Elena Allende

Resection for hepatocellular carcinoma is a good option in Child‐Turcotte‐Pugh class A patients with cirrhosis who are eligible for liver transplantation

The best treatment option for patients with single, early hepatocellular carcinoma (HCC) and cirrhosis, good liver function, and absence of portal hypertension remains to be established. The aim of this work was to compare the outcome of liver resection (LR) with that of liver transplantation (LT) for single, early HCC in Child‐Turcotte‐Pugh class A patients with cirrhosis younger than 70 years of age. Thirty‐seven of 134 patients who underwent LR and 36 of 125 who underwent LT for HCC in our unit fulfilled the inclusion criteria. No differences were observed in mean tumor size (3 cm); HCV cirrhosis predominated in the LT group and older age in the LR group. Postoperative mortality was higher and hospital stay longer in the LT group. Patient survival was similar in both groups. Tumor recurrence was higher in the LR group (59% vs. 11%), extrahepatic recurrences predominated after LT and hepatic recurrences after LR. Disease‐free survival was significantly better after LT. Eighteen patients presented hepatic recurrence after LR: 5 advanced and 13 early. Seventeen patients—13 with early HCC recurrence and 4 with liver failure—were potential candidates for salvage LT. However, 10 of 17 patients were older than 70 years at this time. Salvage LT could only be performed in 6 patients: 5 for HCC recurrence and 1 for liver failure. Results of salvage LT were similar to those of primary LT. In conclusion, only 27.6% of resected patients were eligible for LT. LR is a good option since it offers similar survival to LT. Salvage liver transplantation was performed in 16.2% of resected patients, with older age being the main contraindication. Outcome of salvage LT was similar to that of primary LT. (Liver Transpl 2005;11:1242–1251.)

A prospective randomized trial comparing tacrolimus and steroids with tacrolimus monotherapy in liver transplantation: the impact on recurrence of hepatitis C

The aim of this prospective randomized trial was to study the efficacy and safety of tacrolimus monotherapy (TACRO) and compare it with our standard treatment of tacrolimus plus steroids (TACRO + ST) after liver transplant (LT). Furthermore, the impact of steroid‐free immunosuppression on outcome of hepatitis C virus (HCV) was analysed. Between 1998 and 2000, 60 patients (mean age: 57 years) were included in the study and randomized to receive TACRO (n = 28) or TACRO + ST (n = 32). Indication for LT was postnecrotic cirrhosis in all cases (58.3% were HCV‐positive). Mean follow‐up was 44 months. Survival, incidence of rejection, infection and side‐effects were compared between the two groups. In patients with HCV infection, incidence and severity of acute hepatitis C, long‐term outcome of recurrent hepatitis C and survival were studied in an intention‐to‐treat analysis or in the real group analysis (real‐TACRO versus real‐TACRO + ST). Patient survival at 1, 3 and 5 years, tacrolimus pharmacokinetics, incidence of rejection infections and side‐effects were similar. In patients with HCV, the incidence and severity of graft hepatitis C tended to be lower in TACRO (47%) compared with TACRO + ST (67%) (P = NS), and also in real‐TACRO (42%) compared with real‐TACRO + ST (61%) (P = NS). A poor outcome considered as evolution to cirrhosis at 3 years was observed in one (9%) living patient in real‐TACRO and nine (45%) in real‐TACRO + ST (P = 0.04). Patient survival at 1, 3 and 5 years was 92%, 92% and 73% for real‐TACRO and 78%, 61% and 51% for real TACRO + ST (P = 0.07). Steroid‐free immunosuppression appears to be safe and efficacious. The main advantage of this regimen could be in HCV patients, as recurrence of hepatitis in the graft was less severe in the group of patients in whom steroids could be avoided completely.

Incidence and outcome of hepatitis C virus infection after liver transplantation

Abstract The objective of this study was to determine the incidence and outcome of hepatitis C virus (HCV) infection after liver transplantation (OLT). Fifty‐two transplanted patients were studied. Serum samples were examined for antibodies to HCV (anti‐HCV) and HCV‐RNA by PCR, before and after OLT. Patients were distributed into two groups: group 1 consisted of 24 patients (pretransplant anti‐HCV positive) and group 2 consisted of 28 patients (pretransplant anti‐HCV negative). One year after OLT, HCV‐infected patients were evaluated by liver biopsy. HCV‐RNA was detected in 28 of the 52 (53.9%) patients after OLT. Twenty‐two patients in group 1 (96%) were reinfected. In group 2, acquired HCV infection was detected in six (21.4%) patients. At 6 and 12 months, one and five of six patients had seroconverted, respectively. Liver biopsy in 23 HCV‐infected patients showed chronic hepatitis in 18 (78%) cases (2, chronic persistent hepatitis; 3, chronic lobular hepatitis and 13, chronic active hepatitis). Fourteen of the 23 (60.8 %) patients were asymptomatic. Most symptomatic patients had chronic hepatitis with cholestasis. Overall, 18 of 20 cases of chronic hepatitis diagnosed in OLT recipients were HCV related. Mortality beyond 6 months after OLT was slightly higher in the HCV‐infected group (P= 0.055). In conclusion, HCV reinfection is almost universal. Acquired HCV infection post‐OLT is frequent. HCV‐infected patients frequently develop chronic hepatitis. Most chronic hepatitis after transplantation are HCV related.

