Carcinoma hepatocelular en el anciano: características clínicas, análisis de supervivencia y factores pronósticos en una cohorte de pacientes españoles mayores de 75 años / No disponible

Objetivos: el carcinoma hepatocelular (CHC) permanece malcaracterizado en pacientes de edad avanzada y comorbilidad, circunstanciaque limita su manejo clínico. Pretendemos analizar lahistoria natural del CHC en mayores de 75 años y determinar losfactores que condicionan su supervivencia.Pacientes y métodos: análisis retrospectivo de 235 pacientescon CHC categorizados según su edad al diagnóstico: ≤ 75 años (n= 186) y > 75 años (n = 49). Tras comparar sus variables clínicas(χ2 y t-Student), realizamos un análisis de regresión logística para determinarlos factores asociados a la recepción de tratamiento locorregional(vs. sintomático); la supervivencia entre ambos grupos fuecomparada mediante el test de log-rank, con posterior análisis multivariante(modelo de riesgos proporcionales de Cox).Resultados: no se obtuvieron diferencias entre ambos gruposen su distribución por sexo, presencia de cirrosis, etiología, Child-Pugh, estadio BCLC, ascitis, trombosis portal, o valores de bilirrubina,AST, ALT, γGT, LDH o hematocrito. Los pacientes de edadavanzada fueron más frecuentemente diagnosticados en presenciade manifestaciones clínicas, con enfermedad multifocal, no localizada,y niveles de α-fetoproteína > 400 ng/ml (todas, p < 0,05). Estegrupo recibió tratamiento exclusivamente sintomático en el 78% delos casos (vs. 33% entre pacientes jóvenes), y sólo tres de ellos fueronsometidos a resección (p < 0,0001). La edad > 75 años actuócomo predictor de la no recepción de terapia locorregional (p <0,0001). La supervivencia del grupo de mayor edad (9,8 ± 1 meses)difirió significativamente respecto a la de los pacientes más jóvenes(25,6 ± 2 meses) (p < 0,00001). En el análisis multivariante, la edadavanzada se mantuvo como factor pronóstico de pobre supervivencia(p = 0,025); sin embargo, pierde su significación al estratificar dichoanálisis por sub-grupos de tratamiento (p = 0,344).Conclusiones: la menor supervivencia demostrada en pacientesancianos con CHC, al margen de diferencias en cuanto a extensióntumoral o insuficiencia hepatocelular, parece condicionada por la aplicaciónde abordajes terapéuticos subóptimos en esta población

Aims: hepatocellular carcinoma (HCC) remains poorly characterizedin elderly patients with comorbid conditions, a fact thatlimits the clinical management of the disease. This study analyzesthe natural history of HCC in patients older than 75, and determinesfactors that condition their survival.Patients and methods: a retrospective analysis of 235 patientswith HCC divided into 2 groups by age at diagnosis: ≤ 75(n = 186) and > 75 (n = 49). After comparing their clinical variables(χ2 and t test), a logistic regression analysis was performed todetermine factors associated with receiving locoregional treatment(versus symptomatic treatment). Survival in the 2 groups wascompared using a log rank test with subsequent multivariateanalysis (Cox proportional hazards model).Results: there were no differences between groups for sex,presence of cirrhosis, etiology, Child-Pugh score, BCLC stage,presence of ascites or portal thrombosis, or bilirubin, AST, ALT,γGT, LDH or hematocrit values. Patients of advanced age weremore frequently diagnosed in the presence of clinical manifestations,and had multifocal, non-localized disease and α-fetoproteinlevels > 400 ng/mL (all p < 0.05). This group received exclusivelysymptomatic treatment in 78% of cases (compared to 33% inyounger patients), and only 3 of them underwent surgical resection(p < 0.0001). Age older than 75 was a predictive factor fornot receiving locoregional therapy (p < 0.0001). Survival in theelderly group (9.8 ± 1 months) differed substantially from that ofyounger patients (25.6 ± 2 months) (p < .00001). Advanced agecontinued to be a prognostic factor of poor survival in the multivariateanalysis (p = 0.025), but lost significance when the analysiswas stratified by treatment subgroups (p = 0.344).Conclusions: the lower survival seen in elderly patients withHCC, beyond differences in tumor extension or liver failure, seemsconditioned by the use of suboptimal treatment in this population

[Hepatocellular carcinoma in the elderly: clinical characteristics, survival analysis, and prognostic indicators in a cohort of Spanish patients older than 75 years]. / Carcinoma hepatocelular en el anciano: características clínicas, análisis de supervivencia y factores pronósticos en una cohorte de pacientes españoles mayores de 75 años.

