Three-dimensional bioprinted hepatorganoids prolong survival of mice with liver failure.

OBJECTIVE: Shortage of organ donors, a critical challenge for treatment of end-stage organ failure, has motivated the development of alternative strategies to generate organs in vitro. Here, we aim to describe the hepatorganoids, which is a liver tissue model generated by three-dimensional (3D) bioprinting of HepaRG cells and investigate its liver functions in vitro and in vivo. DESIGN: 3D bioprinted hepatorganoids (3DP-HOs) were constructed using HepaRG cells and bioink, according to specific 3D printing procedures. Liver functions of 3DP-HOs were detected after 7 days of differentiation in vitro, which were later transplanted into Fah-deficient mice. The in vivo liver functions of 3DP-HOs were evaluated by survival time and liver damage of mice, human liver function markers and human-specific debrisoquine metabolite production. RESULTS: 3DP-HOs broadly acquired liver functions, such as ALBUMIN secretion, drug metabolism and glycogen storage after 7 days of differentiation. After transplantation into abdominal cavity of Fah-/-Rag2-/- mouse model of liver injury, 3DP-HOs further matured and displayed increased synthesis of liver-specific proteins. Particularly, the mice acquired human-specific drug metabolism activities. Functional vascular systems were also formed in transplanted 3DP-HOs, further enhancing the material transport and liver functions of 3DP-HOs. Most importantly, transplantation of 3DP-HOs significantly improved the survival of mice. CONCLUSIONS: Our results demonstrated a comprehensive proof of principle, which indicated that 3DP-HO model of liver tissues possessed in vivo hepatic functions and alleviated liver failure after transplantation, suggesting that 3D bioprinting could be used to generate human liver tissues as the alternative transplantation donors for treatment of liver diseases.

Application of associating liver partition and portal vein ligation for staged hepatectomy for hepatocellular carcinoma related to hepatitis B virus: comparison with traditional one-stage right hepatectomy.

BACKGROUND: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has recently been suggested to cause rapid liver hypertrophy among patients having inadequate future liver remnant (FLR). However, ALPPS is still considered as a controversial hepatocellular carcinoma (HCC) treatment, especially for those with cirrhosis. This is ascribed to the high mortality and morbidity. The present study aimed to evaluate the ALPPS safety and feasibility for HCC patients related to hepatitis B virus (HBV). METHODS: This was a retrospective observational study. Consecutive HCC cases undergoing ALPPS or RH at our hospital between September 2014 and June 2018 were included. The demographic and clinical data of patients were collected, and oncological results of ALPPS patients were compared with those receiving right hepatectomy (RH). RESULTS: A total of 14 ALPPS patients and 21 RH patients were consecutively collected between September 2014 and June 2018. All ALPPS patients received stage II operations, with 100% resection of R0. The median growth of FLR between operations was 48% (range, ‒0.06% to 100%) in 17 days (range, 9-30 days). 3 ALPPS patients (21.4%) suffered from severe complications (grade ≥IIIb) according to the Clavien-Dindo grade, including 1 with renal failure, and 2 with the FLR/SLV of <30% and liver failure, and 1 (4.8%) with severe complication (liver failure) after the stage I RH. Difference in the long-term survival, either overall survival (OS) or disease-free survival (DFS), between ALPPS and RH was not statistically significant. CONCLUSIONS: Our results suggest that ALPPS should be performed in highly selected patients with cirrhosis. Patients with 30%< the FLR/SLV <30% and ages <60 years old are recommended. And a longer interval time between stages is suggested to improve the safety of ALPPS. Because the long-term survival after ALPPS is similar to that after RH, which indicates that the long waiting time between stage does not increase the risk of tumor progression.

Reassessment of different criteria for diagnosing post-hepatectomy liver failure: a single-center study of 1683 hepatectomy.

