Liver Transplantation For Treatment Research Articles

Transplant Oncology: An Emerging Discipline of Cancer Treatment.

Transplant oncology is an emerging concept of cancer treatment with a promising prospective outcome. The applications of oncology, transplant medicine, and surgery are the core of transplant oncology to improve patients' survival and quality of life. The main concept of transplant oncology is to radically cure cancer by removing the diseased organ and replacing it with a healthy one, aiming to improve the survival outcomes and quality of life of cancer patients. Subsequently, it seeks to expand the treatment options and research for hepatobiliary malignancies, which have seen significantly improved survival outcomes after the implementation of liver transplantation (LT). In the case of colorectal cancer (CRC) in the transplant setting, where the liver is the most common site of metastasis of patients who are considered to have unresectable disease, initial studies have shown improved survival for LT treatment compared to palliative therapy interventions. The indications of LT for hepatobiliary malignancies have been slowly expanded over the years beyond Milan criteria in a stepwise manner. However, the outcome improvements and overall patient survival are limited to the specifics of the setting and systematic intervention options. This review aims to illustrate the representative concepts and history of transplant oncology as an emerging discipline for the management of hepatobiliary malignancies, in addition to other emerging concepts, such as the uses of immunotherapy in a peri-transplant setting as well as the use of circulating tumor DNA (ctDNA) for surveillance post-transplantation.

Predicting the outcomes of hepatocellular carcinoma downstaging with the use of clinical and radiomics features

BackgroundDownstaging of hepatocellular carcinoma (HCC) makes it possible for patients beyond the criteria to have the chance of liver transplantation (LT) and improved outcomes. Thus, a procedure to predict the prognosis of the treatment is an urgent requisite. The present study aimed to construct a comprehensive framework with clinical information and radiomics features to accurately predict the prognosis of downstaging treatment.MethodsSpecifically, three-dimensional (3D) tumor segmentation from contrast-enhanced computed tomography (CT) is employed to extract spatial information of the lesions. Then, the radiomics features within the segmented region are calculated. Combining radiomics features and clinical data prompts the development of feature selection to enhance the robustness and generalizability of the model. Finally, we adopt the support vector machine (SVM) algorithm to establish a classification model for predicting HCC downstaging outcomes.ResultsHerein, a comparative study was conducted on three different models: a radiomics features-based model (R model), a clinical features-based model (C model), and a joint radiomics clinical features-based model (R-C model). The average accuracy of the three models was 0.712, 0.792, and 0.844, and the average area under the receiver-operating characteristic (AUROC) of the three models was 0.775, 0.804, and 0.877, respectively.ConclusionsThe novel and practical R-C model accurately predicted the downstaging outcomes, which could be utilized to guide the HCC downstaging toward LT treatment.

ScRNA-seq revealed disruption in CD8+ NKG2A+ natural killer T cells in patients after liver transplantation and immunosuppressive therapy.

Liver transplantation (LT) offers a good survival chance for both the patient in short or long term, but still faces many challenges in the treatment of LT, such as the side effects associated with long-term immunosuppression, which is one of the side effects that occurs in most patients. However, the dynamics of the cellular immune system composition over time during immune tolerance to LT after immunosuppressive therapy are not known. Using single-cell transcriptome sequencing, we analyzed five peripheral blood samples (one normal individual and four patients who underwent LT and received immunosuppressive therapy for 2 months, 1 year, 3 years, and 7 years, respectively) for immune cell composition and gene expression. A total of 17,462 peripheral blood mononuclear cells were acquired from a normal individual without LT and patients who underwent LT and received immunosuppressive therapy for 2 months, 1 year, 3 years, and 7 years, respectively. A total of 24 cell clusters were obtained and categorized into four different cell types based on gene expression characteristics as follows: eight clusters of T cells, two clusters of B cells, two clusters of neutrophils, two clusters of monocytes, natural killer cells, and natural killer T (NKT) cells (n = 4), and six other cell clusters. Cell subset analysis, pseudotime analysis, and intercellular communication analysis revealed that the CD8+ NKT cells specifically expressed NKG2A (KLRC1, CD159A), which may be an important cell group for CD8+ NKG2A+ NKT cells in LT, thereby highlighting the heterogeneity and functional diversity in patients who undergo LT. We comprehensively analyzed single-cell RNA sequencing data from a normal individual and patients who underwent LT and elucidated the mechanism underlying the development of immune tolerance in LT. CD8+ NKT cells specifically expressing KLRC1 play a crucial role in LT, and dynamic monitoring of these cells may provide novel avenues for the diagnosis and treatment of LT-related immune rejection.