AIMS: Hepatocellular carcinoma (HCC) remains poorly characterized in elderly patients with comorbid conditions, a fact that limits the clinical management of the disease. This study analyzes the natural history of HCC in patients older than 75, and determines factors that condition their survival. PATIENTS AND METHODS: A retrospective analysis of 235 patients with HCC divided into 2 groups by age at diagnosis: < or = 75 (n = 186) and > 75 (n = 49). After comparing their clinical variables (chi2 and t test), a logistic regression analysis was performed to determine factors associated with receiving locoregional treatment (versus symptomatic treatment). Survival in the 2 groups was compared using a log rank test with subsequent multivariate analysis (Cox proportional hazards model). RESULTS: There were no differences between groups for sex, presence of cirrhosis, etiology, Child-Pugh score, BCLCancer stage, presence of ascites or portal thrombosis, or bilirubin, AST, ALT, gammaGT, LDH or hematocrit values. Patients of advanced age were more frequently diagnosed in the presence of clinical manifestations, and had multifocal, non-localized disease and alpha-fetoprotein levels > 400 ng/mL (all p < 0.05). This group received exclusively symptomatic treatment in 78% of cases (compared to 33% in younger patients), and only 3 of them underwent surgical resection (p < 0.0001). Age older than 75 was a predictive factor for not receiving locoregional therapy (p < 0.0001). Survival in the elderly group (9.8 +/- 1 months) differed substantially from that of younger patients (25.6 +/- 2 months) (p < .00001). Advanced age continued to be a prognostic factor of poor survival in the multivariate analysis (p = 0.025), but lost significance when the analysis was stratified by treatment subgroups (p = 0.344). CONCLUSIONS: The lower survival seen in elderly patients with HCC, beyond differences in tumor extension or liver failure, seems conditioned by the use of suboptimal treatment in this population.

Pérdida del injerto en trasplante hepático. Estudio anatomoclínico de 131 injertos fracasados en la primera década (1986-1996) del programa del hospital 12 de octubre / Graft loss in liver transplantation: pathological and clinical study of 131 graft failures during the first decade (1986-1996) of the liver transplant program at Hospital 12 de Octubre

Introducción. Existen diversas complicaciones que pueden conducir a la pérdida del injerto hepático (por retrasplante o fallecimiento). Los objetivos del presente trabajo son conocer las complicaciones morfológicas que se desarrollan en estos injertos fracasados y determinar cuáles son las causas de fracaso más relevantes en esta terapéutica. Pacientes y métodos. En el Hospital 12 de Octubre (Madrid) se realizaron 494 trasplantes hepáticos entre 1986 y 1996. Su indicación más frecuente fue la cirrosis (criptogénica, alcohólica y por hepatitis C). En 61 pacientes se indicó retrasplante. En 22 se realizó un segundo retrasplante y en dos un tercer retrasplante. En 56 pacientes fallecidos (40 por ciento de los fallecimientos del programa) se realizó autopsia. Un total de 131 injertos fracasados (75 obtenidos en el retrasplante y 56 tras autopsia) fueron estudiados morfológicamente de forma protocolizada. Las causas de fracaso fueron establecidas tras la oportuna correlación anatomoclínica. Resultados. En 109 injertos las lesiones hepáticas explicaban su fracaso. El rechazo crónico (31 por ciento), las alteraciones circulatorias (31 por ciento) y el fallo primario (16 por ciento) fueron las causas hepáticas de fracaso más frecuentes. Las alteraciones circulatorias fueron infartos, necrosis isquémicas parenquimatosas zonales y/o colangitis isquémicas, no siempre asociadas a lesiones vasculares del injerto. En los injertos con fallo primario se observaron lesiones isquémicas parenquimatosas con algunas características similares a las de los injertos con alteraciones circulatorias. La causa más común de muerte fue la sepsis (46 por ciento), frecuentemente asociada a alteraciones circulatorias. La causa más frecuente de retrasplante fue el rechazo crónico (40 por ciento; 75 = 100 por ciento), seguido de las alteraciones circulatorias (27 por ciento) y del fallo primario (21 por ciento). Sin embargo, la incidencia de rechazo crónico decreció de manera muy notable en el segundo lustro de la década estudiada, cediendo su puesto a las alteraciones circulatorias como primera causa de fracaso. Conclusiones. Tras el descenso del rechazo crónico del injerto como causa de su fracaso, se requiere mejorar el control de los factores favorecedores de cualquier forma de isquemia en el injerto para continuar reduciendo el número de injertos fracasados (AU)