Assessing the incidence and severity of post-hepatectomy liver failure (PHLF) can be based on different criteria, and we wished to compare the diagnostic efficiency and specificity of different PHLF criteria. Data from patients (n=1683) who received hepatectomies in the liver surgery department of Peking Union Medical College Hospital from April 2008 to August 2014 were retrospectively analyzed. Possible PHLF patients were screened according to the criteria of the International Study Group of Liver Surgery (ISGLS). Subsequently, other PHLF evaluation methods, including Child-Pugh score, "50-50" criteria, Model for End-Stage Liver Disease (MELD) score, and Clavien-Dindo classification were used to assess the suspected PHLF patients, and statistical analysis was performed for correlation of these methods with clinical prognoses. Using ISGLS grading, 40 cases (2.38%) were suspected to have PHLF, among whom 5 (0.30%) patients died. Of the 40 cases there were 9 patients of ISGLS grade A, 21 of grade B, and 10 of grade C. Among the entire group, Child-Pugh scoring showed 3 patients in grade A, 35 in grade B, and 2 in grade C, while only 5 patients met the "50-50" criteria. Interestingly, MELD scores ≥11 points were found only in 3 cases. Twenty-eight patients were classified as Clavien-Dindo grade I, 8 as grade II, 3 as grade III, and 1 as grade IV. Prothrombin time on postoperative day 5 (PT5), ISGLS, and Clavien-Dindo were found to have significant correlation with the prognosis of PHLF (r>0.5, p <0.05), thus can be used as prognosis predictors for PHLF patients.

Differential Diagnosis of Immunoglobulin G4-associated Cholangitis From Cholangiocarcinoma.

BACKGROUND AND AIM: Immunoglobulin G4-associated cholangitis (IAC) shares many similar symptoms with cholangiocarcinoma (CCA). However, the treatment and the prognosis are substantially different. This study aimed to identify the important markers for the differential diagnosis of these 2 diseases. METHODS: Thirty IAC patients and 275 CCA patients were reviewed retrospectively for their clinical symptoms, serological tests, and imaging characteristics. Posttreatment responses were also studied. RESULTS: IgG4 had 100% specificity for IAC at a cutoff of 6 times the upper normal limit. IAC patients had a significantly higher incidence of weight loss (P=0.025) and a higher level of weight loss (P=0.008) than CCA patients. The positive rates of biological markers CA199, CA242, and CEA in CCA and IAC were 81.5% versus 42.9%, 45.5% versus 4.5%, and 29.2% versus 7.1%, respectively. Levels of these tumor markers in CCA were significantly higher than in IAC (P<0.05). The thickened wall [17/18 (94.4%) vs. 3/10 (30%), P=0.001] and the occupying lesion on the bile duct [1/18 (5.6%) vs. 8/10 (80%), P<0.001] were found to be significantly different in IAC and CCA, respectively, by endoscopic ultrasonography. Autoimmune pancreatitis was the most frequently observed comorbidity of IAC (25/30). All IAC patients respond positively to steroid treatment. CONCLUSIONS: Increased tumor markers, 6-fold higher levels of serum IgG4, and other organs' involvement could be the reference factors for a differential diagnosis of IAC and CCA. Endoscopic ultrasonography might be an effective imaging tool for diagnosis, although clinical signs and symptoms of IAC and CCA are similar. Experimental steroid treatment can be useful in the diagnosis for certain difficult cases.

Surgical resection improves the outcome of the patients with neuroendocrine tumor liver metastases: large data from Asia.

How to properly manage neuroendocrine liver metastasis (NELM) remains debatable, and only limited clinical data have been published from Asian population. The objective of this study is to identify possible prognostic factors affecting overall survival time and to provide a guideline for future clinical practice. A retrospective study was performed on 1286 patients who had neuroendocrine tumors in our specialized center, and data from 130 patients who had NELM were summarized. Demographic and clinicopathologic data, tumor grade, treatment method, and prognosis were statistically analyzed. Most of the NELMs originated from pancreas (65.4%). Important prognostic factors that included tumor location and size were identified with multivariate analysis. Patients with either primary tumor resection or liver metastasis resection showed a 5-year survival of 35.7% or 33.3%, respectively, whereas resection of both resulted in a 50% 5-year survival. More importantly, resection was performed on 7 patients with grade 3 (G3) tumors, and resulted in 1-year, 3-year, and 5-year survival of 100%, 42.8%, and 28.6%, respectively, whereas the other 9 G3 patients without resection died within 3 years. P = 0.49 comparing the resected group with nonresected group in G3 patients. Besides, the overall 5-year survival rates for resected and nonresected patients were 40.5% and 5.4%, respectively. Multiple prognostic factors influenced the overall outcome of NELM including patient age, tumor location, and size, etc. Aggressive surgical approaches could be considered for maximum survival time disregarding the pathological grade of the tumor. Study with larger sample size should be considered to reevaluate the recommendation of the WHO guidelines for G3 neuroendocrine tumors.

