Jae Berm Park

Solid pseudopapillary tumor of the pancreas: Can malignancy be predicted?

BACKGROUNDnThe objective of this study was to examine the clinicopathologic characteristics of solid pseudopapillary tumors (SPTs) of the pancreas, including the risk factors for disease recurrence and their effects on survival.nnnMETHODSnThe medical records of 114 patients who underwent surgery for a pathologically confirmed SPT between January 1995 and December 2007 were reviewed retrospectively.nnnRESULTSnOf the 114 patients, 98 (86.9%) were female, and the median age was 36 years (range, 11-75). All 114 patients underwent curative intent surgery and 13 (11.4%) underwent laparoscopic surgery. Of the 114 patients, 26 (22.8%) had solid pseudopapillary carcinoma (SPC). There were no differences in any clinical factors between the benign SPT and SPC groups; however, the only 4 recurrences identified were in the SPC group. After follow-up ranging from 11 to 177 months, all 114 patients were alive, with only 4 showing evidence of recurrence. Recurrence was observed in young patients with metastasis at first operation, invasion of an adjacent organ, and a large mass (≥13 cm).nnnCONCLUSIONnAdequate operative resection including laparoscopic surgery is the mainstay of treatment for SPT. Although statistically significant risk factors for recurrence cannot be determined, tumor metastasis at the first operation, invasion of adjacent organ, large tumor size, young patient age, tumor rupture, and inadequate resection may increase the risk of recurrence. Our results demonstrate that long-term survival could be achieved by aggressive operative resection and interventional treatment of recurrent disease.

Surgical outcomes of pancreatic arteriovenous malformation in a single center and review of literature.

Objective Pancreatic arteriovenous malformation (P-AVM) is an extremely rare condition that can be accompanied by fatal complications. We have attempted to identify the possible management guidelines based on our and others’ clinical experience. Methods We retrospectively analyzed our findings including clinical characteristics, imaging modalities, and treatment in 12 patients. Sporadic reports of 69 patients with P-AVM were surveyed for representative characteristics and treatment strategy. Results The mean age at diagnosis was 49.8 years (range, 44–64 years), and all 12 were male. The mean body mass index was 21.5 kg/m2 (range, 18.3–24.3 kg/m2) and 6 (50%) were heavy smokers (mean, 30.9 pack-years; range, 7.5–120 pack-years). The most common clinical symptom is gastrointestinal bleeding, followed by abdominal pain. All patients were diagnosed with abdominal disease using computed tomography. Of the 12 patients, 11 underwent pancreatic resection and 1 patient was managed conservatively. No patient experienced any major postoperative complications during the median follow-up of 37 months. Conclusions In patients with symptomatic P-AVM, surgical resection of the affected pancreas showed a successful result. When a patient is at a high risk for surgical treatment, transjugular intrahepatic portosystemic shunt, transarterial embolization, and radiation therapy might be other treatment options.

How to avoid graft thrombosis requiring graftectomy: immediate posttransplant CT angiography in pancreas transplantation.

Background Graft thrombosis immediately after surgery remains a problem for successful pancreas transplantation. The present study evaluated the efficacy of computed tomography (CT) angiography for monitoring of graft patency in the immediate postoperative period. Methods The study involved 119 patients who underwent pancreas transplantation between July 1992 and December 2009 in a single center. The anticoagulation strategy was heparin during and after transplantation and then oral warfarin for 1 to 6 months. Graft thrombosis was monitored using color Doppler ultrasonography until July 2005 (group A) and, thereafter, using CT angiography (group B). We retrospectively analyzed the efficacy of diagnosis of graft thrombosis in two groups. Graft survival was assessed using Kaplan-Meier analysis. Results Group A comprised 51 patients, and group B comprised 68 patients. Total vascular thrombosis was diagnosed in three (5.9%) group A and one (1.4%) group B patients, and partial venous thrombosis was diagnosed in 1 (2.0%) group A and 19 (31.6%) group B patients. Eighteen of the 19 grafts with partial thrombosis in group B were successfully treated using heparin-based anticoagulant therapy. There were no CT contrast media-related complications in group B. In group B, graft survival rates were the same for grafts with partial thrombosis and grafts without thrombosis. Conclusions CT angiography was safe and effective for evaluating graft patency after pancreas transplantation. Partial vascular thrombosis in the immediate posttransplantation period showed no effect on graft survival under intensive anticoagulation and monitoring by CT angiography.

Infectious risks and optimal strength of maintenance immunosuppressants in rituximab-treated kidney transplantation.