DNA ploidy study of resected hepatocellular carcinoma in cirrhotic liver

BACKGROUND/AIMS Results of several studies on DNA ploidy as a prognostic indicator in hepatocellular carcinoma are contradictory. The present study analysed the correlations between DNA ploidy of resected hepatocellular carcinoma and tumour characteristics, tumour recurrence, risk factors and survival. METHODS Tumoural DNA ploidy of hepatocellular carcinomas from 37 patients with cirrhosis who underwent curative tumour resection was studied by flow cytometry. RESULTS A diploid pattern was found in 23 hepatocellular carcinomas (62.2%) and an aneuploid pattern in 14 (37.8%). The tumour recurrence rate did not differ statistically between diploid (69.6%) and aneuploid (50%) hepatocellular carcinomas. The only prognostic variable with significant difference in DNA pattern was the histologic tumour type; the majority of non-trabecular tumours were aneuploid while most trabecular hepatocellular carcinomas had a diploid DNA pattern. Actuarial survival at 1, 2, 3 and 4 years of patients with diploid and aneuploid tumours was 69.6%, 40.6%, 16.2% and 0%, and 69.3%, 59.4%, 49.5% and 32.9%, respectively (log rank p = 0.1927). CONCLUSION These results indicate that DNA ploidy has no prognostic value in hepatocellular carcinoma.

Tumor de Krukenberg como manifestación inicial de hepatocarcinoma fibrolamelar

Krukenbergs tumor refers to unilateral or bilateral ovarian metastatic tumors whose origin may be known or unknown. The incidence of this type of tumor is difficult to evaluate but may represent between 3% and 8% of ovarian tumors. In most cases, the primary tumor is identified and is usually digestive (basically gastric or colorectal). There are some references to primary hepatic tumors (gall bladder tumor and hepatocarcinoma) but none to fibrolamellar hepatocarcinoma as the primary tumor. We present the case of a 45-year-old woman who presented with lower hemiabdominal pain and who was diagnosed with Krukenbergs tumor of hepatic origin. Although ovarian involvement in primary digestive tumors is possible, hepatic origin is rare.

Colangiocarcinoma periférico: resultados del tratamiento quirúrgico

INTRODUCTION: Peripheral cholangiocarcinoma (PC) is an uncommon primary hepatic tumor that represents 10% of hepatic resections for primary malignant tumors in our experience. PATIENTS AND METHODS: From 1988 to 2004, 29 patients with a diagnosis of PC were treated in our unit. One patient was treated with chemoembolization and the remainder underwent surgery. In 7 patients, hepatectomy was not performed due to the presence of an extrahepatic tumor or massive hepatic invasion. The resectability index was 75%. Twenty-one patients underwent radical excision of PC and comprised the study group. RESULTS: The mean age was 60 years with a slight predominance of women. Sixty-two patients were symptomatic and tumoral markers were elevated in 58%. PC developed in normal liver in 15 patients, in cirrhotic liver in 2 patients and in the context of chronic hepatitis in 4 patients. The mean tumoral size was 7 cm (between 1.6 and 13 cm). Multiple tumors were found in 3 patients, invasion of the hepatic hilum lymph nodes was found in 8 patients and vascular invasion was observed in a further 8 patients. Major hepatectomy was performed in 90% of the patients; radical lymphadenectomy of the hepatic hilum was performed in 15 patients and excision of the extrahepatic biliary tract followed by Roux-en-Y hepaticojejunostomy in 4 patients. Operative mortality occurred in 3 patients (14%); one cirrhotic patient died 4 days after surgery from cardiovascular causes and 2 patients died from liver failure after extensive hepatectomies that included resection of the inferior vena cava and suprahepatic veins. Complications occurred in 33% of the patients. Ten patients (47%) died. Of these, 6 died from tumoral recurrence. Tumoral recurrence occurred in 9 patients (5 hepatic and 4 extrahepatic). Hepatic recurrences were treated with radiofrequency ablation in 2 patients and chemotherapy in 5 patients. The median survival was 11 months. Actuarial survival at 1, 3 and 5 years was 60%, 47% and 47% respectively. Disease-free survival at 1, 3 and 5 years was 50%, 31% and 31% respectively. In univariate analysis, significant risk factors for mortality were lymphatic invasion and a resection margin of less than 1 cm. In multivariate analysis, negative factors for tumoral recurrence were lymphatic invasion, satellitosis, and poor tumoral delimitation. CONCLUSION: Surgical treatment of PC through radical hepatic resection with margins of more than 1 cm in patients without nodal invasion provides good results with a 5-year survival of 79%.

