Thrombotic Ringed Polytetrafluoroethylene Graft With Infection After Living-Donor Liver Transplantation.

BACKGROUND: The safety of the living donor in living-donor liver transplantation (LDLT) is always the first priority, meanwhile, the graft-to-recipient weight ratio (GRWR) and the anatomy of the liver allograft must also not be compromised in order to warrant tranplatation success. When it comes to the allograft of the right lobe of the liver without the middle hepatic vein (R-M), the outflow and adequate drainage for the territory of middle hepatic vein (MHV) is one critical concern. Despite publications in some high-volume transplant centers on the positive results of using expanded polytetrafluoroethylene (ePTFE) grafts to substitute those of autologous veins, complications related to the ePTFE graft have not been well discussed. METHODS: From July 2012 to June 2016, 129 adult patients who underwent living donor liver transplantation in Taipei Veterans General Hospital were analyzed. There were 3 cases of adjacent organ erosion with gas bubbles in the lumen of an ePTFE graft, including gastrointestinal (GI) tract penetration in 2 out of the first 15 cases that used the venous graft of ringed expanded polytetrafluoroethylene (rPTFE). The patient survival rate during this period was compared and radiological findings of rPTFE function and clinical signs of erosion with infection were also examined to raise the concerns of safety as well as early detection of complications of rPTFE. RESULTS: The overall 1-year patient survival rate was 90%, of which the right lobe wih MHV (R+M) group was 93.5% and the R-M group was 91.9%. For the mean of GRWR, the R+M group was 1.05 ± 0.19 and R-M group was 1.19 ± 0.27, while those who needed reconstruction with vein grafts was 0.96 ± 0.11. Among the R-M group, 24 out of 88 cases (27.3%) needed reconstruction of MHV tributaries. Of the 24 cases, 15 cases were done with rPTFE and the 1-year patient survival rate of the rPTFE group was 73%, which is significantly worse (P = .008) than the non-rPTFE (89%) and non-reconstructed (97%) groups. The mean GRWR is significantly higher (P = .001) in the non-reconstructed group (1.19 ± 0.27) than in the rPTFE (0.99 ± 0.11) and non-rPTFE (0.94 ± 0.11) groups. The venous grafts patency rate between the different graft types is no different, and there is also significance in warm ischemic time (P = .009) between the non-reconstructed (49 ± 15), rPTFE (81 ± 51), and non-rPTFE (56 ± 18) groups in the mean minutes. CONCLUSION: In cases of fever of unknown cause in patients receiving LDLT with rPTFE graft, a regular computed tomography (CT) scan with contrast and gas bubbles within the graft lumen is the best way for early detection of graft related infection and suspicious GI tract penetration. To decrease the risks of tissue reaction induced by ePTFE graft in LDLT, omentum patches or other inert agents can be introduced as a buffer between the graft and adjacent organs, especially the GI tracts. However, research in material science shall be explored to solve the problem in the future.

Comparison of Two Devices for Intraoperative Portal Venous Flow Measurement in Living-Donor Liver Transplantation: Transit Time Ultrasound and Conventional Doppler Ultrasound.

BACKGROUND: Intraoperative portal venous flow measurement provides surgeons with instant guidance for portal flow modulation during living-donor liver transplantation (LDLT). In this study, we compared the agreement of portal flow measurement obtained by 2 devices: transit time ultrasound (TTU) and conventional Doppler ultrasound (CDU). METHODS: Fifty-four recipients of LDLT underwent intraoperative measurement of portal flow after completion of vascular anastomosis of the implanted partial liver graft. Both TTU and CDU were used concurrently. Agreement of TTU and CDU was assessed by intraclass correlation coefficient using a model of 2-way random effects, absolute agreement, and single measurement. A Bland-Altman plot was applied to assess the variability between the 2 devices. RESULTS: The mean, median, and range of portal venous flow was 1456, 1418, and 117 to 2776 mL/min according to TTU; and 1564, 1566, and 119 to 3216 mL/min according to CDU. The intraclass correlation coefficient of portal venous flow between TTU and CDU was 0.68 (95% confidence interval, 0.51-0.80). The Bland-Altman plots revealed an average variation of 4.8% between TTU and CDU but with a rather wide 95% confidence interval of variation ranging from -57.7% to 67.4%. CONCLUSIONS: Intraoperative TTU and CDU showed moderate agreement in portal flow measurement. However, a relatively wide range of variation exists between TTU and CDU, indicating that data obtained from the 2 devices may not be interchangeable.

