Megan Templin

Survival analysis of patients with stage I and II hepatocellular carcinoma after a liver transplantation or liver resection

INTRODUCTION Liver transplantation (LT) is a treatment option in select patients with hepatocellular carcinoma (HCC). The aim of the present study was to compare survival in Stage I or II HCC patients undergoing either liver transplant (LT) or a liver resection (LR). METHOD The study is a retrospective analysis of the National Cancer Data Base (1998-2011). In total, 148,882 patients with liver cancer were identified, of which 5-year survival data (1998-2006) were available for 64,227 patients. Patients were stratified by the American Joint Committee on Cancer (AJCC) clinical stage I and II. Kaplan-Meier curves and log-rank tests were used for statistical analysis. RESULTS 3340 HCC patients met analysis criteria. Among stage I HCC, 860 had LT and 871 had LR. Among stage II HCC, 833 had LT and 776 LR. In stage I patients the median survival for LT and LR were 127.9 and 56.7 months, respectively, (P < 0.0001) and in stage II patients the median survival was 110.8 and 42.8 months (P < 0.0001). Unlike LT patients, LR patients with Stage I HCC had a longer median survival compared with Stage II patients (P = 0.0002). CONCLUSION Liver transplantation offers a survival advantage compared with a liver resection among patients with Stage I and II HCC. LT is the best surgical treatment for early stage (I/II) HCC in patients with advanced fibrosis or cirrhosis, whereas LR provides equivalent outcomes to LT in patients without advanced fibrosis and should be considered as the first surgical option.

Interobserver and Intraobserver Agreement on Qualitative Assessments of Right Ventricular Dysfunction With Echocardiography in Patients With Pulmonary Embolism

To evaluate observer agreement using qualitative goal‐directed echocardiographic criteria for right ventricular (RV) dysfunction prognostication in submassive pulmonary embolism (PE).

Impact of recipient twin preoperative myocardial performance index in twin–twin transfusion syndrome treated with laser*

Abstract Objective: To validate the efficacy of laser therapy for twin–twin transfusion syndrome (TTTS) in the treatment of recipient twin cardiomyopathy and investigate whether severity of preoperative cardiomyopathy can predict fetal survival postoperatively. Study design: Retrospective study of monochorionic-diamniotic (MCDA) pregnancies complicated by TTTS treated by selective fetoscopic laser photocoagulation (SFLP) performed between March 2010 and October 2014 at a single center. The recipient right ventricular (RV) and left ventricular (LV) myocardial performance index (MPI) were measured both pre- and postoperatively. The data were analyzed with the Wilcoxon signed rank and parametric t-tests. Results: Forty-three women met inclusion criteria during the study period. There was a substantial improvement in recipient LV (0.57 ± 0.13 versus 0.43 ± 0.13, p ≤ 0.0001) and RV (0.60 ± 0.16 versus 0.49 ± 0.18, p ≤ 0.0001) MPI postoperatively (median = 8 days). Recipient preoperative LV and RV MPI did not correlate with recipient or donor survival at 24 hours, 7 days or at birth. Thirty-seven recipients (95%) showed improvement in either LV or RV MPI and 22 (56%) showed complete resolution of cardiac dysfunction. Conclusion: Laser treatment for TTTS causes rapid improvement in the cardiac function of recipient fetuses. The severity of recipient preoperative MPI does not correlate with survival of either twin postoperatively.

Outcomes of surgical resection and loco‐regional therapy in patients with stage 3A hepatocellular carcinoma: a retrospective review from the national cancer database