Mejoría de los resultados de la resección quirúrgica del hepatocarcinoma

Objetivo Presentar los resultados de las hepatectomias por hepatocarcinoma de una unidad especializada comparando la experiencia inicial, 1987-1993, con el segundo periodo, 1995-2000, en que se limitaron las indicaciones a los pacientes Child-Pugh A sin hipertension portal y se introdujeron mejorias tecnicas como los pinzamientos hiliares selectivos e intermitentes y una politica transfusional mas restrictiva. Pacientes Y Metodos En los ultimos 12 anos se han realizado en nuestra unidad 110 hepatectomias en 105 pacientes por hepatocarcinoma. El 80% asentaba en un higado cirrotico y la etiologia predominante fue el virus de la hepatitis C. En el segundo periodo se realizo una endoscopia digestiva alta de forma sistematica para estudiar la presencia de varices y, opcionalmente, un estudio hemodinamico para descartar una hipertension portal. Resultados En el segundo periodo se resecaron tumores mas grandes y se realizaron mas hepatectomias mayores, ya que aumentaron tambien los hepatocarcinomas en el higado no cirrotico, y ademas se transfundieron menos pacientes. La mortalidad temprana descendio del 21 al 1,8%, y la supervivencia media aumento de forma significativa de 37 a 52 meses. La supervivencia actuarial ascendio del 64 al 91% al ano y del 23 al 52% a los 5 anos, en el primer y el segundo periodos, respectivamente. La supervivencia libre de enfermedad tambien fue significativamente mejor: el 53 y el 84% al ano y el 27 y el 40% a los 5 anos en el primer y segundo periodos, respectivamente. El analisis de los resultados en los pacientes cirroticos tambien puso de manifiesto una mejoria estadisticamente significativa en la mortalidad temprana y la supervivencia. En el analisis multivariado de factores pronostico de supervivencia se evidencio que la ausencia de transfusion sanguinea, los pacientes resecados en el segundo periodo y la presencia de seudocapsula eran factores independientes de mejor supervivencia. Conclusiones Los resultados de la reseccion hepatica por hepatocarcinoma han mejorado significativamente debido a la disminucion de la mortalidad temprana gracias a una seleccion mas rigurosa de los pacientes y a las mejoras tecnicas introducidas.

Angiomiolipoma hepático en dos pacientes con infección por el virus de la hepatitis C

Resumen Objetivo El objetivo de este estudio era presentar nuestra experiencia con 2 casos de angiomiolipoma hepatico en pacientes con virus de la hepatitis C (VHC) positivo, y realizar una actualizacion del manejo clinico y tratamiento del angiomiolipoma hepatico. Observaciones clinicas Ambos casos se presentaron en mujeres en la cuarta-quinta decadas de la vida. La presentacion clinica fue sintomatica en una de ellas e incidental en la otra. Las 2 pacientes presentaban anticuerpos contra el VHC, y se planteo el diagnostico diferencial con el hepatocarcinoma. Los valores de alfafetoproteina fueron normales. Las pruebas de imagen no fueron concluyentes y solo la puncion-aspiracion con aguja fina y la inmunohistoquimica orientaron el diagnostico de angiomiolipoma. El tamano de las tumoraciones fue grande: 4,8 y 8 cm de diametro, respectivamente. En ambos casos se requirio la realizacion de cirugia exeretica para descartar definitivamente la malignidad. No hay evidencia de recidiva tras 6 y 3 anos de seguimiento, respectivamente. Discusion y conclusion El angiomiolipoma es una tumoracion hepatica benigna poco frecuente, que mimetiza otras lesiones hepaticas. Pese a la dificultad diagnostica, una serie de datos radiologicos apoyan el diagnostico de esta enfermedad. No obstante, el diagnostico definitivo lo proporciona la anatomia patologica y la immunohistoquimica (HMB-45). Se trata de una lesion compuesta por tejido adiposo, celulas musculares lisas y vasos sanguineos en diversas proporciones. Pese a su caracter benigno, la dificultad para descartar su malignidad obliga al tratamiento quirurgico. No esta descrita su relacion etiopatogenica con el VHC, por lo que consideramos nuestros casos como un hallazgo coincidente.