L. Puviani

Endolymphatic immunotherapy in inoperable hepatocellular carcinoma.

INTRODUCTION We report the preliminary results of endolymphatic immunotherapy in patients with inoperable hepatocellular carcinoma (HCC). METHODS From 2003 to 2005 we enrolled 31 patients with inoperable HCC. The patients underwent monthly endolymphatic injections of 15-30 x 10(6) interleukin-2 (IL-2)-activated peripheral autologous lymphocytes (LAK) and 250 IU of IL-2. Follow-up included blood biochemistry every 3 months and imaging studies every 6 months. To assess therapy efficacy we considered 12 biochemical parameters, vascular invasion or thrombosis, Child-Pugh scoring system, histological grading, lymphadenopathy, viral state, and alpha-fetoprotein. RESULTS Sixteen patients completed at least 3 cycles, and 10 patients completed more than 6. No clinically significant adverse reactions occurred. Imaging studies showed no significant decrease in tumor mass. However, the survival of patients who completed 12 therapy cycles was significantly higher than survival of patients with fewer than 12 cycles. Both are significantly higher than that of untreated patients. All patients with 12 completed cycles showed an improvement of 9 parameters or more. DISCUSSION Endolymphatic immunotherapy is safe, easily performed, inexpensive, and effective in terms of survival. This study should encourage future large-scale investigations so as to reach a firmer conclusion and define uniform inclusion criteria.

An experimental pilot study on controlled portal vein arterialization with an extracorporeal device in the swine model of partial liver resection and ischemia.

Aim To determine whether the physiologically oxygenated arterial blood reversed in the portal system by means of portal vein arterialization (PVA) through an extracorporeal device which we have called L.E.O2.NARDO (Liver Extracorporeal Oxygen. NARDO) is effective in treating swine with subtotal hepatectomy leading to acute liver failure (ALF). Methods Ten swine with ALF induced by 85–90% liver resection and five minutes of ischemia-reperfusion injury were randomly divided into two groups: five animals received PVA extracoporeal treatment and five swine were not-treated (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system. An extracorporeal device was interposed between the outflow and the inflow in order to monitoring the hemodynamic parameters. Each treatment lasted 6 hours. Serum and liver samples were collected in both groups. The survival was assessed at 1 week. Results The PVA-extracorporeal treatment yielded beneficial effects for subtotal hepatectomy-induced ALF swine with decreased serum ammonia, transaminases and total bilirubin as compared with the untreated group. INR recovered rapidly in the PVA-extracorporeal group remaining significantly lower than in untreated animals. The 7-day survival of PVA-extracorporeal group swine was significantly higher than that of untreated animals, with a statistically significant difference (p<0.05). Four swine in the PVA-extracorporeal group survived at 1 week while none of the swine in the control group were alive at that time; an average time of 144h±13h and 24.4h±5h was observed in the PVA-extracorporeal and control groups, respectively. Conclusions Arterial blood supply in the portal system through the extracorporeal device is easily applicable, efficacious, safe and may represent a novel approach for ALF swine induced by subtotal liver resection.

Endolymphatic immunotherapy for advanced hepatocellular carcinoma: an update of our experience

Aim: We report an update of our experience on endolymphatic immunotherapy in patients with advanced hepatocellular carcinoma (HCC) not eligible for surgery. Methods: From 2003 to 2009 we enrolled 39 patients with advanced HCC not suitable for surgery. Patients underwent monthly endolymphatic injections of 1.5 × 10-3.0 × 10 IL-2-activated peripheral autologous lymphocytes and 250U of IL-2. Blood biochemistry every 3 months and imaging studies every 6 months were performed. Evaluation of the results was done according to clinical and pathological characters mainly including etiology, Child-Pugh class, size and number of lesions, α-fetoprotein, lymphadenopathy, vascular invasion, Response Evaluation Criteria in Solid Tumours criteria for tumour burden, biochemical parameters and survival rates. Results: Ten patients completed 12 therapy cycles, 6 received 6 infusions, 10 only 3-4 injection and 13 patients received less than 3 injections and where considered not suitable for evaluation. No clinically significant adverse reactions occurred. Imaging studies showed no significant decrease in tumour mass. Survival of treated patients was significantly higher with respect to control group (P < 0.0001). The 1-year survival was 0% in the control group vs. 50% in the treated group. In addition survival of patients who completed 12 therapy cycles appeared higher with respect to patients who underwent less than 6 cycles without reaching statistical significance due to the small number of patients. All patients with 12 completed cycles showed an improvement of 9 parameters or more. Conclusion: Endolymphatic administration of immunotherapy appeared safe, easy to perform and effective in terms of survival. This study should encourage future large scale studies in order to reach a firmer conclusion and define uniform inclusion criteria.