OBJECTIVES In advanced stages, hepatocellular carcinoma (HCC) is often associated with major vascular involvement (cava, portal vein). The aim of the present study was to analyse the role of surgical resection (SR) and loco-regional therapy (LRT) in these advanced stage patients to determine if there was a survival benefit. METHODS The study is a retrospective analysis from the Commission on Cancers National Cancer Data Base (NCDB) from 1998 to 2011. In total, 148,882 patients with liver cancer were identified, of which 126,984 had HCC. Of these, 64,264 patients (1998-2006) had 5-year survival data available and 8825 patients had Stage 3A disease based on AJCC classification. Of these patients, 884 had SR, 771 had LRT and 7170 patients had neither intervention. Kaplan-Meier curves and log-rank tests were used for statistical analysis. RESULTS Eight thousand eight hundred and twenty-five patients met analysis criteria. The mean age (years) in the SR, LRT and no intervention group were 62.5, 64.3 and 64.2, respectively. Most patients were males in all three groups (77.5%, 74.5% and 68.1%). The mean tumour size (cm) in the three groups was 9.8, 6.4 and 8.4, respectively. SR and LRT were primarily performed in major academic and comprehensive cancer programmes compared with community cancer programmes and other centres (SR: 93% versus 7%; LRT: 94.6% versus 5.4%). The median 5-year survival (months) was 26.6 in SR, 16.5 in LRT and 4.8 in the no intervention group (P < 0.0001). CONCLUSION A SR and LRT offer a survival benefit in select patients diagnosed with Stage 3A HCC.

Cortistatin is endogenous to the human intervertebral disc and exerts in vitro mitogenic effects on annulus cells and a downregulatory effect on TNF-α expression

BACKGROUND CONTEXT Cortistatin (CST) is a recently discovered cyclic neuropeptide with biologic anti-inflammatory properties relevant to disc degeneration. PURPOSE To test whether CST is present in the disc tissue, whether its expression is influenced by tumor necrosis factor-α (TNF-α), and whether it influences cell proliferation. STUDY DESIGN Institutional review board-approved study using immunohistochemistry on human disc tissue, in vitro annulus cultures to determine the effect of CST on cell proliferation, and the effect of TNF-α on CST gene expression. PATIENT SAMPLE Discs from 12 subjects used for immunohistochemistry, four annulus specimens used for cell culture with proinflammatory cytokines, and 11 used for cell proliferation analyses. OUTCOME MEASURES Immunohistochemical localization of CST, gene expression of CST, and cell proliferation analyses. METHODS Immunohistochemistry localized CST in disc tissue. Microarray analysis measured CST gene expression. Human annulus cells were exposed to CST for proliferation tests or cultured for the effect of TNF-α on CST expression. Standard statistical analyses were performed. RESULTS Immunohistochemistry identified CST in outer annulus, inner annulus, and nucleus tissue. Annulus cells exposed to TNF-α revealed significantly lower CST expression (p=.013). Exposure to CST significantly increased proliferation. Quantitative real-time polymerase chain reaction also confirmed expression of CST in vitro. CONCLUSIONS Data provide the first evidence that CST is present in the human disc. Addition of CST significantly increased cell proliferation. Cortistatin expression was significantly downregulated by TNF-α exposure in vitro. Findings suggest possible in vivo reduction of the anti-inflammatory actions of CST because of elevated proinflammatory cytokines during degenerating disc.

Risk of donor demise after laser therapy for twin–twin transfusion when complicated by growth discordance and abnormal umbilical artery Doppler findings*

Abstract Objective: To investigate the natural course of abnormal umbilical artery Doppler (UAD) findings in donor fetuses after laser surgery and the prognostic significance of resolution, persistence, or new onset UAD abnormalities with and without the presence of preoperative growth discordance. Study design: Retrospective cohort study of all monochorionic-diamniotic multi-fetal gestations diagnosed with twin-twin transfusion syndrome (TTTS) undergoing laser surgery at a single large metropolitan referral center from 2010-2016. The estimated fetal weight was measured preoperatively and the UAD were measured both pre- and postoperatively (median = 8 days). Patients were grouped according to the presence of abnormal UAD with or without growth discordance pre- and postoperatively. Risk ratios (RR) were calculated for each group for risk of intrauterine fetal demise compared to the pre- and postoperative normal UAD groups as the referents. Results: There were eighty-one women who met inclusion criteria throughout the study period. Forty-three (53.1%) patients had abnormal donor twin UAD preoperatively and 33 (40.7%) were diagnosed with growth discordance. However, 13 (44.8%) had normalization of the UAD postoperatively (median = 8 days) with a similar rate of donor fetal demise as the non-discordant preoperative normal UAD group (7.7% versus 10.3%, p = .79). Abnormal preoperative UAD was associated with an increased risk of donor demise (RR 3.6, CI 1.1–12.1), which was further elevated in the presence of growth discordance (RR 5.2, CI 1.7–16.3). The greatest risk for donor demise was seen if the UAD remained abnormal postoperatively with concomitant growth discordance (RR 10.3, CI 2.5–41.6). Conclusions: Preoperative abnormal donor UAD is a significant risk for donor demise post-laser therapy for TTTS. Persistent postoperative abnormal UAD with concomitant growth discordance confers the greatest risk for donor demise. However, resolution of abnormal UAD has a similar rate of donor demise when compared to patients with normal UAD preoperatively.