Isolated Crystalloid Podocytopathy With Focal Segmental Glomerulosclerosis in Renal Allograft: An Unusual Presentation of Post-Transplant Monoclonal Gammopathy of Renal Significance-A Case Report.

BACKGROUND: Monoclonal gammopathy of renal significance denotes a spectrum of hematologic disorders that cause direct or indirect renal damage. CASE PRESENTATION: A 51-year-old man had received a living-donor kidney transplant from his wife in 2008. He had gradual increased proteinuria 4 years later. His renal biopsy results revealed cytoplasmic crystalloid inclusions in the podocytes. No crystalloid inclusion was found in other renal cells. Despite that immunofluorescent examination failed to show light-chain deposition, the serum immuno-electrophoresis revealed monoclonal immunoglobulin-Gκ. Bone marrow biopsy showed interstitial infiltration of plasma cells of approximately 10%. A follow-up renal biopsy was performed in 2016. Light microscopy showed focal segmental glomerulosclerosis. The immunofluorescent examination remained negative for light chain, but κ-light chain could be demonstrated after antigen retrieval. Similar to previous biopsy results, cytoplasmic inclusions were found only in podocytes without involving other renal cells. CONCLUSIONS: To the best of our knowledge, this is the first report of monoclonal gammopathy of renal significance presenting as isolated crystalloid podocytopathy in the allograft kidney. The mechanism of preferential podocyte deposition of crystalloid immunoglobulin remains unclear. The inherent features of crystalloid podocytopathy may mislead the pathologic diagnosis.

How to Improve the Positive Predictive Value of Urinary Decoy Cell Surveillance for Polyomavirus BK-Associated Nephropathy in Kidney Transplant Patients.

BACKGROUND: Polyomavirus BK-associated nephropathy (BKVN) has been a serious problem after kidney transplantation. Detection of urinary decoy cells (UDCs) and assessment of polyomavirus BK nucleic acids by polymerase chain reactions (PCRs) are currently used, noninvasive tests. PCRs have better positive predictive value (PPV) but higher cost and lower accessibility. This study investigated ways to improve the PPV of UDCs for BKVN prediction. METHODS: From 2000 to 2013, kidney transplant recipients with sustained UDCs for more than half a month and who had received allograft biopsies were enrolled. We analyzed the PPV of UDCs for BKVN with 2 variables: (i) the percentage changes in serum creatinine (SCr) levels and (ii) the duration of sustained UDCs by receiver operating characteristic (ROC) curve analysis; we predicted the percentage changes in SCr levels with the corresponding PPV using a linear regression model. RESULTS: BKVN was diagnosed in 26 of 68 enrolled patients. The percentage changes in SCr levels significantly deteriorated in the BKVN group during 1-2 months of UDC positivity. According to ROC curve analysis, percentage changes in SCr levels had a significant discriminating power for BKVN during 1-1.5 month, and if the percentage changes in SCr levels were >19%, the PPV of UDCs for BKVN was 50%. CONCLUSIONS: An UDC surveillance program is a judicious strategy to predict BKVN in kidney transplant patients, particularly when graft renal function shows deterioration after 1 month of UDC positivity.

Incidence and Risk Factors for Tuberculosis After Liver Transplantation in an Endemic Area: A Nationwide Population-Based Matched Cohort Study.

