Increased duration of dual pegylated interferon and ribavirin therapy for genotype 1 hepatitis C post-liver transplantation increases sustained virologic response: a retrospective review

In patients with advanced post-transplant hepatitis C virus [HCV] recurrence, antiviral treatment [AVT] with interferon and ribavirin is indicated to prevent graft failure. The aim of this study was to determine and report Canadian data with respect to the safety, efficacy, and spontaneous virologic response [SVR] predictors of AVT among transplanted patients with HCV recurrence. A retrospective chart review was performed on patients transplanted in London, Ontario and Edmonton, Alberta from 2002 to 2012 who were treated for HCV. Demographic, medical, and treatment information was collected and analyzed. A total of 85 patients with HCV received pegylated interferon with ribavirin post-liver transplantation and 28 of the 65 patients [43%] with genotype 1 achieved SVR. Of the patients having genotype 1 HCV who achieved SVR, there was a significantly lower stage of fibrosis [1.37 +/- 0.88 vs. 1.89 +/- 0.96; P = 0.03], increased ribavirin dose [total daily dose 1057 +/- 230 vs. 856 +/- 399 mg; P = 0.02], increased rapid virologic response [RVR] [6/27 vs. 0/31; P = 0.05], increased early virologic response [EVR]28/28 vs. 18/35; P = 0.006], and longer duration of therapy [54.7 +/- 13.4 weeks vs. 40.2 +/- 18.7; P = 0.001]. A logistic regression model using gender, age, RVR, EVR, anemia, duration of therapy, viral load, years' post-transplant, and type of organ [donation after cardiac death vs. donation after brain death] significantly predicted SVR [P < 0.001], with duration of therapy having a significant odds ratio of 1.078 [P = 0.007]. This study identified factors that predict SVR in HCV-positive patients who received dual therapy post-transplantation. Extending therapy from 48 weeks to 72 weeks of dual therapy is associated with increased SVR rates. Future studies examining the role of extended therapy are needed to confirm these findings, since the current study is a retrospective one

safety and efficacy of gastric fundal variceal obliteration using N-butyl-2-cyanoacrylate; the experience of a single Canadian tertiary care centre

Bleeding from Gastric Varices [GV] is not only life threatening, but also leads to many hospitalizations, contributes to morbidity and is resource intensive. GV are difficult to diagnose and their treatment can be challenging due to their location and complex structure. To assess the safety and efficacy of endoscopic gastric fundal variceal gluing using periodic endoscopic injections of N-butyl-2-cyanoacylate [NBCA] and to assess the utility of endoscopic ultrasound [EUS] in assessing for the eradication of GV post-NBCA treatment. Analysis of prospectively collected data of a cohort of patients with GV who underwent periodic endoscopic variceal gluing from 2005 to 2011. Outcomes included success of GV obliteration, incidence of rebleeding, complications from the procedure, and analysis of factors that might predict GV rebleeding. The success of GV eradication was assessed by both EUS and direct endoscopy. The cohort consisted of 29 consecutive patients that had undergone NBCA injection for GV. The mean age was 60.8 years standard deviations [SD 13.3, range 20-81]. The average follow-up was 28 months [SD 19.61, range 1-64] and the most common cause for GV was alcoholic liver cirrhosis [34.48%]. A total of 91 sessions of NBCA injections were carried out for 29 patients [average of 3.14 sessions/patient, SD 1.79, range 1-8] with a total of 124 injections applied [average of 4.28 injections/patient, SD 3.09, range 1-13]. 24 patients were treated for previously documented GV bleeding while five were treated for primary prevention. Overall, 79% of patients were free of rebleeding once three sessions of histoacryl[registered sign] injection were completed. None of the patients treated for primary prevention developed bleeding during follow-up. 11 of the 24 patients [46%] with previous bleeding however had rebleeding. 4/11 [36%] patients had GV rebleeding while awaiting scheduled additional NBCA sessions. 19/29 [60%] patients had complete eradication of GV, 11/19 [58%] documented by endoscopic assessment alone, 4/19 [21%] by EUS alone and 4/19 [21%] by both techniques. Two of the 11 [18%] patients that had rebleeding had recurrence of GV bleeding after documented eradication by EUS compared to 5/11 [45%] patients documented eradication by endoscopic assessment and 2/11 [18%] patients that had rebleeding after documented eradication by both modalities. Twenty five patients in total had documented residual GV by EUS [14, 56%], direct endoscopic assessment [18, 72%] or both modalities [9, 36%], two of which developed recurrent bleeding [13%]. No immediate or long-term complications of NBCA injection occurred, nor any related endoscopic complications were reported in any of these cases during the time of follow-up. NBCA injection of GV is a safe and successful therapeutic intervention. A minimum of three endoscopic sessions is required to significantly decrease the risk of bleeding/rebleeding. In this small sample of patients, neither EUS nor direct endoscopic assessment was reliable in predicting the recurrence of GV bleeding

Hepatic metastasis from adrenocortical carcinoma fifteen years after primary resection

We report the case of a 73-year-old man who presented with an asymptomatic hepatic mass during investigation of mild chronic obstructive pulmonary disease by a plain chest radiograph, followed by ultrasonography, which revealed a solitary hepatic lesion measuring 7.1 cm x 6.5 cm x 5.8 cm in dimension. Fine- needle aspiration of the mass revealed malignant cells compatible with hepatocellular carcinoma. Interestingly, the patient had a left adrenalectomy and complete left nephrectomy in 1987, for a non-functioning left adrenocortical carcinoma [ACC]. The ACC was diagnosed as stage two, with no evidence of local invasion or distant metastases. No adjuvant therapy was recommended postoperatively. After a five-year follow-up, there was no evidence of ACC recurrence and the patient was declared cured from his ACC. The patient underwent a complete segmental resection of the right lobe of the liver successfully. The final diagnosis of the mass was a well-differentiated metastatic adrenocortical carcinoma