Treatment of hilar cholangiocarcinoma (Klatskin tumors) with hepatic resection or transplantation

Background: Because of the rarity of hilar cholangiocarcinoma, its prognostic risk factors have not been sufficiently analyzed. This retrospective study was undertaken to evaluate various pathologic risk factors which influenced survival after curative hepatic resection or transplantation. Methods: Between 1981 and 1996, 72 patients (43 males and 29 females) with hilar cholangiocarcinoma underwent hepatic resection (34 patients) or transplantation (38 patients) with curative intent. Medical records and pathologic specimens were reviewed to examine the various prognostic risk factors. Survival was calculated by the method of Kaplan- Meier using the log rank test with adjustment for the type of operation. Survival statistics were calculated first for each kind of treatment separately, and then combined for the calculation of the final significance value. Results: Survival rates for 1, 3, and 5 years after hepatic resection were 74%, 34%, and 9%, respectively, and those after transplantation were 60%, 32%, and 25%, respectively. Univariate analysis revealed that T-3, positive lymph nodes, positive surgical margins, and pTNM stage III and IV were statistically significant poor prognostic factors. Multivariate analysis revealed that pTNM stage 0, I, and II, negative lymph node, and negative surgical margins were statistically significant good prognostic factors. For the patients in pTNM stage 0-II with negative surgical margins, 1-, 3-, and 5-year survivals were 80%, 73%, and 73%, respectively. For patients in pTNM stage IV-A with negative lymph nodes and surgical margins, 1-, 3-, and 5- year survivals were 66%, 37%, and 37%, respectively. Conclusions: Satisfactory longterm survivals can be obtained by curative surgery for hilar cholangiocarcinoma either with hepatic resection or liver transplantation. Redefining pTNM stage III and IV-A is proposed to better define prognosis

Is juvenile dermatomyositis a different disease in children up to three years of age at onset than in children above three years at onset? A retrospective review of 23 years of a single center’s experience

BACKGROUND: We tested the hypothesis that the course and outcome of juvenile dermatomyositis (JDM) in children seen at one center with the JDM disease onset at or below three years of age is different from that in the children with disease onset at greater than three years of age. METHODS: Institutional Review Board approval was obtained to retrospectively review the charts of 78 patients from age 0–18 years with JDM seen in the pediatric rheumatology clinic at Nationwide Children’s Hospital in Columbus, Ohio over the past 23 years from January 1988. The diagnosis was made by the treating pediatric rheumatologist. Not all the patients met the Bohan and Peter criteria, as muscle biopsy and EMG were not always performed and we utilized a modified JDM criteria. The data regarding disease course and outcome were collected as of the last clinic follow-up or to July 1, 2010. We used the Wilcoxon Two-Sample test to compare numerical variables between two age groups, and used logistic regression to compare categorical variables between two age groups in SAS 9.1.3. Minitab-16 was used to calculate various mean, median, modes, standard deviations and range. For survival analysis, we used Kaplan-Meier method with log-rank test. RESULTS: The mean age of onset in the two groups at Nationwide Children’s Hospital was 27 months and 91 months. The mean times between onset of symptoms to diagnosis in the younger and older age groups was 5.6 months and 4.5 months, respectively, not a statistically significant difference. The younger onset group had more females (p=0.05) and their disease onset occurred less frequently during the typical winter-spring seasons (p=0.031). The younger onset group was more likely to have a preceding fever (p=0.029) and family history of autoimmune diseases (p=0.012). The younger onset group was less likely to have heliotrope rash (p=0.04), Gottron’s sign (p=0.049), capillary loop abnormalities (p=0.010), or elevations in creatine kinase (CK, p=0.022), aspartate aminotransferase (AST, p=0.021) or aldolase (p=0.035). The younger onset group was treated less often with pulse methylprednisolone at diagnosis (p=0.043) and less often with hydroxychloroquine (p=0.035). There were no differences between the two groups regarding initial oral steroid dose (p=0.8017), number of patients who received methotrexate at diagnosis (p=0.709), and the number who ever received other immunosuppressants (p=0.323). The mean and maximum duration (mean duration 24.3 months vs. 35.2 months, maximum duration 51 vs. 124 months in younger and older onset group respectively) of methotrexate therapy, and the mean and maximum duration of oral steroid therapy (Mean duration 16.8 months vs. 33.3 months, maximum duration 50 vs. 151 months in younger and older onset group respectively), was shorter in the younger group. The younger onset patients were less likely to have active disease at 5 years (9% vs. 35.7%, p=0.015) and 10 years post-diagnosis (9% vs. 45.1%, p=0.011, Table 7). The younger patients were less likely to have osteonecrosis (p=0.023). Two disease-related deaths occurred in the younger group, none in the older group. The results of the survival analysis showed that the difference between the age groups was statistically significant (p < 0.012). The sex and race were not significant (p> 0.26 and p>0.95, respectively). CONCLUSIONS: There were significant differences between JDM patients with disease onset at or below age three years at our center, compared to their older counterparts. Younger patients in our cohort had fewer typical findings at diagnosis and a milder disease course without needing as long a duration of corticosteroids and immunosuppression. Patients with a younger onset had a higher mortality rate but mortalities were unusual and numbers small. The younger group had a similar complication rate compared to the older onset patients, except for osteonecrosis which was higher in the older onset group. These findings differ from the previous reports that a younger age of onset in JDM is often associated with a more severe disease, as results at our center suggest that children with younger onset JDM appear to be atypical but may do well compared to the older JDM patients

