Mohamad Khalife

Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Background.The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis.Methods.We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph nodepositive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<.25, .25–.49, .50–.74, .75–1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS.Results.On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25.Conclusions.Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.

Status of Liver Transplantation in the Arab World

The liver transplantation experience of 11 countries in the League of Arab States is presented in this Regional Perspective and provided in an ongoing series of such perspectives through the auspices of The Transplantation Society (1Y3). The history and current experience of 27 liver transplant centers throughout these 11 countries is a seminal recording of both deceased (DDLT) and living donor (LDLT) liver transplantation in the Arab World. The data of this report were assembled by responses to an email questionnaire from 26 of the 27 centers with information regarding the date of the first liver transplant (LT), the total number of LT (including DDLT and LDLT), and the most common indication for LT in those centers. The Arab World is composed of 22 countries in the League of Arab States founded in 1945. It has a combined population of approximately 350 million people and is united by Arabic language, culture, Islamic religion, and geographic contiguity. Additionally, certain Arab countries share a high prevalence of viral hepatitis with an increasing need for LT in those countries (4, 5). The first DDLT in the Arab World was performed in 1990 at Riyadh Military Hospital in Saudi Arabia (6). The first LDLTwas performed in 1991 at the National Liver Institute in Egypt (7). Between 1990 and August 2013, 3,804 liver transplants (3,052 [80%] LDLT and 752 [20%] DDLT) were performed at the 27 in 11 Arab countries (Table 1). The largest percentage of liver transplantation has been performed by 13 transplant centers in Egypt (56%) followed by four transplant centers in Saudi Arabia (35%) and two transplant centers in Jordan (5%). In the remaining eight Arab countries, liver transplant activity has been limited to one program in each country. The most common indication for LT in this series was end-stage liver cirrhosis caused by hepatitis C virus or hepatitis B virus, with or without hepatocellular carcinoma. More than 70% of the LDLT in this series were performed by the transplant centers in Egypt (Table 2) with five living donor deaths reported (0.2% rate of mortality) (8Y12). Egypt has the highest prevalence of hepatitis C virus (HCV) worldwide, estimated to be 15% and 26% of the population (13). More than 90% of the DDLT in this series were performed in Saudi Arabia; four liver transplant centers in Saudi Arabia have collectively performed 1,338 LT (52% DDLT and 48% LDLT), including 13 split LT procedures. There were no reported living donor deaths in Saudi Arabia (14, 15). A small number of transplants have been performed in Algeria, Tunisia, and Lebanon (16, 17). The initial transplant programs in Libya, Kuwait, and United Arab Emirates performed a few liver transplants, but they were subsequently suspended because of logistical and technical reasons. A program for LDLT has recently been developed in Iraq with a potential of performing 15 LDLT per year; also, a DDLT program has begun in Qatar with four transplants performed to date (18). Missing in this report are the current annual data of patient and allograft survival. The progress of liver transplantation Transplantation Society Regional Perspectives

Hepatitis C antiviral response in thalassemia: what is the role of liver iron concentration?

Dear Editor, Patients with thalassemia receive their first blood transfusions within 2 years of birth, and hepatitis C virus (HCV) infection is acquired around the age of 4 years. We have previously reported that the combination of peginterferon alpha-2a and ribavirin is effective and probably safe in the treatment of HCV infection in patients with thalassemia [1]. During the course of our practice, a transfusion-dependent thalassemia major patient who initially experienced an early viral response (EVR) but failed to develop a sustained viral response (SVR) with combination therapy subsequently achieved both rapid viral response (RVR) and SVR following alteration of his iron chelation therapy from the subcutaneous formulation deferoxamine to the oral iron chelator deferasirox. The patient is a 20-year-old male, who was diagnosed with chronic hepatitis C (CHC) by liver biopsy at an early age. He had evidence of genotype 4 HCV infection, had no concurrent hepatitis B or HIV infection, no decompensated liver disease, and no previous history of antiviral therapy. The course of his iron chelation and antiviral treatment is outlined in Fig. 1. Elevated iron-related serum markers as well as increased hepatic iron deposition have been shown to correlate with the severity of hepatic inflammation and fibrosis in patients with CHC [2]. Increased hepatic iron stores in CHC were also related to resistance to interferon/ribavirin treatment [3, 4]. Consequently, several investigators considered iron depletion as an adjuvant or a replacement to antiviral therapy in CHC infection. Most studies revolved around the role of phlebotomy in improving histological activity, fibrosis scores, virological response, and incidence of decompensation and hepatocellular carcinoma [5]. The efficacy of dietary iron restriction for improvement of hepatic inflammation in CHC patients has also been documented [6]. Recently, Goubran et al. [7] observed a significantly higher rate of RVR in CHC patients who received pre-treatment deferasirox compared to patients who received combination therapy only. In thalassemia patients, the use of phlebotomy is not considered since the hemoglobin status of these patients is already compromised. Subsequently, since iron chelation therapy is already undertaken in patients with thalassemia, its effect on CHC infection parameters merits consideration. We previously reported a virological response secondary to deferasirox treatment in three thalassemic patients with CHC who never received antiviral therapy [8]. Our experience described herein further adds to our previous observation, and highlights the role of iron chelation in upgrading the response to peginterferon/ribavirin therapy in thalassemia major patients. Deferasirox and deferoxamine have been shown to provide similar iron chelation efficacy [9]. However, the relation of the improved chelation and viral response in our patient to the shift from deferoxamine to deferasirox may be explained in part by the fact that the latter relies on the liver for iron excretion and has been shown to exhibit more patient compliance [9]. This was clearly evident through serum ferritin, and more importantly, liver iron concentration (LIC) measurements in our patient. Ann Hematol (2009) 88:1033–1034 DOI 10.1007/s00277-009-0713-y

