, data generated in such models have only limited relevance for in vivo conditions in humans. We present here an ex vivo perfusion system using human liver samples that enables the characterization of parameters in a functionally intact tissue context. Resected samples of noncirrhotic liver (NC; n = 10) and cirrhotic liver (CL; n = 12) were perfused for 6-h periods. General and liver-specific parameters (glucose, lactate, oxygen, albumin, urea, and bile acids), liver enzymes (aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, glutamate dehydrogenase, and γ-glutamyl transferase), overall (M65) and apoptotic (M30) cell-death markers, and indicators of phase-I/phase-II biotransformations were analyzed. The measurement readings closely resembled (patho)physiological characteristics in patients with NC and CL. Mean courses of glucose levels reflected the CLs' reduced glycogen storage capability. Furthermore, CL samples exhibited significantly stronger increases in lactate, bile acids, and the M30/M65 ratio than NC specimens. Likewise, NC samples exhibited more rapid phase-I transformations of phenacetin, midazolam, and diclofenac and phase-I to phase-II turnover rates of the respective intermediates than CL tissue. Collectively, these findings reveal the better hepatic functionality in NC. Perfusion of human liver tissue with this system emulates in vivo conditions and clearly discriminates between noncirrhotic and cirrhotic tissue. This highly reliable device for investigating basic hepatic functionality and testing safety/toxicity, pharmacokinetics/pharmacodynamics and efficacies of novel therapeutic modalities promises to generate superior data compared with those obtained via existing economic perfusion systems.

Changes in staging for hepatocellular carcinoma after radiofrequency ablation prior to liver transplantation as found in the explanted liver

BACKGROUND/AIMS

To analyze the efficacy of radiofrequency ablation (RFA) prior to liver transplantation (LT) in liver explants.

METHODOLOGY

We reviewed pathological findings in the explanted livers of 13 patients with histologically proven HCC and liver cirrhosis who underwent RFA as bridging treatment prior to LT. Eight patients had solitary nodules with a median diameter of 4cm, whereas five patients had two tumors each with a median total diameter of 3.3cm prior to RFA. One session of RFA was performed by all patients.

RESULTS

Tumor regression was proved in 3/13 patients whereas steady disease was observed in 5/13 patients (38%). Tumor regression was observed only in one of the five patients having two tumors prior to RFA. Pathology proved a multifocal tumor in four patients, including one patient with a radiological presumed solitary tumor. Tumor progression was observed in 5/13 patients (38%).

CONCLUSIONS

Although the majority of our patients (8/13, 62%) had a solitary tumor at the beginning of treatment, tumor progression was observed in a large proportion (38%) among them. The underestimation of tumor lesions in radiology and partial necrosis of the tumor achieved in most patients limit the role of RFA as bridging treatment prior to LT.

Long-term outcomes of liver transplant patients with human immunodeficiency virus infection and end-stage-liver-disease: single center experience

Objective

Orthotopic-liver-transplantation (OLT) in patients with Human-Immunodeficiency-Virus infection (HIV) and end-stage-liver-disease (ESDL) is rarely reported. The purpose of this study is to describe our institutional experience on OLT for HIV positive patients.

Material and methods

This is a retrospective study of all HIV-infected patients who underwent OLT at the University Hospital of Essen, from January 1996 to December 2009. Age, sex, HIV transmission-way, CDC-stage, etiology of ESDL, concomitant liver disease, last CD4cell count and HIV-viral load prior to OLT were collected and analysed. Standard calcineurin-inhibitors-based immunosuppression was applied. All patients received anti-fungal and anti-pneumocystis carinii pneumonia prophylaxis post-OLT.

Results

Eight transplanted HIV-infected patients with a median age of 46 years (range 35-61 years) were included. OLT indications were HCV (n = 5), HBV (n = 2), HCV/HBV/HDV-related cirrhosis (n = 1) and acute liver-failure (n = 1). At OLT, CD4 cell-counts ranged from 113-621 cells/μl, and HIV viral-loads from < 50-175,000 copies/ml. Seven of eight patients were exposed to HAART before OLT. Patients were followed-up between 1-145 months. Five died 1, 3, 10, 31 and 34 months after OLT due to sepsis and graftfailure respectively. Graft-failure causes were recurrent hepatic-artery thrombosis, HCV-associated hepatitis, and chemotherapy-induced liver damage due to Hodgkin-disease. One survivor is relisted for OLT due to recurrent chronic HCV-disease but non-progredient HIV-infection 145 months post-OLT. Two other survivors show stable liver function and non-progredient HIV-disease under HAART 21 and 58 months post-OLT.

Conclusions

OLT in HIV-infected patients and ESLD is an acceptable therapeutic option in selected patients. Long-term survival can be achieved without HIV disease-progression under antiretroviral therapy and management of the viral hepatitis co-infection.

Liver transplantation using donor organs with markedly elevated liver enzymes: how far can we go?

BACKGROUND

The disparity between the demand for solid organs and the current supply is a growing problem for patients with end-stage liver disease. To overcome organ shortage, extended criteria donor organs are also accepted for liver transplantation.

AIMS

We here unprecedentedly report the clinical course of patients receiving livers with markedly elevated liver enzymes.

METHODS

Between November 2007 and December 2010, 15 donor livers with markedly elevated liver enzymes [median aspartate aminotransferase (AST) 1400 (500-7538) U/l, median alanine aminotransferase (ALT) 1026 (308-9179) U/l] were offered to our transplant centre. Based on elaborate judgment, seven of these donor livers were rejected and eight donor livers were transplanted.

RESULTS

All eight transplanted patients showed a liver enzyme peak on the day of surgery (AST 2076 ± 1808 U/l, ALT 1087 ± 833 U/l) and a statistically significant decrease from day 0 to day 7 post-liver transplantation. INR decreased and platelet count increased statistically significantly within 1 week after liver transplantation. The patients were discharged from the hospital 28 ± 11 days after liver transplantation in good clinical condition.

CONCLUSIONS

These data demonstrate that using donor livers with markedly elevated liver enzymes may be an acceptable option to expand the donor pool. Universal objective parameters for acceptance should be defined in future studies.

Use of marginal organs in kidney transplantation for marginal recipients: too close to the margins of safety?

Objective

Due to organ shortage, average waiting time for a kidney in Germany is about 4 years after start of dialysis. Number of kidney grafts recovered can only be maintained by accepting older and expanded criteria donors. The aim of this study was to analyse the impact of donor and recipient risk on kidney long-term function.

Methods

All deceased kidney transplantations were considered. We retrospectively studied 332 patients between 2002 and 2006; divided in 4 groups reflecting donor and recipient risk.

Results

Non-marginal recipients were less likely to receive a marginal organ (69 of 207, 33%) as compared to marginal recipients, of whom two-thirds received a marginal organ (p < 0.0001). Graft function significantly differed between the groups, but detrimental effect of marginal recipient status on eGFR after 12 months (-6 ml/min/1.73 qm, 95% CI -2 to -9) was clearly smaller than the effect of marginal donor status (-10 ml/min/1.73 qm, 95% CI -7 to -14).

Conclusions

As we were able to show expanded criteria donor has a far bigger effect on long-term graft function than the "extra risk" recipient. Although there have been attempts to define groups of recipients who should be offered ECD kidneys primarily the discussion is still ongoing.