Význam inzulinové rezistence a NAFLD po transplantaci jater na přežívání pacientů a rozvoj chronického onemocnění ledvin

Summary: Introduction: Insulin resistance (IR) is a hallmark of non-alcoholic fatty liver disease (NAFLD), which has been associated with worse long-term survival and more frequent occurrence of chronic kidney disease (CKD) than in patients without NAFLD. The aim of our study was to evaluate the impact of NAFLD and IR on survival and renal function in patients after liver transplantation (LT). Methods: Our prospective study included 96 LT candidates who were observed after LT. We evaluated patient survival and occurrence of CKD (defined as estimated glomerular filtration [eGFR] ≤1.00 mL/s/1.73 m2 or overt proteinuria) 5 years after LT and at the end of follow-up. Clinical, laboratory, MR and elastographic evaluation before and 1 year after LT were performed as well as liver biopsy 1 year after LT. Results: Of the factors present 1 year after LT, higher ALT (P = 0.021), ALP (P = 0.012) and everolimus treatment (P = 0.025) increased the risk of death at the end of follow-up, borderline significance was found also for higher waist circumference (P = 0.058), AST (P = 0.059), HOMA-IR (P = 0.056) and presence of fibrosis stage ≥3 in biopsy (P = 0.055). In addition to the presence of CKD 1 year after LT (P <0.001), other independent posttransplant risk factors of CKD 5 years after LT included presence of IR defined as HOMA-IR ≥3 (OR 4.33; 95% CI 1.25–15.04; P = 0.021) and higher serum high-molecular-weight (HMW) adiponectin (OR 1.25; 95% CI 1.03–1.50; P = 0.021). Of the factors present 1 year after LT, diabetes treated by antidiabetics (P = 0.008), higher serum levels od triglycerides (P = 0.031), C-peptide (P = 0.022) and leptin (P = 0.002) and lower total bilirubin (P = 0.006) were associated with lower eGFR at the end of follow-up. We observed a trend towards higher eGFR levels in patients treated with everolimus (P = 0.055). We did not observe an impact of grade of steatosis and presence of steatohepatitis on biopsy 1 year after LT on survival or renal functions. Conclusion: Presence of IR 1 year after LT independently increased the risk of CKD 5 year after LT. Patients with higher HOMA-IR 1 year after LT had a trend towards worse survival at the end of follow-up. Key words: insulin resistance – non-alcoholic fatty liver disease – liver transplantation – chronic kidney disease – survival

Circulating tumor DNA is a potential prognostic risk factor of recurrence in patients with hepatocellular carcinoma treated by liver transplantation.