Hepatic resection and transplantation for peripheral cholangiocarcinoma

Background: Recent publications have questioned the role of orthotopic liver transplantation (OLT) in treating advanced or unresectable peripheral cholangiocarcinoma (Ch-Ca). Study Design: We reviewed our experience with Ch- Ca to determine survival rates, recurrence patterns, and risk factors in 54 patients who underwent either hepatic resection or OLT between 1981 and 1994. Liver transplantation was performed in patients with unresectable tumors (n = 12) and in those with advanced cirrhosis (n = 8). There were 33 women (61%) and 21 men (39%), with a mean age of 54.3 years. The median followup period was 6.8 years. Prognostic risk factors were analyzed by univariate and multivariate analyses. Results: Mortality within 30 days was 7.4%. Overall patient and tumor-free survival rates were 64% and 57% at 1 year, 34% and 34% at 3 years, and 26% and 27% at 5 years after operation. Thirty-two patients (59.3%) experienced tumor recurrence. Univariate analysis revealed that multiple tumors, bilobar tumor distribution, regional lymph node involvement, presence of metastasis, positive surgical margins, and advanced pTNM stages were significant negative predictors of both tumor-free and patient survival. Multivariate analysis revealed that positive margins, multiple tumors, and lymph node involvement were independently associated with poor prognosis. When patients with these three negative predictors were excluded, the patient survivals at 1, 3, and 5 years were 74%, 64%, and 62%, respectively. Conclusions: Both hepatic resection and OLT are effective therapies for Ch- Ca when the tumor can be removed with adequate margins, the lesion is singular, and lymph nodes are not involved

Hepatic resection for metastatic colorectal adenocarcinoma: A proposal of a prognostic scoring system

Background: Hepatic resection for metastatic colorectal cancer provides excellent longterm results in a substantial proportion of patients. Although various prognostic risk factors have been identified, there has been no dependable staging or prognostic scoring system for metastatic hepatic tumors. Study Design: Various clinical and pathologic risk factors were examined in 305 consecutive patients who underwent primary hepatic resections for metastatic colorectal cancer. Survival rates were estimated by the Cox proportional hazards model using the equation: S(t) = [S(o)(t)](exp(R - R(o))), where S(o)(t) is the survival rate of patients with none of the identified risk factors and R(o) = 0. Results: Preliminary multivariate analysis revealed that independently significant negative prognosticators were: (1) positive surgical margins, (2) extrahepatic tumor involvement including the lymph node(s), (3) tumor number of three or more, (4) bilobar tumors, and (5) time from treatment of the primary tumor to hepatic recurrence of 30 months or less. Because the survival rates of the 62 patients with positive margins or extrahepatic tumor were uniformly very poor, multivariate analysis was repeated in the remaining 243 patients who did not have these lethal risk factors. The reanalysis revealed that independently significant poor prognosticators were: (1) tumor number of three or more, (2) tumor size greater than 8 cm, (3) time to hepatic recurrence of 30 months or less, and (4) bilobar tumors. Risk scores (R) for tumor recurrence of the culled cohort (n = 243) were calculated by summation of coefficients from the multivariate analysis and were divided into five groups: grade 1, no risk factors (R = 0); grade 2, one risk factor (R = 0.3 to 0.7); grade 3, two risk factors (R = 0.7 to 1.1); grade 4, three risk factors (R = 1.2 to 1.6); and grade 5, four risk factors (R > 1.6). Grade 6 consisted of the 62 culled patients with positive margins or extrahepatic tumor. Kaplan-Meier and Cox proportional hazards estimated 5-year survival rates of grade 1 to 6 patients were 48.3% and 48.3%, 36.6% and 33.7%, 19.9% and 17.9%, 11.9% and 6.4%, 0% and 1.1%, and 0% and 0%, respectively (p < 0.0001). Conclusions: The proposed risk-score grading predicted the survival differences extremely well. Estimated survival as determined by the Cox proportional hazards model was similar to that determined by the Kaplan-Meier method. Verification and further improvements of the proposed system are awaited by other centers or international collaborative studies