Background: Rituximab, an anti-CD20 antibody, effectively depletes B lymphocytes. It is not clear whether the use of conventional doses of mycophenolate mofetil (MMF), methylprednisolone and tacrolimus as maintenance immunosuppression in rituximab-treated kidney transplantation is associated with increased risk. Methods: We retrospectively evaluated 67 patients who underwent HLA-sensitized or ABO-incompatible living donor kidney transplantation after one dose of rituximab (200 or 500 mg) (group 1). Eighty-seven kidney transplant recipients who did not require rituximab served as a control (group 2). Results: Cytomegalovirus infection (16.4 vs. 5.7%, p = 0.031) and pneumonia (9.0 vs. 1.1%, p = 0.043) occurred more often in group 1, and 2 patients of group 1 died of infection. The doses of methylprednisolone and tacrolimus levels of the two groups were not different. MMF dose was reduced when serious infection occurred. The doses of MMF (in grams/day) at the following times postoperatively were lower in group 1 than in group 2: 1 month: 1.26 ± 0.42 vs. 1.40 ± 0.39, p = 0.033; 3 months: 1.14 ± 0.51 vs. 1.36 ± 0.39, p = 0.011; 6 months: 1.07 ± 0.50 vs. 1.30 ± 0.42, p = 0.012; 1 year: 0.88 ± 0.52 vs. 1.19 ± 0.44, p = 0.009; 2 years: 0.69 ± 0.55 vs. 1.25 ± 0.49, p = 0.059, but the reduction of MMF doses did not increase the incidence of acute rejection in group 1 (4.5% in group 1 vs. 9.2% in group 2, p = 0.351). If patients who died with functioning graft were excluded, graft survival was 98.5% in group 1 and 100% in group 2. Conclusions: Serious infectious complications were increased in rituximab-treated kidney transplant recipients and it might be adequate to reduce the MMF dose from the early postoperative period.

Radiofrequency ablation of liver metastasis in patients with locally controlled pancreatic ductal adenocarcinoma.

PURPOSEnTo evaluate retrospectively the role of radiofrequency (RF) ablation for liver metastases arising from pancreatic ductal adenocarcinoma simultaneously with pancreatic resection or after curative resection in patient survival.nnnMATERIALS AND METHODSnRF ablation of liver metastases was performed on 34 patients with pancreatic ductal adenocarcinoma postoperatively after pancreatectomy or intraoperatively at pancreatectomy between December 2002 and June 2009. Criteria for RF ablation were liver metastasis ≤ 3 cm diameter in size, five or fewer lesions, and no definite suspicious lesion other than liver metastasis. Patient survival was assessed by the Kaplan-Meier method, and prognostic factors were analyzed.nnnRESULTSnOf the patients receiving RF ablation treatment (n = 34), 18 underwent one session of RF ablation, and 16 underwent more than one session. In each session, all the targeted lesions were successfully ablated by ultrasound-guided RF ablation. Median duration of follow-up was 15 months (range, 3-65 mo). The interval between pancreatic resection and liver metastasis was 3 months (range, 0-33 mo). Median survival time after liver metastasis was 14 months. Univariate analysis of factors affecting survival showed that better patient survival after RF ablation was associated with a single, < 2 cm diameter liver metastasis (P = .007) and well or moderate differentiation (P = .032). In multivariate analysis, a single < 2 cm diameter liver metastasis and good or moderate differentiation were independent predictors for longer patient survival (P = .027, P = .016).nnnCONCLUSIONSnRF ablation in liver metastasis occurring after locally controlled pancreatic ductal adenocarcinoma can be a safe and feasible strategy for extending survival in selected patients.

Long-term outcome of Hepatitis B-positive renal allograft recipients after development of antiviral treatment.