e16196 Background: Liver transplantation (LT) is one of the most effective therapeutic strategies for hepatocellular carcinoma (HCC), however, tumour recurrence after LT often leads to poor outcomes. At present, clinical characteristic profile, imaging diagnosis as well as level of serum biomarkers prior to LT could predict the prognosis in HCC patients treated by LT. However, the sensitivity and specificity of these biomarkers are limited, highlighting the crucial need to identify novel biomarkers. Previous clinical studies have shown that postoperative circulating tumor DNA (ctDNA) can be used as a predictive biomarker for the risk of recurrence in stage I-III solid tumor. This study aimed at investigating the relationship between the level of ctDNA and the probability of recurrence in HCC patients treated by LT. Methods: HCC patients receiving LT treatment were enrolled. Peripheral blood samples before LT and available matched tissue samples were collected. Targeted sequencing of 328 cancer-related genes were conducted. The clinicopathologic data of the patients was retrospectively analyzed. The predictive efficiency for recurrence after LT of different clinicopathologic parameters and ctDNA were accessed. Results: A total of 45 patients were enrolled, including 42 males (93%) and 3 females (7%), with a median age of 51 (range 31-76 years). Thirty-five patients (78%) had detectable ctDNA before LT while gene alterations were identified in tumor tissue of all the patients. Larger tumor size (> 5cm), cirrhosis, portal vein tumor thrombus (PVTT) and elevated AFP level (≥400ng/ml) prior to LT were associated with higher percentage of positive ctDNA (94% vs 73%, 84% vs 75%, 88% vs 79%, 88% vs 76%, respectively). Patients with micro-vessel invasion (MVI) had higher ctDNA abundance (maxVAF, P < 0.05). Interestingly, after over 3 years’ follow-up, clinical factors including MVI, PVTT, BCLC stage, maximum tumor diameter and serum AFP failed to predict disease free survival (DFS) and overall survival (OS). In contrast, the recurrence rate was remarkably augmented (48.6% vs 0%) and the median DFS was significantly decreased (390 days vs not reached, p< 0.05) in patients with detectable ctDNA. Conclusions: In conclusion, ctDNA could be a potential biomarker to sensitively predict the recurrence in patients with HCC treated by LT, which may help to improve the post-transplant management of these patients.

Rare Malignant Indications for Liver Transplantation: A Collaborative Transplant Study Report.

Introduction: Hepatocellular carcinoma (HCC) is by far the leading malignant indication for liver transplantation (LT). Few other malignancies, including cholangiocellular carcinoma (CCC), metastases from neuroendocrine tumors (NET), and sarcomas of the liver (LSAR), also are commonly accepted indications for LT. However, there is limited information on their outcome after LT.Methods: Graft and patient survival in 14,623 LTs performed in patients with hepatocellular carcinoma, CCC, NET, and LSAR from 1988 to 2017 and reported to the Collaborative Transplant Study were analyzed.Results: The study group consisted of 13,862 patients who had HCC (94.8%), 498 (3.4%) who had CCC, 100 (0.7%) who had NET, and 163 (1.1%) who had LSAR. CCC patients showed a 5-year graft survival rate of 32.1%, strikingly lower than the 63.2% rate in HCC, 51.6% rate in NET, and 64.5% rate in LSAR patients (P < 0.001 for all vs. CCC). Multivariable Cox regression analysis revealed a significantly higher risk of graft loss and death due to cancer during the first five post-transplant years in CCC vs. HCC patients (HR 1.77 and 2.56; P < 0.001 for both). The same risks were increased also in NET and LSAR patients but did not reach statistical significance.Conclusion: Among patients with rare malignant indications for LT, CCC patients showed significantly impaired graft as well as patient survival compared to HCC patients. The observed differences might challenge traditional decision-making processes for LT indication and palliative treatment in specific hepatic malignancies.

Liver transplantation for pediatric inherited metabolic liver diseases.

Liver transplantation (LT) remains the gold standard treatment for end stage liver disease in the pediatric population. For liver based metabolic disorders (LBMDs), the decision for LT is predicated on a different set of paradigms. With improved outcomes post-transplantation, LT is no longer merely life saving, but has the potential to also significantly improve quality of life. This review summarizes the clinical presentation, medical treatment and indications for LT for some of the common LBMDs. We also provide a practical update on the dilemmas and controversies surrounding the indications for transplantation, surgical considerations and prognosis and long terms outcomes for pediatric LT in LBMDs. Important progress has been made in understanding these diseases in recent years and with that we outline some of the new therapies that have emerged.

Mitochondrial Consequences of Organ Preservation Techniques during Liver Transplantation.