Liver transplantation for hepatocellular carcinoma: A proposal of a prognostic scoring system

Background: The current staging system of hepatocellular carcinoma established by the International Union Against Cancer and the American Joint Committee on Cancer does not necessarily predict the outcomes after hepatic resection or transplantation. Study Design: Various clinical and pathologic risk factors for tumor recurrence were examined on 344 consecutive patients who received hepatic transplantation in the presence of nonfibrolamellar hepatocellular carcinoma to establish a reliable risk scoring system. Results: Multivariate analysis identified three factors as independently significant poor prognosticators: 1) bilobarly distributed tumors, 2) size of the greatest tumor (2 to 5 cm and > 5 cm), and 3) vascular invasion (microscopic and macroscopic). Prognostic risk score (PRS) of each patient was calculated from the relative risks of multivariate analysis. The patients were grouped into five grades of tumor recurrence risk: grade 1: PRS = 0 to 11.0 to 15.0; grade 4: PRS ≥ 15.0; and grade 5: positive node, metastasis, or margin. The proposed PRS system correlated extremely well with tumor-free survival after liver transplantation (100%, 61%, 40%, 5%, and 0%, from grades 1 to 5, respectively, at 5 years), but current pTNM staging did not. Conclusions: 1) Patients with grades 1 and 2 are effectively treated with liver transplantation, 2) patients with grades 4 and 5 are poor candidates for liver transplantation, and 3) patients with grade 1 do not benefit from adjuvant chemotherapy. (C) 2000 by the American College of Surgeons

DISPOSITION AND TOXICITY OF A MIXED BACKBONE ANTISENSE OLIGONUCLEOTIDE, TARGETED AGAINST HUMAN CYTOMEGALOVIRUS, AFTER INTRAVITREAL INJECTION OF ESCALATING SINGLE DOSES IN THE RABBIT

