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Systematic review of surgical resection vs radiofrequency ablation for hepatocellular carcinoma

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World Journal of Gastroenterology 2013年第26期19卷 4106-4118页

作者： Alessandro Cucchetti Fabio Piscaglia Matteo Cescon Giorgio Ercolani antonio daniele pinna General Surgery and Transplant Unit Department of General Surgery and Organ Transplantation Alma Mater Studiorum-University of Bologna Policlinico Sant'Orsola-Malpighi University of Bologna Division of Internal Medicine Department of Clinical Medicine S Orsola-Malpighi Hospital Alma Mater Studiorum-University of Bologna

Hepatocellular carcinoma (HCC) represents one of the most common neoplasms worldwide. Surgical resection and local ablative therapies represent the most frequent first lines therapies adopted when liver transplantation can not be offered or is not immediately accessible. Hepatic resection (HR) is currently considered the most curative strategy, but in the last decade local ablative therapies have started to obtain satisfactory results in term of efficacy and, of them, radiofrequency ablation (RFA) is considered the reference standard. An extensive literature review, from the year 2000, was performed, focusing on results coming from studies that directly compared HR and RFA. Qualities of the studies, characteristics of patients included, and patient survival and recurrence rates were analyzed. Except for three randomized controlled trials (RCT), most studies are affected by uncertain methodological approaches since surgical and ablated patients represent different populations as regards clinical and tumor features that are known to affect prognosis. Unfortunately, even the available RCTs report conflicting results. Until further evidences become available, it seems reasonable to offer RFA to very small HCC ( 2 cm and especially if > 3 cm, and/or in tumor locations in which ablation is not expected to be effective or safe, surgical removal is to be preferred.

关键词： Hepatocellular carcinoma Hepatic resection Surgical therapy Ablation techniques Survival Liver failure

Liver grafts from hepatitis B surface antigen-positive donors: A review of the literature

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World Journal of Gastroenterology 2016年第35期22卷 8010-8016页

作者： Elisabetta Loggi Fabio Conti Alessandro Cucchetti Giorgio Ercolani antonio daniele pinna Pietro Andreone Dipartimento di Scienze Mediche e Chirurgiche Università degli Studi di Bologna Centro di Ricerca per lo Studio delle Epatiti Università degli Studi di Bologna

The scarcity of available organs and the gap between supply and demand continue to be the main limitations of liver transplantation. To relieve the organ shortage, current transplant strategies have implemented extended criteria, which include the use of liver from patients with signs of past or present hepatitis B virus(HBV) infection. While the use of liver grafts from donors with evidence of past HBV infection is quite limited, some data have been collected regarding the feasibility of transplanting a liver graft from a hepatitis B surface antigen(HBs Ag) positive donor. The aim of the present work was to review the literature regarding liver transplants from HBs Ag-positive donors. A total of 17 studies were identified by a search in Medline. To date, HBs Ag positive grafts have preferentially been allocated to HBs Ag positive recipients. The large majority of these patients continue to be HBs Ag positive despite the use of immunoglobulin, and infection prevention can only be guaranteed by using antiviral prophylaxis. Although serological persistence is evident, no significant HBV-related disease has been observed, except in patients coinfected with delta virus. Consistently less data are available for HBs Ag negative recipients, although they are mostly promising. HBs Agpositive grafts could be an additional organ source for liver transplantation, provided that the risk of reinfection/reactivation is properly prevented.

关键词： Liver transplantation Hepatitis B Marginal grafts Hepatitis B positive graft Hepatitis B surface antigen positive donor

Liver transplantation for hepatocellular carcinoma:Role of inflammatory and immunological state on recurrence and prognosis

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World Journal of Gastroenterology 2013年第48期19卷 9174-9182页

作者： Matteo Cescon Valentina Rosa Bertuzzo Giorgio Ercolani Matteo Ravaioli Federica Odaldi antonio daniele pinna General Surgery and Transplant Unit Department of Medical and Surgical Sciences Alma Mater Studiorum-University of Bologna40138 Bologna Italy