Allograft ischemia during liver transplantation (LT) adversely affects the function of mitochondria, resulting in impairment of oxidative phosphorylation and compromised post-transplant recovery of the affected organ. Several preservation methods have been developed to improve donor organ quality; however, their effects on mitochondrial functions have not yet been compared. This study aimed to summarize the available data on mitochondrial effects of graft preservation methods in preclinical models of LT. Furthermore, a network meta-analysis was conducted to determine if any of these treatments provide a superior benefit, suggesting that they might be used on humans. A systematic search was conducted using electronic databases (EMBASE, MEDLINE (via PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science) for controlled animal studies using preservation methods for LT. The ATP content of the graft was the primary outcome, as this is an indicator overall mitochondrial function. Secondary outcomes were the respiratory activity of mitochondrial complexes, cytochrome c and aspartate aminotransferase (ALT) release. Both a random-effects model and the SYRCLE risk of bias analysis for animal studies were used. After a comprehensive search of the databases, 25 studies were enrolled in the analysis. Treatments that had the most significant protective effect on ATP content included hypothermic and subnormothermic machine perfusion (HMP and SNMP) (MD = −1.0, 95% CI: (−2.3, 0.3) and MD = −1.1, 95% CI: (−3.2, 1.02)), while the effects of warm ischemia (WI) without cold storage (WI) and normothermic machine perfusion (NMP) were less pronounced (MD = −1.8, 95% CI: (−2.9, −0.7) and MD = −2.1 MD; CI: (−4.6; 0.4)). The subgroup of static cold storage (SCS) with shorter preservation time (< 12 h) yielded better results than SCS ≥ 12 h, NMP and WI, in terms of ATP preservation and the respiratory capacity of complexes. HMP and SNMP stand out in terms of mitochondrial protection when compared to other treatments for LT in animals. The shorter storage time at lower temperatures, together with the dynamic preservation, provided superior protection for the grafts in terms of mitochondrial function. Additional clinical studies on human patients including marginal donors and longer ischemia times are needed to confirm any superiority of preservation methods with respect to mitochondrial function.

Postoperative complications of ex vivo liver resection combined with autologous liver transplantation in treatment of advanced hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies

Objective To investigate the postoperative complications of ex vivo liver resection combined with autologous liver transplantation in the treatment of end-stage hepatic alveolar echinococcosis at high altitude and related prevention and treatment strategies. Methods Surgical data and follow-up data were collected from 11 patients with end-stage hepatic alveolar echinococcosis who underwent autologous liver transplantation in Qinghai People's Hospital from January 2013 to March 2019, and intraoperative and postoperative conditions were analyzed. Results All 11 patients underwent autologous liver transplantation successfully, without intraoperative death, among whom 2(18.18%) underwent hemi-extracorporeal hepatectomy and 9 (81.82%) underwent total extracorporeal hepatectomy. For the reconstruction of the retrohepatic inferior vena cava, 2 patients (18.18%) underwent reconstruction with the autologous great saphenous vein, 4 patients (36.36%) underwent reconstruction with artificial vessels, and the autologous retrohepatic inferior vena cava was preserved in 5 patients (45.45%). For biliary reconstruction, 8 patients (72.73%) underwent choledochoenterostomy and 3 (27.27%) underwent choledochocholedochostomy. The main postoperative complications of the 11 patients included bleeding in 2 patients (18.18%), bile leakage and abdominal infection in 4 patients (36.36%), bilioenteric anastomotic stenosis in 1 patient (9.09%), thrombus in 2 patients (18.18%), pulmonary infection and pleural effusion in 2 patients (18.18%), and echinococcosis recurrence in 1 patient (9.09%). Of all 11 patients, 2 (18.18%) died during the perioperative period, and the other 9 patients (81.82%) were improved and discharged. Conclusion Bleeding, biliary complications, and infection are the main causes of death in patients undergoing autologous liver transplantation at high altitude. An accurate understanding of surgical indication, careful multidisciplinary evaluation before surgery, superb operation during surgery, standardized surgical procedures, and fine perioperative management are the key to reducing perioperative mortality, avoiding and reducing postoperative complications, and achieving good long-term survival in patients undergoing autologous liver transplantation.