This paper is available online at http://www.dmd.org ABSTRACT: The ocular disposition and toxicity of GEM132, a mixed backbone phosphorothioate oligonucleotide developed for the treatment of cytomegalovirus-induced retinitis, were studied in rabbits for 6 months following single intravitreal injection of 5, 20, or 100 g/eye (toxicity) and 3.7, 15.7, or 78.5 g/eye (disposition). Intraocular pressure, electroretinograms, and ophthalmoscopy were evaluated in the toxicity arm as well as gross and microscopic pathology at the termination of the study. Vitreous humor, retina, and the remaining ocular tissues were collected from all animals in the disposition arm. No toxicities were observed in the low-dose group. Intraocular pressure was transiently mildly increased in the mid-and high-dose groups; macroscopic findings were mild and infrequent. Changes in electroretinograms and histopathological findings attributed to GEM132 were observed by 4 weeks postdose in the high-dose group. Area under the curve values in all ocular tissues sampled were proportional to dose, suggesting GEM132 disposition exhibited first-order kinetics. Vitreous humor concentrations decreased in a multiphasic manner, consistent with rapid distribution. Polyacrylamide gel electrophoresis analysis of retinal extracts indicated that, at 4 weeks postdose, 90% of the radioactivity was associated with parent compound. At 8 weeks postdose, this had decreased to 70%, and subsequently to 50% at 21 weeks postdose. In retina, GEM132 reached concentrations &gt;5 times IC 90 by 1 week postdose, with maximum concentrations 4 to 8 weeks postdose. Retinal concentrations of intact GEM132 then declined at a very slow rate. Microautoradiography suggested that radioactivity was distributed throughout the retinal layers, the largest amount being located in the middle layers. The advancement of antisense oligonucleotides to human clinical trials as anticancer Human cytomegalovirus (HCMV), a common opportunistic infection in immunocompromised persons, is a major cause of life-threatening disease. CMV-induced retinitis, if left untreated, will cause severe, irreversible damage to the retina, resulting in progressive loss of vision in the involved eye(s). Currently available therapies for CMV-induced retinitis include ganciclovir, foscamet, cidofovir, and the recently approved PS antisense oligonucleotide, fomivirsen (ISIS 2922). GEM132 is a 20-mer mixed backbone oligonucleotide (MBO) with 2Ј-O-methylribonucleosides at the two 3Ј-and four 5Ј-terminal nucleotides. It is antisense, complementary to the intron-exon boundary of the UL35 and UL37 premRNA transcripts of HCMV, and has shown antiviral activity in vitro with an IC 90 of about 0.1 M against standard laboratory strains of the virus Although studies have been published on the pharmacokinetics of PS oligonucleotides after intravitreal dosing Materials and Methods Synthesis and Purification of GEM132. GEM132 is a 20-base phosphorothioate MBO (5Ј-UGGGGCTTACCTTGCGAACA-3Ј), 6605-Da molecular 1255 mass (free acid), in which two deoxynucleosides at the 5Ј end and four deoxynucleosides at the 3Ј end (underlined) are substituted with 2Ј-O-methylribonucleosides. GEM132 was chemically synthesized using deoxynucleoside phosphoramidites (Milligen, Milford, MA) and 2Ј-O-methylribonucleoside phosphoramidites (Glen Research, Sterling, VA) on an automated synthesizer as previously described Experimental Design. Male Dutch Belted rabbits were given a single intravitreal injection (50 l) of GEM132 in both eyes. Control animals received saline only. For the disposition study, [ 14 C]GEM132 was administered; eyes and selected tissues were harvested at various times postdosing (n ϭ 3 eyes/time point). The oligonucleotide was dissolved in 0.9% saline, and the doses administered were 3.7 g/eye (0.07 Ci), 15.7 g/eye (0.3 Ci), and 78.5 g/eye (1.5 Ci). For the toxicity study, unlabeled GEM132 was administered at doses of 5, 20, or 100 g/eye. Electroretinograms (ERGs). Electroretinograms were obtained from all animals in the study at regular intervals. Light stimuli included scotopic blue, red, and white single flash and 30 Hz white flicker. The animals were anesthetized with ketamine (50 mg/kg)/xylazine (5 mg/kg) and dark-adapted at least 30 min before recording of the ERG. A mydriatic agent was applied to the eyes to dilate the pupils before testing. Sample Processing and Storage Conditions. At each time point, the left eye from the even-numbered animals and both eyes from the odd-numbered animals were dissected, and retina, vitreous humor, and remaining ocular tissue were removed and weighed. The weighed vitreous humor (0.724 Ϯ 0.031 g, mean Ϯ S.D.) and retina (0.0283 Ϯ 0.0003 g) samples were homogenized in 2 ml of 0.9% saline in preweighed glass tubes with a Teflon probe. After homogenization, aliquots of retina were solubilized in 35% tetraethylammonium hydroxide. Ten milliliters of Hionic Fluor scintillation fluid (Canberra Packard, Ontario, Canada) was added to vitreous humor and solubilized retina, and radioactivity was measured by liquid scintillation spectroscopy. Remaining ocular tissue samples (1.47 Ϯ 0.18 g) were minced and digested in toto in 35% tetraethylammonium hydroxide. Duplicate aliquots of the digest were added to 10 ml of scintillation fluid, and radioactivity was determined. Samples having a radioactivity level of less than or equal to double background were considered below the limit of quantitation and considered zero. Autoradiography and Microautoradiography Conditions. At each time point, the right eye of each even-numbered animal was removed and fixed in a 2.5% gluteraldehyde solution, stored, refrigerated, and transferred within 24 h to 10% neutral buffered Formalin where they remained for at least 