Retrospective and comparative study of inflammatory myofibroblastic tumor of the liver.

BACKGROUND AND AIM: Inflammatory myofibroblastic tumor of the liver (IMTL) is a very rare benign disease with a good prognosis. The study aims to determine the clinical, radiological, and pathological characteristics of IMTL. The diagnosis and treatment strategies were discussed. METHODS: A total of 11 patients with pathologically confirmed IMTL receiving treatment over a 15-year period were reviewed retrospectively. The analysis included demographics information and pertinent clinical data. Results obtained from patients with hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and metastatic liver cancer (MLC) receiving surgical resection were compared. RESULTS: In comparison to HCC, IHCC, and MLC, IMTL has an earlier onset (P < 0.001). IMTL patients had significantly lower aspartate aminotransferase (P = 0.003) and higher alkaline phosphatase (P = 0.034) than HCC patients, and higher gamma-glutamyl transpeptidase (P = 0.010) than MLC patients. Increased serum α-fetoprotein level was detected in only one patient. Serum α-fetoprotein was significantly lower in patients with IMTL (P = 0.000) than in those with HCC but not IHCC (P = 0.558) or MLC (P = 0.514). In contrast to elevated serum CA19-9 in patients with HCC/IHCC/MLC, the serum CA19-9 in IMTL cases was generally normal (vs HCC P = 0.008; vs IHCC P = 0.000; vs MLC P = 0.022). In nine IMTL patients, the tumor appeared as a hypoechogenic solid mass on the ultrasonography. In contrast, most patients with HCC, IHCC, or MLC showed hybrid echo. In contrast computed tomography and magnetic resonance imaging, the lesion of IMTL and MLC appeared as peripheral enhancement. CONCLUSION: Lab tests, imaging features, and patient history are helpful in the differential diagnosis of IMTL from HCC/IHCC/MLC. Surgical resection is curative for IMTL.

Using Dynamic 99mT c-GSA SPECT/CT fusion images for hepatectomy planning and postoperative liver failure prediction.

BACKGROUND: Available tools in liver surgery planning rely on the future remnant liver (FRL) volume. Inappropriate decision might be made since the same FRL volume might represent different liver functions depending on the severity of underlying liver damage. This study developed an alternative system to estimate FRL function and to predict the risk of postoperative liver failure. METHODS: Current study recruited 71 prehepatectomy patients and 71 healthy volunteers. A technetium-99-labelled asialoglycoproteins was given to participants and SPECT was used to capture the intensity of the signal, represented by uptake index (UI). The agreement between preoperative UI values, liver function tests, and Child scores were evaluated. Linear regression was used to evaluate the agreement between predicted UI for FRL and postoperative UI values. Area under the receiver operating characteristic (AUC) curve was used to evaluate the discriminative performance of UI in differentiating patient with high risk of liver failure. RESULTS: Preoperative UIs are highly correlated with Child score (P < 0.0001), especially to identify patients with ascites and elevated bilirubin. The predicted UIs were in close agreement with the actual postoperative UI values (r = 0.95 P < 0.001). The AUC analysis indicated that UI values had a high accuracy in predicting the risk of liver failure (AUC = 0.95, P < 0.0001). The best cut-off point was 0.9 and the corresponding sensitivity was 100 % and specificity was 92 %. CONCLUSIONS: The new methodology reliably estimates FRL function and predicts the risk of liver failure. It provides a visual aid for liver surgeon in surgery planning and risk assessment.

[Cellular adhesion signal transduction network of tumor necrosis factor-alpha induced hepatocellular carcinoma cells].