Risk Factors and Outcomes of Carbapenem-Resistant Enterobacteriaceae Infection After Liver Transplantation: A Retrospective Study in a Chinese Population.

BackgroundThere is an increasing prevalence of carbapenem-resistant Enterobacteriaceae (CRE) infection after liver transplantation (LT). Improved understanding of the risk factors and outcomes of CRE infections can help us to develop effective preventive strategies and even guide early treatment of high-risk LT patients.MethodsThis was a retrospective study involving all Chinese adult patients who underwent LT between December 2017 and September 2019 in our center. We analyzed the possible risk factors and outcomes associated with CRE infections in the first 30 days post-LT.ResultsA total of 387 patients underwent LT. Among them, 26 patients (6.7%) developed CRE infections within 30 days after transplantation. Patients with CRE infections had significantly lower 30-day and 180-day survival rates (80.8% vs 96.4%, p<0.001; 51.5% vs 92.4%, p<0.001). Multivariate analysis identified that intraoperative blood loss equal to or more than 1500 mL (odds ratio [OR], 3.666; 95% confidence interval [CI], 1.407–9.550; p=0.008), CRE rectal carriage within 30 days post-LT (OR, 5.516; 95% CI, 2.113–14.399; p=0.000), biliary complications (OR, 3.779; 95% CI, 1.033–13.831; p=0.045) and renal replacement therapy for more than 3 days (OR, 3.762; 95% CI, 1.196–11.833; p=0.023) were independent risk factors for CRE infections within 30 days post-LT.ConclusionCRE infections within 30 days post-LT were associated with worse outcomes. Intraoperative blood loss equal to or more than 1500 mL, CRE rectal carriage within 30 days post-LT, biliary complications and renal replacement therapy for more than 3 days were independent risk factors of CRE infections after LT.

Acute-on-chronic liver failure in liver transplant candidates with non-alcoholic steatohepatitis

Non-alcoholic fatty liver disease (NAFLD) has become the most common liver disease worldwide. It is expected that non-alcoholic steatohepatitis (NASH), NASH-related cirrhosis and its decompensated forms will increase further in the next two decades. Acute-on-chronic liver failure (ACLF) is a distinct syndrome characterized by rapid deterioration of liver function in patients with chronic liver disease that is associated with development of one or more organ failures, and carries a very high short-term mortality. There is a paucity of data on ACLF in patients with NASH cirrhosis. Recent studies have shown that although ACLF incidence due to NASH is lower when compared to other etiologies, NASH is the fastest growing liver disease etiology among all ACLF hospitalizations. Higher rates of infections, as a precipitating factor, and circulatory failure were noted in this population. Metabolic derangements such as obesity and diabetes might also play a confounding role in the pathophysiology, clinical course, and prognosis of NASH patients with ACLF. Patients with ACLF due to NASH have shown a lower inpatient mortality despite a longer hospital length-of-stay and a higher 28- and 90-day mortality. Patients with ACLF should be promptly transferred to a transplant center and evaluated for liver transplantation (LT). Optimal prognostic scores, timing of LT, and the best bridge to LT therapy and treatment of post-LT complications need to be elucidated in prospective studies.