24 h before trimming. Eyes were then trimmed, dehydrated, infiltrated, and imbedded in paraffin within 8 days after necropsy. Six-micrometer-thick sections were prepared. The following procedures were conducted under reduced safety light conditions: sections were subjected to deparaffination, dipped in diluted and warmed Kodak NTB-2 nuclear track emulsion, followed by a 30-min rinse in hot distilled water and controlled drying. After drying, the emulsion-coated slides were stored in lightproof plastic boxes at 4 -8°C. All slides were developed after 15 days of exposure using a solution of Kodak D-19 developer, washed, fixed in Kodak Rapid Fixer, and washed. Slides were stained with H&amp;E, mounted, and evaluated for the localization and relative concentration of radioactivity (visualized as small, reduced silver grains lying on cellular surfaces). A four-grade (1, slight; 2, mild; 3, moderate; and 4, severe) grading scheme was used to semiquantify the amount of radioactivity. The amount of radioactivity present in underlying sclera was used to establish a threshold between a negative and a slight deposition of radioactivity in the retina. Polyacrylamide Gel Electrophoresis (PAGE) and Phosphor Image Analysis. Retinal homogenates were subjected to protein digestion by incubation with proteinase K enzyme (0.25 ml of a 20 mg/ml solution) containing 20 mM Tris EDTA for 3 h at 60°C. Samples were extracted twice with Tris ETDA-saturated phenol-chloroform solution (1:1, v/v) and once with chloroform to remove proteinase K, digested protein, and lipids from nucleic acids. After extraction, an aliquot of the organic and aqueous phase from each sample was removed, and total radioactivity was determined by liquid scintillation spectroscopy. This allowed for the determination of extraction recovery. The average recoveries (ϮS.D.) were 79.7 Ϯ 13.2% (quality control standards), 74.3 Ϯ 19.1% (day 7), 75.7 Ϯ 6.4% (day 14), 72.4 Ϯ 10.3% (day 28), 74.1 Ϯ 8.2% (day 56), 87.3 Ϯ 3.6% (day 114), and 87.4 Ϯ 12.0% (day 149). No radioactivity (Ն2ϫ background) was measurable in the organic phase, indicating that all the GEM132-associated radioactivities were retained in the aqueous phase following extraction. Loss of radioactivity was believed to be due to the difficulty in completely separating the two phases; a thin layer of the aqueous phase was always left behind. An 8-l aliquot of the aqueous phase was loaded on a 20% polyacrylamide gel containing 7.5 M urea and subjected to electrophoresis (70 -290 V, 3-14 mA, 60 -153 min). Quality control standards (0.11, 0.60, and 4.1 mg/ml, corresponding to 780, 4,500, and 21,000 dpm) were prepared by adding known amounts of radiolabeled GEM132 to retinal homogenates obtained from control rabbits. Duplicate standards were loaded on each of the two outer channels of the gel. After electrophoresis, Southern blots of the gels were performed on 0.45-nitrocellulose membranes over a period of about 12 h. The nitrocellulose membranes were then removed and allowed to dry at room temperature. Membranes were exposed to the phosphor screen for 25 to 288 h (Molecular Dynamics Storage Phosphor Screen, Sunnyvale, CA) at room temperature, after which the phosphor screen was scanned by a phosphor imager (Molecular Dynamics Phosphor Imager SI) to obtain radioactivity profiles. The lower limit of detection was determined to be an area of Ն15 phosphor image units. Concentrations of intact GEM132 were calculated by multiplying the measured total radioactivity in the retina (total MBO) by the fraction eluting with the same mobility as the standards, as determined by PAGE/phosphor image analysis and correcting for purity (90%). Intergel variability and intragel variability were determined for phosphor image analysis. Intergel variability ranged from 8.6 to 5.3%. For intragel variability, the %CV for four samples processed on the same gel ranged from 5.5 to 11.1%. The limit of quantification for phosphor image analysis, determined for four different exposure times, was as follows: 295 dpm (24 h), 200 dpm (48 and 96 h), and 100 dpm (144 h). Results Ophthalmic Examinations. Signs of ocular irritation attributed to the injection of GEM132 were infrequent, mild, and transient. Mild cellular infiltrate in the anterior vitreous occurred almost exclusively in the high-dose animals from 2 to 16 weeks postdose. Signs of iritis were also mild and infrequent. Retinal lesions were observed almost exclusively in the high-dose animals. Changes in intraocular pressures were mild and transient and considered only potentially related to treatment. Electroretinograms. Representative data for ERGs are shown in Histopathology. Histopathological findings attributed to the administration of GEM132 were seen in the retina, lens, and optic nerve of a few animals in the mid-dose group at 8 and 21 weeks and the high-dose group at 4, 8, and 16 weeks postdose. Slight retinal degen- DVORCHIK AND MARQUIS eration characterized by partial disorganization of the inner and outer plexiform layer and the ganglion cell layer was observed in one high-dose animal at week 4 and in three high-dose animals at week 8. This finding was also observed in one mid-dose animal at weeks 8 and 21 and in one control and two low-dose animals at week 21. Retinal detachment was observed in one high-dose animal at week 8. A basophilic granular material was observed in the retina of one highdose animal at week 4, in three high-dose animals at week 8, and in two high-dose animals at week 16. One mid-dose animal at week 8 also presented with this finding. A slight to mild mononuclear infiltration was seen in the optic nerves of some high-dose animals at weeks 4 and 6 and in one high-dose animal at week 16. This was also observed in some mid-dose animals at week 8