Impact of Age on Survival after Partial Portal Vein Arterialization for the Treatment of Post-Hepatectomy Liver Failure in a Rat Model

Introduction: Post-operative liver failure (PLF) occurs in approximately 10% of patients undergoing major hepatectomy. Partial portal vein arterialization (PPVA) enhances the regenerative capacity of the resected liver. The aim of this study was to investigate the impact of age on survival after PPVA for the treatment of post-operative liver failure in a rat model. Materials and Methods: 24 rats underwent extended liver resection, that leaded to PLF. 12 rats were divided in 2 groups treated with PPVA: group 1a-young rats (n=6, age 2 months) and group 2a-old rats (n=6, age 30 months). Two control groups of rats of the same age were not treated with PPVA: group 1b-young and group 2b-old. Results: on postoperative day 7, no significant differences were observed among all groups in terms of ALT levels, prothrombin activity and serum creatinine. As for the liver regeneration markers, the level of mitotic index was greater in the groups treated with PPVA compared to the control groups (without significant differences between young and old groups). The 75% (9/12) of the rats treated with PPVA survived up to 7 days, with no significant differences between young (5/6) and elderly rats 66.7% (4/6). Conclusion: PPVA treatment had the same beneficial effect both in young and old rats.

Portal blood arterialization with an extracorporeal device to treat toxic acute hepatic failure in a swine model.

Purpose This study aimed to determine whether a controlled portal blood arterialization by a liver extracorporeal device (L.E.O2 NARDO) is effective in treating acute hepatic failure (AHF) induced through CCl4 administration in a swine model. Methods 20 swines with AHF induced by intraperitoneal injection of carbon tetrachloride (CCl4) in oil solution, were randomly divided into two groups: animals receiving L.E.O2 NARDO treatment 48 h after the intoxication (study group); animals sham operated 48 h after the intoxication (control group). Blood was withdrawn from the iliac artery and reversed in the portal venous system by an interposed extracorporeal device. Each treatment lasted 6 h. The survival was assessed at 5 days after L.E.O2 NARDO treatment or sham operation. In both groups blood samples were collected for biochemical analysis at different time points and liver biopsies were collected 48 h after intoxication and at sacrifice. Results We observed decreased transaminases levels and a more rapid INR recovery in the study group, as compared to the control group. Eight animals of the study group vs. two animals of the control group survived at five days after surgery with a statistically significant difference (p<0.05). Liver biopsies performed at sacrifice showed a reduction of the damaged hepatic areas in the study group as compared to the control group. Conclusions Arterial blood supply in the portal system through the L.E.O2 NARDO device is easily applicable, efficacious, and safe in a swine model of AHF induced by CCl4 intoxication.

LIVER TRANSPLANTATION FOR FULMINANT HEPATIC FAILURE: EXPERIENCE WITH 40 ADULT PATIENTS OVER A 17 YEAR PERIOD

INTRODUCTION To evaluate the influence of pretransplantation recipient and donor prognostic factors on graft-patient survival. MATERIALS AND METHODS Between April 1986 and June 2003, 40 liver transplantation (LT) procedures to treat fulminant hepatic failure were performed (5.7%). Twenty-one pre-LT recipient and donor variables were retrospectively considered for analysis. RESULTS The indications for LT were hyperacute (62.5%), acute (35%), and subacute hepatic failure (2.5%). Glasgow Coma Scale scores ranged from <5 in 22 patients to > or =5 in 18 patients. The causes were hepatitis B (n = 21), unknown (n = 10), Amanita phalloides (n = 5), and other (n = 4). The 1-year graft and patient survival rates were 48.3% and 61.3%, respectively. Perioperative and late mortality was 27.5% and 22.5%. The only variable statistically significant for graft survival was waiting list time for LT <48 hours (P = .05). DISCUSSION Liver transplantation is the best treatment for fulminant hepatic failure, with a 1-year patient survival rate of 61.3%. The short waiting list time has an important role in outcome.

CCL4-INDUCED ACUTE LIVER FAILURE WITH PORTAL VEIN ARTERIALIZATION IN THE RAT

BACKGROUND Optimization of the conditions for regeneration is a major goal in the management of patients with acute liver failure (ALF). Previous observations suggested that hyperoxygenation of the liver may improve its regenerative capacity. Thus, this study aimed to determine whether an additional supply of oxygenated blood achieved by portal vein arterialization (PVA) is protective in rat ALF caused by toxin administration or hepatectomy. METHODS Sprague-Dawley rats were subjected or not to PVA after CCl(4) intoxication or extended hepatectomy. PVA was performed by interposing a stent between the left renal artery and splenic vein after left nephrectomy and splenectomy. Liver injury was evaluated by the serum ALT level and necrotic cell count. Hepatocyte regeneration was assessed by calculating the mitotic index and bromodeoxyuridine (BrdU) staining. The 10-day survival was assessed in separate experimental groups. RESULTS The pO(2) in portal blood increased significantly following PVA. In the CCl(4)-induced ALF, serum ALT levels and necrosis were significantly reduced in arterialized than non-arterialized rats. PVA greatly promotes liver regeneration in both models. Finally, PVA significantly improved survival compared to controls (CCl(4): 100 versus 40%; 90% hepatectomy: 90 versus 30%). Interestingly, in the CCl(4)-induced ALF, survival was 100% even when the shunt was closed after 48 h. CONCLUSION These data indicate that the additional supply of arterial oxygenated blood through PVA promotes a rapid regeneration leading to the resolution of toxic-induced massive liver necrosis and a faster restoration of liver mass after partial hepatectomy in rats. Thus, PVA may represent a novel tool for optimizing hepatocyte regeneration.