1023 Early Treatment of Recurrent Hepatitis C Post-Liver Transplant

INTRODUCTION: The rate of hepatitis C virus (HCV) recurrence after liver transplant (LT) is greater than 95% and chronic recurrence is more aggressive in the setting of immunosuppressive therapy (IS) in LT patients. Sustained viral response (SVR) is associated with lower mortality rates related to hepatic and extrahepatic manifestations of HCV including renal disease. Currently, however, there are no clear guidelines for the timing of HCV treatment post LT. The goal of this study is to examine the effects of early HCV treatment post-LT on kidney function, liver function and IS. METHODS: This is a retrospective study of 38 LT patients who received HCV treatment within 1 year between 2015 and 2018. Renal function, hepatic function and immunosuppressive regimens were compared at HCV treatment initiation and when patients achieved SVR post treatment. 86% of patients received a Sofosbuvir based regimen. RESULTS: The study included 38 patients with recurrent HCV post LT. Patients were 79% male, 71% Caucasian, with mean age being 57 [range 33-73]. The mean number of days between LT and HCV treatment initiation was 129 days [range 15-321]. All patients were initiated on treatment within the first year of LT. SVR rate was 100% in patients that were compliant with the regimen. No serious side effects were reported. There was no significant difference in mean pre and post-HCV treatment creatinine or number of patients with GFR &lt; 60-pre/post treatment. There was no significant difference between number of patients on Mycophenolate or Tacrolimus before and after treatment. There was no significant difference in the mean dose of steroids, Azathioprine, Mycophenolate or Tacrolimus before and after HCV treatment. CONCLUSION: In patients completing treatment for recurrent HCV within 1 year of LT as early as 15 days post LT, treatment was well tolerated and effective with 100% SVR rate. There was no significant change in number of patients with Cr &lt; 60 before and after treatment and no significant change in the dose of IS. Further studies will help compare outcomes and effects of HCV treatment within one year post LT vs later particularly on renal function and IS therapy.

Orthotopic Liver Transplantation for Treatment of Sinusoidal Obstruction Syndrome: A Case Report

We here report the case of successful orthotopic liver transplantation (LT) following acute liver failure (ALF) related to sinusoidal obstruction syndrome (SOS). This syndrome is one of the main causes of death early after bone marrow transplantation (BMT); LT seems to be an effective treatment of the most severe forms of SOS but no official recommendation exist about this subject. With this clinical case we would like to show that after careful patient selection and appropriate timing, LT for treatment of severe SOS is safe and effective.

Liver transplantation for treatment of hilar cholangiocarcinoma with a report of three cases

Objective To investigate the feasibility of liver transplantation in the treatment of inoperable hilar cholangiocarcinoma. Methods The clinical data for 3 patients with unresectable hilar cholangiocarcinoma who underwent liver transplantation in the Department of Hepatobiliary Surgery of Fuzhou General Hospital of People′s Liberation Army from January 2006 to December 2012 were retrospectively analyzed. The patients were followed up by phone, outpatient service, and hospitalization. The starting point of the follow-up was the operation date. The patient's death was the end point. The clinical and pathological features, postoperative survival, tumor recurrence, and prognostic factors were observed. The follow-up deadline was December 2017. Results All 3 patients underwent classical orthotopic liver transplantation using retrograde perfusion through inferior vena cava and no perioperative deaths occurred. All 3 patients were followed up for 10 to 132 months. During the follow-up period, of 1 patient who died of tumor recurrence, the pathological TNM stage was T4aN1M0, and both had Union for International Cancer Control stage Ⅳa, and the tumor-free survival time was 3 months, and the survival time was 12 months. Of 1 patient who died of other causes, the pathological TNM stage was T3N1M0, and both had Union for International Cancer Control stage Ⅲ, and the tumor-free survival time was 12 months, and the survival time was 12 months. One case as of the end of follow-up, the patient has survived for 132 months, the pathological TNM staging was T2aN0M0, and both had Union for International Cancer Control stage Ⅱ. Conclusions Lymph node positive and high pathological TNM stage were poor prognosis factor for hilar cholangiocarcinoma who underwent liver transplantation. Patients with early hilar cholangiocarcinoma who don′t have lymph node metastasis are expected to benefit from liver transplantation. Key words: Liver transplantation; Bile duct neoplasms; Hilar cholangiocarcinoma

Changes in DNA Methylation of Glucocorticoid-Induced Tumor Necrosis Factor Receptor and Its Ligand in Liver Transplantation