Giant primary malignant mesothelioma of the liver: A case report

Highlights • Malignant mesothelioma is a rare neoplasm of mesothelial cells.• It occurs mostly in the pleura or peritoneum and less frequently in the liver.• Primary intrahepatic mesothelioma is not in the WHO classification of hepatic tumors.• Mesothelioma is more common in men with a mean age of 58 years.• We present a rare case of primary liver malignant mesothelioma in a young female.

Liver resection for metastatic colorectal leiomyosarcoma: a single center experience

BACKGROUND Leiomyosarcoma arising in the colorectum is a rare malignancy of the smooth muscles accounting for less than 1% of gastrointestinal tumors. Surgery remains the most accepted modality for the treatment of this entity however management of liver metastases remains controversial. METHODS & RESULTS From 1998 to 2009, five patients diagnosed with primary leiomyosarcoma of colorectal origin with metastatic liver disease, underwent liver resections at the American University of Beirut Medical Center. The median overall survival was 47 months (range, 7-135 months). CONCLUSIONS Leiomyosarcoma of colorectal origin with liver metastasis is a very rare entity. Long-term survival can be achieved after surgical resection and should be considered for all patients.

Percutaneous hepaticojejunostomy with use of a metal stent for injury of the right hepatic duct after laparoscopic cholecystectomy.

Bile-duct injuries related to laparoscopic cholecystectomy may be complex and require a multidisciplinary approach. The authors report a case of a high hepatic duct injury treated surgically by a left hepaticojejunostomy and an ischemic right hepatic duct that could not be identified during the operation. The right hepatic lobe was subsequently drained radiologically by the percutaneous creation of a right hepaticojejunostomy, through and into a jejunal access loop, followed by deployment of a metallic stent. The patient remained well at 3-year follow-up.

McKittrick–Wheelock syndrome presenting with dermatomyositis and rectal prolapsed

McKittrick–Wheelock syndrome is a rare disease characterized by a large hypersecretory rectosigmoid villous adenoma resulting in persistent large volume diarrhea, electrolyte abnormalities, and renal dysfunction. We report an unusual presentation of this syndrome in a patient who developed persistent diarrhea along with dermatomyositis and rectal prolapse and was later discovered to have a large rectal villous adenoma along with a smaller sigmoid tubulovillous adenoma. In our literature review, we were able to find one case report of a dermatomyositis occurring in conjunction with a tubulovillous adenoma and few case reports of rectal prolapse in the setting of a secretory villous adenoma. However, there were no reports on both occurring in association with McKittrick–Wheelock syndrome. This report highlights the variable manifestations of colorectal adenomas and the importance of searching for an underlying neoplastic entity in patients with new onset dermatomyositis or rectal prolapse or both.

JAK2V617F and prothrombin G20210A gene mutations in a patient with Budd-Chiari syndrome and essential thrombocythemia

Myeloproliferative disorders and the inherited thrombophilias have been described as the main causes underlying the Budd-Chiari syndrome. Moreover, the presence of the JAK2V617F was associated with a higher frequency of Budd-Chiari syndrome in patients who have overt or even latent myeloproliferative disorder. We herein describe a 28-year-old woman who was diagnosed with Budd-Chiari syndrome and later developed an overt myeloproliferative disorder. The patient was found to carry both the JAK2V617F and the prothrombin G20210A mutation in the heterozygous form. The significance of the chronology of diagnosis is highlighted.

Preoperative Localization of Mediastinal Parathyroid Adenoma with Intra-arterial Methylene Blue

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.

Aggressive angiomyxoma presenting with back and perineal bulge; a complex surgical approach: A case report.

Highlights • 90% of patients are women.• Different incisions allows full mobilization of the tumor.• Wide excision should keep capsule intact.• R0 resection should be achieved.• Follow-up should be at 1–2 yearly intervals.