Criteria for liver transplantation(LT)for hepatocellular carcinoma(HCC)and post-LT indicators of prognosis are historically based on the measurement of the tumor ***,high throughput technologies have increased the prediction of recurrence,but these tools are not yet routinely *** interaction between HCC and the immune system has revealed an imbalance of lymphocyte phenotypes in the peritumoral tissue,and the increase of regulatory T cells with respect to cytotoxic lymphocytes has been linked to a higher rate of post-LT HCC ***,some inflammatory markers have shown good reliability in predicting cancer reappearance after surgery,as a result of either a systemic inflammatory response or a decreased capacity of the organism to control the tumor *** these markers,the neutrophil-tolymphocyte ratio appears to be the most promising and easily available serum parameter able to predict HCC recurrence after LT and following other types of treatment,although the exact mechanisms determining its elevation have not been ***-LT immunosuppression may impact on cancer control,and the exposure to high levels of calcineurin inhibitors or other immunusuppressants has recently emerged as a negative prognostic factor for HCC recurrence and patient *** the absence of prospective randomized trials,inhibitors of the mammalian target of rapamycin have been shown to be associated with lower rates of tumor recurrence compared to other immunosuppressors,suggesting their use especially in patients with HCC exceeding the conventional indication criteria for LT.

关键词： Liver transplantation Hepatocellular carcinoma Inflammation Immunosuppression Recurrence

Liver transplantation for hepatic tumors:a systematic review

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World Journal of Gastroenterology 2014年第18期20卷 5345-5352页

作者： Matteo Ravaioli Giorgio Ercolani Flavia Neri Matteo Cescon Giacomo Stacchini Massimo Del Gaudio Alessandro Cucchetti antonio daniele pinna Department of General Surgery and Transplantation Sant’Orsola-Malpighi HospitalUniversity of Bologna40138 BolognaItaly

Improvements in the medical and pharmacological management of liver transplantation (LT) recipients have led to a better long-term outcome and extension of the indications for this procedure. Liver tumors are relevant to LT; however, the use of LT to treat malignancies remains a debated issue because the high risk of recurrence. In this review we considered LT for hepatocellular carcinoma (HCC), cholangiocarcinoma (CCA), liver metastases (LM) and other rare tumors. We reviewed the literature, focusing on the past 10 years. The highly selected Milan criteria of LT for HCC (single nodule < 5 cm or up to 3 nodules < 3 cm) have been recently extended by a group from the University of S. Francisco (1 lesion < 6.5 cm or up to 3 lesions < 4.5 cm) with satisfying results in terms of recurrence-free survival and the “up-to-seven criteria”. Moreover, using these criteria, other transplant groups have recently developed downstaging protocols, including surgical or loco-regional treatments of HCC, which have increased the post-operative survival of recipients. CCA may be treated by LT in patients who cannot undergo liver resection because of underlying liver disease or for anatomical technical challenges. A well-defined protocol of chemoirradiation and staging laparotomy before LT has been developed by the Mayo Clinic, which has resulted in long term disease-free survival comparable to other indications. LT for LM has also been investigated by multicenter studies. It offers a real benefit for metastases from neuroendocrine tumors that are well differentiated and when a major extrahepatic resection is not required. If LT is an option in these selected cases, liver metastases from colorectal cancer is still a borderline indication because data concerning the disease-free survival are still lacking. Hepatoblastoma and hemangioendothelioma represent rare primary tumors for which LT is often the only possible and effective cure because

关键词： Liver transplantation Liver cancer Hepatocellular carcinoma Cholangiocarcinoma Neuroendocrine carcinoma Liver metastases Hepatoblastoma Hemangioendothelioma

Antimicrobial management of intra-abdominal infections:Literature's guidelines

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World Journal of Gastroenterology 2012年第9期18卷 865-871页

作者： Massimo Sartelli Fausto Catena Federico Coccolini antonio daniele pinna Department of General Surgery Macerata Hospital Department of General Emergency and Transplant SurgerySant'Orsola-Malpighi University Hospital

Antimicrobial management of severe intra-abdominal infections (IAIs) involves a delicate balance of optimizing empirical therapy,which has been shown to improve clinical outcomes,while simultaneously reducing unnecessary antimicrobial *** sets of guidelines for the management of intra-abdominal infections were recently *** 2010,the Surgical Infection Society and the Infectious Diseases Society of America (SIS-IDSA) created guidelines for the diagnosis and management of complicated *** new SIS-IDSA guidelines replace those previously published in 2002 and *** World Society of Emergency Surgery (WSES) guidelines represent additional contributions,made by specialists worldwide,to the debate regarding proper antimicrobial drug *** guidelines represent the conclusions of the consensus conference held in Bologna,Italy,in July 2010 during the first congress of the WSES.