OBJECTIVE: To systemically explore the cellular adhesion signal transduction network of tumor necrosis factor-alpha (TNF-α)-induced hepatocellular carcinoma cells with bioinformatics tools. METHODS: Published microarray dataset of TNF-α-induced HepG2, human transcription factor database HTRI and human protein-protein interaction database HPRD were used to construct and analyze the signal transduction network. RESULTS: In the signal transduction network, MYC and SP1 were the key nodes of signaling transduction. Several genes from the network were closely related with cellular adhesion.Epidermal growth factor receptor (EGFR) is a possible key gene of effectively regulating cellular adhesion during the induction of TNF-α. CONCLUSION: EGFR is a possible key gene for TNF-α-induced metastasis of hepatocellular carcinoma.

Clinical diagnosis and treatment of alpha-fetoprotein-negative small hepatic lesions.

OBJECTIVE: We examined 103 cases over the last five years and discussed diagnosis and treatment of alpha-fetoprotein (AFP)-negative small hepatic lesions. BACKGROUND: Small hepatic lesions (less than 2 cm in diameter) usually have no typical imaging characteristics and therefore are difficult to diagnose, especially when AFP tests provide a negative result. METHODS: A total of 103 patients with AFP-negative small hepatic lesions from January 2003 to December 2008 were retrospectively reviewed. Differential diagnosis was performed by digital subtraction angiography (DSA), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI), contrast-enhanced ultrasound (CEUS), or positron emission tomography-computed tomography (PET-CT) based on the multiplicity of lesions. Ninety-four patients with suspected cancers underwent partial hepatectomy. Clinical data were collected from hospital records and follow-up questionnaires. RESULTS: Hepatocellular carcinoma (HCC) diagnostic sensitivity of DSA, DCE-MRI, CEUS and PET-CT was 88.2%, 93.9%, 88.9% and 88.9%, respectively. The surgery-related complication rate was 6.4%. Prognosis was good, with 1- and 3-year survival rates of 98.8% and 76.1%, respectively. CONCLUSIONS: DSA, DCE-MRI, CEUS and PET-CT are valuable for diagnosis of small hepatic lesions. Partial hepatectomy is a preferred surgical procedure. Surgery for small liver cancers usually has little risk and good prognosis, therefore it can be actively applied in suspected HCC cases.

Improvement of nutritional support strategies after surgery for benign liver tumor through nutritional risk screening: a prospective, randomized, controlled, single-blind clinical study.

OBJECTIVE: The rising of individualized therapy requires nutritional risk screening has become a major topic for each particular disease, yet most of the screenings were for malignancies, less for benign diseases. There is no report on the screening of patients with benign liver tumors postoperatively. We aim to evaluate the nutritional support strategies post operation for benign liver tumors through nutritional risk screening. METHODS: In this prospective, randomized, controlled study, 95 patients who underwent hepatectomy for benign tumors were divided into two groups. Fifty patients in the control group were given routine permissive underfeeding nutritional supply (75 kJ/kg/d), and 45 patients in the experimental group were given lower energy (42 kJ/kg/d) in accordance of their surgical trauma. Routine blood tests, liver/kidney function were monitored before surgery and at the day 1, 3, 5, 9 after surgery, patients were observed for the time of flatus, complications, length of hospitalization (LOH), nutrition-related costs, and other clinical parameters. This completed study is registered with Clinicaltrials.gov, number NCT01292330. RESULTS: The nutrition-related expenses (494.0±181.0 vs. 1,514.4±348.4 RMB, P<0.05) and the total hospital costs (18,495.2±4735.0 vs. 21,432.7±8,291.2 RMB, P<0.05) for patients in the experimental group were significantly lower than those in the control group. Meanwhile, the lowered energy supply after the surgeries did not have adverse effects on clinical parameters, complications, and LOH. CONCLUSIONS: Patient with benign liver tumors can adopt an even lower postoperative nutritional supply that close to that for mild non-surgical conditions, and lower than the postoperative permissive underfeeding standard.

Diagnosis and treatment of hepatic angiomyolipoma.

BACKGROUND: Hepatic angiomyolipoma (HAML) is a rare liver tumor. This paper summarized the clinical, radiological and pathological features of HAML. METHODS: Seventeen cases of HAML were analyzed retrospectively. All patients were subjected to surgical resection of tumor, one of which was performed emergency surgery because of hemorrhage of tumor. RESULTS: There are 13 females and 4 males, most of whom were asymptotic except 4 had minimal abdominal discomfort. US, CT and/or MRI were taken and corresponding data was comprehensively analyzed with other clinical signs and symptoms. Correct preoperative diagnosis was able to be achieved in 9 patients. Pathological analysis and immunohistochemistry of HMB-45 was used as final diagnosis. All patients were followed up and survived without recurrence. CONCLUSIONS: Preoperative diagnosis of HAML can be benefited from comprehensive analysis of clinical manifestations. The malignant potential and fast growth of tumor suggested surgical removal of tumor while it was diagnosed.