Treatment of fibrolamellar hepatoma with subtotal hepatectomy or transplantation

Fibrolamellar hepatoma (FL-HCC) is an uncommon variant of hepatocellular carcinoma (HCC), distinguished by histopathological features suggesting greater differentiation than conventional HCC. However, the optimal treatment and the prognosis of FL-HCC have been controversial. Follow-up studies are available from 1 year to 27 years, after 41 patients with FL-HCC were treated with partial hepatectomy (PHx) (28 patients) or liver transplantation (13 patients). In this retrospective study, the effect on outcome was determined for the pTNM stage and other prognostic factors routinely recorded at the time of surgery. Cumulative survival at 1, 3, 5, and 10 years was 97.6%, 72.3%, 66.2%, and 47.4%. Tumor-free survival at these times was 80.3%, 49.4%, 33%, and 29.3%. The TNM stage was significantly associated with tumor-free survival. Patients with positive nodes had a shorter tumor-free survival than those with negative nodes (P < .015). Patient survival was most adversely affected by the presence of vascular invasion (P < .05). FL-HCC is an indolently growing tumor of the liver, which usually was diagnosed in our patients at a stage too advanced for effective surgical treatment of most conventional HCC. Nevertheless, long-term survival frequently was achieved with aggressive surgical treatment. When a subtotal hepatectomy could not be performed, total hepatectomy (THx) with liver transplantation was a valuable option

Kidney after nonrenal transplantation-the impact of alemtuzumab induction

BACKGROUND.: Calcineurin inhibitor nephrotoxicity in nonrenal allograft recipients can lead to end-stage renal disease and the need for kidney transplantation. We sought to evaluate the role of alemtuzumab induction in this population. PATIENTS AND METHODS.: We evaluated 144 patients undergoing kidney transplantation after nonrenal transplantation between May 18, 1998, and October 8, 2007. Seventy-two patients transplanted between January 15, 2003, and October 8, 2007, received alemtuzumab induction and continued their pretransplant immunosuppression. Seventy-two patients transplanted between May 18, 1998, and July 21, 2007, did not receive alemtuzumab induction, but received additional steroids and maintenance immunosuppression. Donor and recipient demographics were comparable. RESULTS.: Overall, 1-and 3-year patient survival and renal function were comparable between the two groups. One-and 3-year graft survival was 93.0% and 75.3% in the alemtuzumab group and 83.3% and 68.7% in the no alemtuzumab group, respectively (P=0.051). The incidence of acute rejection was lower in the alemtuzumab group, 15.3%, than in the no alemtuzumab group, 41.7% (P=0.0001). The incidence of delayed graft function was lower in the alemtuzumab group, 9.7%, than in the no alemtuzumab group, 25.0% (P=0.003). The incidence of viral complications was comparable. CONCLUSION.: Alemtuzumab induction with simple resumption of baseline immunosuppression in patients undergoing kidney transplantation after nonrenal transplantation represents a reasonable immunosuppressive strategy. Copyright © 2009 by Lippincott Williams & Wilkins