BACKGROUND/AIMSnHepatitis B virus (HBV) infection can adversely affect the clinical outcome of kidney transplantation (KT). Short-term efficacy of lamivudine has been demonstrated for chronic hepatitis B in KT recipients (KTR).nnnMETHODSnTo clarify the long-term impact of antiviral treatment for HBV-positive KTR, we retrospectively reviewed 94 HBV-positive (male 73%) and 282 age/sex-matched HBV-negative patients who underwent KT from February 1997 to November 2009, after lamivudine had come into wide use.nnnRESULTSnMean follow-up was 75.7 months. 56 patients received antiviral agent for prophylaxis, and other 18 for HBV reactivation. During follow-up, 15 died, with 5 deaths being HBV related. Although the patient survival rate was lower for HBVpositive than HBV-negative KTRs (89% vs. 94% at 5 years, 78% vs. 88% at 10 years, p = 0.031), graft survival was comparable (86% vs. 92% at 5 years, 73% vs. 81% at 10 years, p = 0.113). In multivariate analysis, HBsAg positivity was a significant risk factor for patient death (OR 2.19, 95% CI 1.14 - 4.20, p = 0.019), but not significant for graft loss (OR 1.64, 95% CI 0.94 - 2.86, p = 0.079). Of the 26 hepatitis B e antigen (HBeAg)-positive patients, 14 experienced HBV reactivations, but all survived with stable liver chemistry, except for one who died of hepatocellular carcinoma. Among 57 HBeAg-negative patients, 12 died, whereas the remaining 45 survived without hepatic dysfunction.nnnCONCLUSIONnLong-term outcomes of HBV-positive KTRs may be favorable after antiviral agents have been introduced.

Living donor and recipient screening for latent tuberculosis infection by tuberculin skin test and interferon-gamma releasing assay in a country with an intermediate burden of tuberculosis

There are few data on donor screening for latent tuberculosis infection (LTBI) using the tuberculin skin test (TST) and interferon-gamma releasing assay (IGRA). In South Korea, most renal allografts involve living donors (average, 80xa0%). Hence, we have an opportunity to evaluate donor and recipient screening for LTBI by TST and IGRA. All donors and recipients admitted for kidney transplantation during a 20-month period were evaluated prospectively by using TST and Mycobacterium tuberculosis-specific enzyme-linked immunosorbent spot (ELISPOT) assay. The study population consisted of 205 living donor–recipient pairs (≥16xa0years) including 15 (7xa0%) who yielded indeterminate donor or recipient ELISPOT results. Of the 205 donors, 63 (31xa0%) gave a positive TST ≥5xa0mm, 33 (16xa0%) a positive TST ≥10xa0mm, and 96 (47xa0%) a positive ELISPOT. Of the 205 recipients, 9 (5xa0%) gave a positive TST ≥5xa0mm, 3 (2xa0%) a positive TST ≥10xa0mm, and 79 (39xa0%) had a positive ELISPOT. Of the 205 donor–recipient pairs, only 59 (29xa0%) gave negative donor and recipient ELISPOT results and 139 (68xa0%) negative donor and recipient TSTs (<5xa0mm) (Pxa0<xa00.001). One third of donor–recipient pairs tends to be positive in the TST, and two thirds of the donor–recipient pairs tends to be positive in the ELISPOT. Given the high positive rate of LTBI obtained by screening donors, further studies on the clinical value of solid organ transplant donors with positive TST or ELISPOT and health economics analysis in countries with intermediate burden of TB are needed for policy decisions on isoniazid (INH) prophylaxis.

Long-term impact of prophylactic antiviral treatment in Hepatitis B surface antigen positive renal allograft recipients.

BACKGROUNDnAntiviral prophylaxis has been shown to prevent hepatic dysfunction in Hepatitis B virus (HBV)-positive kidney transplantation recipients (KTRs). However the long-term effects of antiviral prophylaxis on the patient death, graft loss, or hepatic decompensation have not been determined.nnnMETHODnWe therefore retrospectively analyzed outcomes in 94 HBV-positive patients, who underwent KT between February 1997 and November 2009 and were followed-up for a mean 75.7 months. Of the 94 KTRs, 56 received antiviral prophylaxis (Group 1), 51 with lamivudine and 5 with entecavir, and 38 did not (Group 2).nnnRESULTnOf the latter group, 20 experienced HBV reactivation and 18 did not (mean 85 months); of those with reactivation, 16 received lamivudine, 2 received entecavir and 2 received no antiviral treatment. Cox-regression analysis showed that antiviral prophylaxis had no benefit on patient death (OR 1.29, 95% CI 0.37 - 4.49, p = 0.693), graft failure (OR 1.25, 0.45 - 3.46, p = 0.666) or hepatic decompensation (OR 2.01, 0.35 - 11.57, p = 0.434). Lamivudine resistance occurred in 21 lamivudine-treated Group 1 and 4 lamivudine-treated Group 2 patients (p = 0.243), with mean times of resistance after KT of 82 and 132 months, respectively (p = 0.001).nnnCONCLUSIONnThese findings indicate that lamivudine-based antiviral prophylaxis for HBV-positive renal recipients has no long-term clinical benefits.