[Nodular regenerative hyperplasia of the liver associated with a CREST syndrome with multiorgan involvement]. / Hiperplasia nodular regenerativa hepática asociada a síndrome CREST con afección multivisceral.

A 52 year old woman with CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal hypomotility and telangiectasia) and visceral involvement of the kidneys, lungs and liver is presented. The hepatic implication was a focal nodular hyperplasia of the liver which is a component not frequently recognized. Another 4 cases of this syndrome, associated to different forms of scleroderma, were described previously. Because of the way in which this case developed, this disease should be suspected when alkaline phosphatase and gamma-glutamyltranspeptidase levels are elevated. We comment on the utility of the laparoscopy and liver biopsy in diagnosing the diseased and the situation found. Finally, we discuss the pathogenic implications of the disease with scleroderma, owing to the vascular mechanism.

Inflammatory fibroid polyps of the gastrointestinal tract. An immunohistochemical and electron microscopic study.

Seven cases of inflammatory fibroid polyp (IFP) are studied, two of them with electron microscopy. The morphologic findings suggest a myofibroblastic origin for the proliferating cells. Other histogenetic hypothesis which propose a neural or vascular nature for this lesion are ruled out. The ultrastructural features of the proliferating cells are different from schwann and endothelial cell tumors. Moreover, the immunohistochemical technique to detect Factor VIII related antigen was negative in the intercapillary cells of the seven cases. Our conclusion is that inflammatory fibroid polyp of the gastrointestinal tract represent a reactive lesion of myofibroblastic nature.

Hepatocellular carcinoma. A study of 50 autopsy cases with detection of hepatitis B surface antigen in fixed tissues.

Fifty patients who died of hepatocellular carcinoma (HCC) were autopsied at the Ciudad Sanitaria "1 degree de Octubre" and the Hospital de la Cruz Roja (Madrid) from 1974 to 1980. Formalin fixed paraffin-embedded autopsy tissue of liver and tumor from the 50 HCC and liver tissue from 50 liver cirrhosis (LC) and from 50 autopsy of non cirrhotic control cases were examined for the presence of cytoplasmic hepatitis B surface antigen (HBsAg). The study was carried out using orcein staining, immunoperoxidase technique (IP) and indirect immunofluorescence (IF). In livers with HCC the HBsAg was detected in the cytoplasm of the hepatocytes in 10 cases (20%) with the orcein staining and in 11 (22%) with the IP and IF techniques. In one case (2%) HBsAg was found in the cytoplasm of tumor cells with the three methods--In four cases (8%) of LC and 2 (4%) control cases cytoplasmic positive cells were found. In 41 patients with HCC HBsAg was studied in the serum by radio-immunoassay (RIA) (13 cases) and immunodiffussion (28 cases). 5 patients (12,1%) were positive and 36 (72%) were negative. In the 5 serum positive HBsAg HCC the staining methods for cytoplasmic HBsAg were positive (100%). In 36 serum negative HBsAg HCC the staining method were positive in 2 cases. The results let us to conclude that HBV is a probable important etiologic factor of HCC in our milieu. 54% of the patients with HCC had a previous history of alcohol abuse; however, histologic features compatible with an alcoholic etiology were found in only 5 cases. Nevertheless we consider that the described histopathologic findings do not exclude excess alcohol consumption as a possible etiologic factor for HCC in our series.