关键词： Intra-abdominal infections Antimicrobial the-rapy Literature's guidelines

Current concepts in hepatic resection for hepatocellular carcinoma in cirrhotic patients

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World Journal of Gastroenterology 2012年第44期18卷 6398-6408页

作者： Alessandro Cucchetti Matteo Cescon Franco Trevisani antonio daniele pinna General Surgery and Transplant Unit Department of General Surgery and Organ TransplantationAlma Mater StudiorumUniversity of Bologna40138 BolognaItaly Department of Clinical Medicine Semeiotica MedicaS.Orsola-Malpighi HospitalAlma Mater StudiorumUniversity of BolognaVia Massarenti 940138 BolognaItaly

Hepatocellular carcinoma(HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with liver *** resection is considered the most potentially curative therapy for HCC patients when liver transplantation is not an option or is not immediately *** review is aimed at investigating the current concepts that drive the surgical choice in the treatment of HCC in cirrhotic patients;Eastern and Western perspectives are *** extensive literature review of the last two decades was performed,on topics covering various aspects of hepatic *** post-operative and long-term outcome measures adopted were firstly analyzed in an attempt to define an optimal standardization useful for research *** need to avoid the development of post-hepatectomy liver failure represents the "conditio sine qua non" of surgical choice and the role of the current tools available for the assessment of liver function reserve were *** of hepatic resection in relationship with tumor burden were compared with those of available competing strategies,namely,radiofrequency ablation for early stages,and trans-arterial chemoembolization for intermediate and advanced ***,the choice for anatomical versus non-anatomical,as well as the role of laparoscopic approach,was *** literature review suggests that partial hepatectomy for HCC should be considered in the context of multi-disciplinary evaluation of cirrhotic *** research on HCC has moved,in recent years,from surgical therapy toward non-surgical approaches and most of the literature regarding topics debated in the present review is represented by observational studies,whereas very few well-designed randomized controlled trials are currently available;thus,no robust recommendations can be derived.

关键词： Hepatocellular carcinoma Hepatic resec-tion Surgical therapy Ablation techniques Transplan-tation Survival Liver failure

Prognostic criteria for postoperative mortality in 170 patients undergoing major right hepatectomy

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Hepatobiliary & Pancreatic Diseases International 2012年第5期11卷 507-512页

作者： Filippo Filicori Xavier M Keutgen Matteo Zanello Giorgio Ercolani Salomone Di Saverio Federico Sacchetti antonio daniele pinna Gian Luca Grazi General Surgery and Transplant Unit Department of General Surgery and Organ TransplantationUniversity of BolognaVia Massarenti 940138 BolognaItaly Department of Surgery New York Presbyterian Hospital Weill Cornell Medical College Department of Surgery New York Presbyterian HospitalWeill Cornell Medical College Department of Emergency Surgery Maggiore HospitalL.go Nigrisoli 240133 BolognaItaly Hepato-Biliary Surgery Unit Istituto Nazionale Tumori Regina ElenaVia Elio Chianesi5300144 RomaItaly