[Diagnosis and treatment of primary hepatic angiosarcoma: a report of 7 cases with a literature review].

OBJECTIVE: To explore the clinical features, diagnosis, treatment and prognosis of primary hepatic angiosarcoma (PHA). METHODS: The clinical data of 7 PHA patients admitted to our hospital from December 2004 to December 2010 were retrospectively analyzed and the relevant literatures reviewed. RESULTS: Seven cases (5 males and 2 females) were diagnosed as PHA among 1027 (0.68%) patients with primary hepatic malignant tumors. Their mean age was 43.3 years old (range: 33 - 74). Four cases were of solitary lesion and three of multiple lesions. No specific clinical features were observed. The PHA lesions were easily misdiagnosed as benign or hepatic metastatic tumors. Contrast enhanced ultrasound (CEUS) showed the lesions with characteristic manifestations. And the positron emission tomography (PET-CT) could confirm the hepatic lesions as malignant tumors. The survival time for two untreated cases was 3 & 5 months, for two cases with liver transplantation (LTx) 3 & 8 months and for two cases treated with surgical resection & targeted therapy was 14 & 19 months respectively. One case was lost to follow-up at 6 months after hepatic resection. CONCLUSION: PHA is a clinically rare and highly malignant tumor with a rapid progression and a poor prognosis. Both CEUS and PET-CT are helpful for its differential and confirmative diagnosis. LTx should be considered as a contraindication for PHA. Hepatic resection has proven to be beneficial for PHA patients with solitary lesion. Surgical resection plus targeted medicines may improve their survival.

The effects of urinary trypsin inhibitor on liver function and inflammatory factors in patients undergoing hepatectomy: a prospective, randomized, controlled clinical study.

BACKGROUND: The inhibition of inflammation exerts benefits following massive hepatectomy in animals but not in the clinic. The aim of this study was to investigate the effectiveness and mechanism of ulinastatin on liver function and outcomes following hepatectomy. METHODS: One hundred seventy-six patients undergoing hepatectomy were randomized into the treatment group (n = 86) and the control group (n = 90), receiving ulinastatin 150,000 U twice daily for 3 days and saline vehicle, respectively. Liver function, coagulation, thrombokinase, lymphocyte subsets CD4 and CD8, C-reactive protein, inducible nitric oxide synthase, and cytokines were measured. Clinical outcomes were also evaluated. RESULTS: Serum alanine transaminase, aspartate transferase, inducible nitric oxide synthase, and tumor necrosis factor-α levels were significantly lower after ulinastatin treatment, and the response of bilirubin was delayed. The benefits of ulinastatin were shown mainly in major hepatectomy earlier after surgery. The treatment significantly reduced hospital length of stay and recovery-related cost. CONCLUSIONS: Ulinastatin protects liver function and improves clinical outcomes, possibly via the inhibition of inflammation and oxidation at an earlier stage following major hepatectomy.

Golgi protein 73 (GOLPH2) is a valuable serum marker for hepatocellular carcinoma.