Liver transplantation (LT) is the criterion standard of care in patients with end-stage liver disease and those with tumors of hepatic origin in the setting of liver dysfunction. Chronic immune rejection of the liver transplant can lead to bad prognosis for patients. Glucocorticoid-induced tumor necrosis factor receptor (GITR) play a key role in dominant immunologic self-tolerance maintained by CD25+/CD4+ regulatory T cells. Here, we investigated the DNA methylation variations of GITR and GITR ligand (GITRL) using pyrosequencing by analyzing blood DNA samples of patients after LT. Our results showed that the methylation level of certain CpGs, such as CpG_13, in GITRL was significantly reduced after LT. Furthermore, we found that the GITRL methylation statuses of cohorts with no chronic immune rejection were significantly lower compared with cohorts with chronic immune rejection after LT treatment. However, the methylation statuses of GITR were less varied. Using linear regression analysis, we further found that factors such as upper gastrointestinal hemorrhage, splenectomy, and creatinine might affect DNA methylation patterns in chronic immune rejection cohorts. These findings provide novel insights into the pivotal role of GITRL as a potential molecular biomarker for the triage of liver transplantation.

Factors determining long-term outcomes of hepatocellular carcinoma within the Milan criteria: liver transplantation versus locoregional therapy: A retrospective cohort study.

Patients with hepatocellular carcinoma (HCC) satisfying the Milan criteria are candidates for liver transplantation (LT), but locoregional therapies could be another options for them.A total of 1859 treatment-naïve HCC patients fulfilling the Milan criteria were analyzed. Survival tree analysis was performed to generate survival nodes with similar survival risks in 1729 non-LT group, and compared with the survival of 130 patients who received LT.Among patients who did not receive LT, survival tree analysis classified patients into 6 nodes according to Child-Pugh (CP) score, serum alphafetoprotein (AFP) levels, tumor size, and age, with different mortality risks (5-year survival rate of 87.3%, 77.5%, 65.8%, 64.7%, 44.0%, and 28.7% for nodes 1–6, respectively; P < 0.001). The overall survival of patients in nodes 1 (CP score 5 with AFP levels <5 ng/mL) and 2 (CP score 5 with maximal tumor size <2.5 cm) were comparable with that of patients who received LT (both P > 0.05), but the survival rates of patients in nodes 3 to 6 were worse than that of LT (P < 0.05 for all). In each survival node, survival differed slightly according to initial treatment modality for patients who did not receive LT. For patients who received LT, tumor stage at the time of LT was associated with long-term outcome.Certain groups of non-LT patients showed survival rates that were similar to the survival rates of LT patients. CP score, AFP levels, tumor size, and age were baseline factors that can help estimate the long-term outcomes of non-LT treatment. In addition, tumor stage at the time of LT and specific initial treatment modality in non-LT patients affected the long-term outcomes. These factors can help estimate the long-term outcomes of HCC patients diagnosed within the Milan criteria.

Clinical analysis of liver transplantation in treatment of liver metastatic cancer

To evaluate the feasibility and outcome of liver transplantation in the treatment of liver metastatic cancer. Four patients with pathologically confirmed liver metastatic cancer underwent liver transplantation, including one of liver metastases from pancreatic endocrine tumor, one from rectal endocrine tumor, one from stomach stromal tumor and one from colorectal carcinoma. Classic surgical method was adopted, i. e. orthotopic liver transplantation for the recipients and transplants came from cadaveric donors. All the four patients had a smooth operation, an uneventful early postoperative recovery and good living quality. The patient with liver metastases from pancreatic endocrine tumor had liver tumor recurrence at four and a half years after the transplantation, and then underwent left lateral hepatic lobectomy, without any recurrence until now. The patient with liver metastases from rectal endocrine tumor had right renal and pelvic tumor metastasis at 16 months after the operation, and died of tumor recurrence 5 years after the liver transplantation. The patient with liver metastases from gastric stromal tumor had extensive pelvic metastases at five and a half months after the transplantation, and survived with tumor for 4 years and 6 months after the operation. The patient with liver metastases from colorectal carcinoma had extensive bilateral lung metastases at 3 months after the transplantation and died one and a half years after the operation. For well-differentiated unresectable metastatic liver cancers, liver transplantation may serve as a treatment option and better treatment results can be achieved for some highly selected patients.