BACKGROUND: Postoperative hepatic failure is a dreadful complication after major hepatectomy and carries high morbidity and mortality rates. In this study, we assessed the accuracy of the 50/50 criteria (bilirubin >2.9 mg/dL and international normalized ratio >1.7 on postoperative day 5) and the Mullen criteria (bilirubin peak >7 mg/dL on postoperative days 1-7) in predicting death from hepatic failure in patients undergoing right hepatectomy only. In addition, we identified prognostic factors linked to intra-hospital morbidity and mortality in these patients. METHODS: One hundred seventy consecutive patients underwent major right hepatectomy at a tertiary medical center from 2000 to 2008. Nineteen (11.2%) patients suffered from liver cirrhosis. Univariate and multivariate analyses were performed to identify predictors of intra-hospital mortality, morbidity and death from hepatic failure. RESULTS: The intra-hospital mortality was 6.5% (11/170). Of the six patients who died from hepatic failure, one was positive for the 50/50 criteria, but all six patients were positive for the Mullen criteria. Multivariate analysis showed that male gender, hepatitis C (HCV), hepatocellular carcinoma, postoperative bilirubin >7 mg/dL and ALT65 years, HCV, reoperation, andrenal failure were significant predictors of overall intra-hospital mortality on multivariate analysis. CONCLUSIONS: The Mullen criteria were more accurate than the 50/50 criteria in predicting death from hepatic failure in patients undergoing right hepatectomy. A bilirubin peak >7 mg/dL in the postoperative period, HCV positivity, hepatocellular carcinoma, and an ALT level <188 U/L on postoperative day 1 were associated with death from hepatic failure in our patient population.

关键词： hepatectomy liver diseases liver failure postoperative complications prothrombin time bilirubin

Competing risk analysis on outcome after hepatic resection of hepatocellular carcinoma in cirrhotic patients

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World Journal of Gastroenterology 2017年第8期23卷 1469-1476页

作者： Alessandro Cucchetti Carlo Sposito antonio daniele pinna Davide Citterio Matteo CesconMarco Bongini Giorgio Ercolani Christian Cotsoglou Lorenzo Maroni Vincenzo Mazzaferro Department of Medical and Surgical Sciences DIMECS.Orsola-Malpighi HospitalAlma Mater StudiorumUniversity of Bologna Gastrointestinal Surgery and Liver Transplantation Fondazione IRCCS Istituto Nazionale Tumori(National Cancer Institute

To investigate death for liver failure and for tumor recurrence as competing events after hepatectomy of hepatocellular *** from 864 cirrhotic Child-Pugh class A consecutive patients, submitted to curative hepatectomy (1997-2013) at two tertiary referral hospitals, were used for competing-risk analysis through the Fine and Gray method, aimed at assessing in which circumstances the oncological benefit from tumour removal is greater than the risk of dying from hepatic decompensation. To accomplish this task, the average risk of these two competing events, over 5 years of follow-up, was calculated through the integral of each cumulative incidence function, and represented the main comparison *** a median follow-up of 5.6 years, death was attributable to tumor recurrence in 63.5%, and to liver failure in 21.2% of cases. In the first 16 mo, the risk of dying due to liver failure exceeded that of dying due to tumor relapse. Tumor stage only affects death from recurrence; whereas hepatitis C infection, Model for End-stage Liver Disease score, extent of hepatectomy and portal hypertension influence death from liver failure (P < 0.05 in all cases). The combination of these clinical and tumoral features identifies those patients in whom the risk of dying from liver failure did not exceed the tumour-related mortality, representing optimal surgical candidates. It also identifies those clinical circumstances where the oncological benefit would be borderline or even where the surgery would be *** knowledge of these competing events can be used to weigh the risks and benefits of hepatic resection in each clinical circumstance, separating optimal from non-optimal surgical candidates.

关键词： Hepatocellular carcinoma Liver failure Hepatic resection Survival Competing risk Tumour recurrence

Gastrointestinal stromal tumor and mitosis,pay attention

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World Journal of Gastroenterology 2012年第6期18卷 587-588页

作者： Federico Coccolini Fausto Catena Luca Ansaloni antonio daniele pinna General and Emergency Surgery Department Ospedali Riuniti 24128 BergamoItaly General and Transplant Surgery Department Sant'Orsola-Malpighi University Hospital24128 BolognaItaly

The difference between stages I and ]]I of gastric gas- trointestinal stromal tumor depends principally on the number of mitosis. According with TNM classification, the presence in the tumor of high mitotic rate deter- mines the upgrading. Many studies exposed different count techniques in evaluating the number of mitosis. An international standardized method to assess mitotic rate is needed.

关键词： Gastrointestinal stromal tumor Mitosis Clas-sification Gastroesophageal Enudeation