BACKGROUND AND AIMS: Golgi protein 73 (GP73) as a potential serum marker for hepatocellular carcinoma (HCC) has not been validated in large cohort studies. Furthermore, its significance in the assessment of tumour recurrence after HCC resection remains unknown. The aim of this study was to determine the value of serum GP73 in the diagnosis of HCC. METHODS: Serum GP73 and alpha-fetoprotein (AFP) were compared in a total of 4217 human subjects in this multicentre study, including 1690 healthy adults, 337 hepatitis B virus (HBV) carriers, 512 patients with cirrhosis, 789 patients with HCC, 61 patients with other malignant liver lesions, 206 patients with benign liver lesions and 622 patients with 14 different kinds of non-liver cancers. The main outcome measures were the specificity and sensitivity of GP73 in patients at risk for the development of HCC. RESULTS: Using 8.5 relative units as a cut-off value, the sensitivity and specificity of serum GP73 for HCC were 74.6% (95% CI 71.5% to 77.6%) and 97.4% (95% CI 96.8 to 98.3%), compared with 58.2% (95% CI 55.2% to 62.1%) and 85.3% (95% CI 83.4% to 88.1%) for AFP (p<0.001) using 35 ng/ml as a cut-off value. The GP73 level was significantly increased in patients with HCC compared with healthy controls (14.7 vs 1.2, p<0.001). Although GP73 levels in HBV carriers (2.9) and patients with cirrhosis (4.7) were somewhat elevated, they were much lower than that in patients with HCC (p<0.001). GP73 decreased following surgical resection of HCC lesions and increased with tumour recurrence. Fourteen types of non-liver cancers were analysed; all the benign and other malignant liver lesions had moderate elevations of GP73, albeit at a much lower level than in HCC. CONCLUSIONS: GP73 is an accurate serum marker for the detection of HCC and its recurrence after surgery, with higher sensitivity and specificity than AFP. Clinical implementation of serum GP73 measurement as a standard test for HCC is recommended.

[A survival analysis of patients with early-stage hepatocellular carcinoma fulfilling Milan criteria and undergoing hepatectomy].

OBJECTIVE: To summarize the experience of hepatectomy in patients with hepatocellular carcinoma fulfilling the Milan criteria and analyze the clinicopathological factors for patient survival and tumor recurrence. METHODS: The clinicopathological data of 104 patients with early-stage hepatocellular carcinoma fulfilling the Milan criteria and underwent hepatectomy at Peking Union Medical College Hospital between April 2003 and June 2009 were retrospectively analyzed. RESULTS: The median follow-up was 24 months. There were 54 recurrent cases. The 1-, 3- and 5-year cumulative disease-free survival rate were 63.0%, 32.6% and 22.4% respectively. Neither univariate analysis nor multivariate analysis indicated any factor significantly correlated with recurrence (P>0.05). The cumulative overall survival rate at 1, 3 and 5 years were 88.8%, 68.1% and 68.1% respectively. Univariate analysis revealed that blood transfusion (P=0.000), involvement of hepatic capsule (P=0.000) and postoperative transarterial chemotherapy (P=0.049) were significantly correlated with survival. And multivariate analysis indicated that blood transfusion (P=0.001) and involvement of hepatic capsule (P=0.000) were independent prognostic factors for survival. CONCLUSION: For the patients with early-stage hepatocellular carcinoma and compensated liver function fulfilling the Milan criteria, hepatectomy serves as the preferred treatment strategy.

A prospective clinical study on early recurrence of hepatocellular carcinoma after hepatectomy.

BACKGROUND: To determine more precisely time interval from resection to recurrence of hepatocellular carcinoma (HCC) and to identify the risk factors associated with postoperative recurrence. METHODS: From January 2004 to December 2007, 178 patients who underwent resection of HCC were followed prospectively for at least 12 months. Recurrence was identified by the digital subtraction angiography (DSA). Demographic, tumor, and disease characteristics were compared between patients with recurrence within 6 months and between 7 and 12 months, and those without recurrence to evaluate for their prognostic significance. Patients with intrahepatic recurrence were treated with trans-arterial chemoembolization (TACE) and re-assessed by CT scans, contrast-enhanced ultrasound, or MRI. RESULTS: Recurrence developed in 52 patients between 1 and 6 months, 11 patients between 7 and 12 months, and 115 patients remained disease free for at least 1 year. The recurrence rates of 6 months and 1 year were 29.2% and 35.4%, respectively. No statistically significant difference between was observed. Fourteen (22.2%) patients with recurrence and 11 (9.6%) patients without recurrence had previously presented as multifocal HCC, and the difference is of statistical significance (P = 0.025). The diagnostic accuracy of DSA as validated by other diagnostic methods was 81.8%. CONCLUSIONS: Recurrences are more likely to develop within the first 6 months after resection for HCC. Multifocal HCC is an important risk factor associated with early recurrence of advanced HCC after hepatectomy. DSA may serve as an important surveillance for early detection of intrahepatic recurrence after surgery.