Effect of cervical length recovery after laser surgery for twin-twin transfusion syndrome

Objective To evaluate the impact of polyhydramnios on preoperative cervical length and whether cervical length recovery after amnioreduction during selective fetoscopic laser photocoagulation (SFLP) is associated with a greater gestational age at delivery in pregnancies complicated by twin-twin transfusion syndrome (TTTS). Methods Retrospective study of 50 pregnancies complicated by TTTS treated with SFLP between March 2010 and July 2014 at a single center. Preoperative maximum vertical pocket (MVP) was measured along with pre- and postoperative cervical length. A cervical length difference was calculated, with a difference of ± 3 mm considered no change. Results Only 12 (34%) patients showed an increased cervical length after amnioreduction during laser surgery. There was no statistical difference between either negative or positive change in cervical length groups and mean gestational age at delivery (p = 0.82). There also was no correlation between preoperative MVP and preoperative cervical length (p = 0.36) or gestational age at delivery (p = 0.77). However, there was a statistically shorter mean preoperative cervical length in patients who delivered <32 weeks of gestation (3.62 ± 0.66 vs. 4.20 ± 0.85 cm; p = 0.03). Conclusion Severity of polyhydramnios does not correlate with preoperative cervical length, and variability of the cervix postoperatively does not appear to affect gestational age at delivery.

Cervical Length and Maximum Vertical Pocket as Predictors of Gestational Age at Delivery in Pregnancies Treated With Selective Fetoscopic Laser Photocoagulation for Severe Twin–Twin Transfusion Syndrome [94]

OBJECTIVE: To evaluate the effect of polyhydramnios on cervical length and whether cervical length recovery after amnioreduction during selective fetoscopic laser photocoagulation is associated with a greater gestational age at delivery in pregnancies complicated by severe twin–twin transfusion syndrome. METHODS: Retrospective study of pregnancies complicated by severe twin–twin transfusion syndrome treated by selective fetoscopic laser photocoagulation performed between March 2010 and October 2013 at a single center. Preoperative maximum vertical pocket and preoperative and postoperative cervical lengths were measured. The cervical length difference was calculated with a difference of ±3 mm considered no change. Data were analyzed with Spearman and Pearson correlation coefficients calculated for gestational age at delivery. RESULTS: Thirty-nine women were included in the study population. Preoperative (&rgr;=0.352; P=.035) and postoperative (&rgr;=0.332, P=.044) cervical lengths were found to have significant positive correlations with gestational age. A subgroup analysis excluding iatrogenic deliveries less than 34 weeks of gestation (n=22) showed a similar correlation with postoperative cervical length, but only a trend toward significance (&rgr;=0.379; P=.06). Change in cervical length and preoperative maximum vertical pocket were not statistically correlated with gestational age at delivery. The overall survival rate was 74.3% (57/78). There were two fetal survivors in 56.4% (22/39) and at least one survivor in 89.7% (35/39). CONCLUSION: Selective fetoscopic laser photocoagulation remains an effective therapy for pregnancies complicated by severe twin–twin transfusion syndrome. This study is concordant with prior research indicating that cervical length before and after treatment has a significant correlation with gestational age at delivery. However, severity of polyhydramnios and change in cervical length postprocedure were not found to be statistically significant.