Liver transplantation in treatment of colorectal liver metastases.

Surgical resection is the only curative modality for colorectal liver metastases (CLM) and 5-year overall survival after resection is about 40%. Nonresectable CLM is not curable and 5-year overall survival is currently about 10%. Before 1995, several liver transplantations for CLMs were performed, but outcome was poor (5-year survival rate: 18%). Liver transplantation for CLMs was abandoned and CLMs were even considered a contraindication to the procedure. Since then, the survival rate after liver transplantation in general has improved by almost 30%. In a prospective pilot study of liver transplantation for nonresectable CLM, a 5-year overall survival rate of 60% was demonstrated, however 19 of 21 patients experienced recurrence of disease. Here, current knowledge and ongoing research in this field is reviewed, and the potential role for liver transplantation as one of several treatment modalities for CLM discussed.

Effect of preoperative splenectomy on liver transplantation in treatment of portal hypertension

Objective To study the influence of preoperative splenectomy on liver transplantation for portal hypertension and the management of complications.Methods From January 2008 to January 2013,a total of 136 patients underwent liver transplantation for portal hypertension (PHT) in Hepatobiliary Surgery Center,Fuzhou General Hospital of PLA Nanjing Military Region.Pre-liver transplantation splenectomy was carried out in 19 patients.We randomly selected according to the operation time 50 cases of liver transplantation as the control group.The operation time,bleeding,blood transfusion,infection,the incidence of acute rejection,biliary complication rate,survival rate,postoperative platelet recovery and arteriovenous thrombosis were analyzed.Results The preoperative group has longer surgical time,intraoperative blood loss,blood transfusion volume increased obviously,infection rate increased significantly compared with the control group.The accumulate survival rate of preoperative splenectomy group was significantly lower than that of the control group.The platelet count of the preoperative splenectomy group was significantly higher than that of the control group.The platelet count of both groups experienced the process of first rise after falling.Although the platelet count of the preoperative splenectomy group was higher than that of the control group,but there was no statistically significant difference.Conclusions Liver transplantation in PHT patients with previous splenectomy may lead to some unfavorable consequences including increases of technical diffculty of surgery,operative duration,intraoperative bleeding,postoperative infection and other serious complications,and surgical mortality.Therefore,splenectomy should be performed cautiously for the patients who may receive liver transplantation in the future. Key words: Hypertension, portal; Liver transplantation; Splenectomy; Infection; Platelets

Sinonasal evaluation and treatment before liver transplantation: a retrospective review of 982 patients.

Immunosuppression after liver transplantation (LT) increases complications from infection. The usefulness of sinonasal evaluation before LT has not been fully evaluated. The aim of this study was to determine the usefulness of routine sinonasal evaluation before LT and pre-transplant treatment of sinusitis. The clinical records of 982 adult patients (age ≥18years) who underwent LT between January 1997 and June 2011 were retrospectively reviewed and analyzed. A total of 920 patients (93.7%) underwent pre-LT sinonasal evaluation, including a sinonasal symptom questionnaire, nasal endoscopy and plain X-ray. Of these patients, 269 (29.2%) had abnormal findings and underwent paranasal CT scans. Based on CT, 102 patients, including 21 with fungal ball, were diagnosed with sinusitis and 62 (60.8%) underwent LT after medical or surgical treatment for sinusitis. Another 40 patients (33 with sinusitis and 7 with fungal ball) underwent LT without treatment for sinusitis. No difference in infectious complications was observed according to sinusitis treatment type. Among chronic rhinosinusitis patients, those who underwent LT (n=48) after adequate treatment had a lower mortality rate than those who did not receive treatment (n=33) (12.5 vs. 33.3%; p=0.024). Sinonasal evaluation preceding LT did not prevent infectious complications but untreated sinusitis might be correlated with increased mortality after LT. Routine pre-LT sinonasal evaluation would be considered for safer transplantation.