Morbidity and mortality from tuberculosis (TB) are high in Taiwan. We conducted a nationwide population-based matched cohort study using data retrieved from the Taiwan's National Health Insurance Research Database to determine the impact of TB after liver transplantation (LT). During 2000-2011, we identified 3202 liver transplant recipients and selected subjects from the general population matched for age, sex, and comorbidities on the same index date of recognition of LT with a 1:10 ratio. The data were analyzed using Cox proportional hazards models. Compared to the matched cohort, liver transplant patients had a higher risk for TB (adjusted HR 2.25, 95% CI 1.65-3.05, p < 0.001), and those with TB showed higher mortality (HR 2.27, 95% CI 1.30-3.97, p = 0.004). Old age (HR 2.64, 95% CI 1.25-5.54, p = 0.011) and mammalian target of rapamycin inhibitors (mTORis) (HR 3.09, 95% CI 1.68-5.69, p < 0.001) were significant risk factors for TB in LT; mTORis were also associated with mortality after adjusting for confounders (HR 2.13, 95% CI 1.73-2.62, p < 0.001). Therefore, regular surveillance of TB and treatment of latent TB infection in high-risk patients after LT are important, especially in TB-endemic areas.

Extracorporeal membrane oxygenation as treatment for acute respiratory failure and subsequent pneumothorax caused by Pneumocystis jirovecii pneumonia in a kidney transplant recipient.

Acute respiratory failure (ARF) accompanied by pneumothorax caused by Pneumocystis jirovecii pneumonia (PJP) is often fatal. We present our experience using extracorporeal membrane oxygenation as treatment for ARF and subsequent pneumothorax caused by PJP in a kidney transplant recipient.

New-onset diabetes mellitus in cyclosporine-treated organ transplant patients in Taiwan: interim analysis (6 months) of postmarketing surveillance.

Posttransplant new-onset diabetes mellitus (NODM) is an important complication among patients receiving immunosuppressants. It has a considerable impact on chronic allograft dysfunction. Calcineurin inhibitors have been implicated in the development of posttransplant NODM. Since high-risk candidates also undergo transplantation, prevention and control of posttransplant NODM is important. A 3-year postmarketing surveillance study is currently underway in Taiwan to evaluate the incidence and risk factors leading to development of NODM among de novo and maintenance solid-organ transplant patients receiving cyclosporine (CsA)-based immunosuppressive therapy. Concomitant therapy consisted of basiliximab, mycophenolate mofetil or enteric-coated mycophenolate sodium, and corticosteroids. Diabetes was diagnosed according to the American Diabetes Association criteria. This 6-month protocol-defined interim analysis included 101 patients (84 de novo, 17 maintenance) who received renal (n = 77), liver (n = 13), or heart (n = 11) transplantation. At the end of 6 months, 8/101 (7.92%) patients experienced NODM. The mean time to NODM was 3.05 months. No significant difference was observed between NODM and non-NODM patients for risk factors: age, body mass index, blood pressure, gender, high-density lipoproteins/triglycerides hdl/tg, and anti-hepatitis C virus. The composite endpoint of biopsy-proven acute rejection, graft loss, or death was reached in four patients, with a mean time to event of 3.81 months. Infections were noted in 34 subjects but, no malignancies. Among 389 adverse events reported in 91 patients (90.1%), the majority were of mild to moderate severity. Two deaths were reported: heart transplant recipients with acute rejection and cytomegalovirus meningitis with respiratory failure. Long-term enrollment with follow-up evaluation of these NODM patients up to 3 years will help evaluate the NODM incidence rates and exact graft survival and overall survival rates of CsA-treated transplant patients in Taiwan.

Hepatic venous congestion after living donor liver transplantation: quantitative assessment of liver stiffness using shear wave elastography--a case report.

We report a 49-year-old right lobe liver transplant recipient, who developed a significant anastomotic stenosis of the right hepatic vein shortly thereafter. Shear wave elastography (SWE) was applied to investigate liver stiffness quantitatively. It showed increased stiffness in the anterior compared with the posterior segment of right lobe graft. The stenotic right hepatic venous anastomosis was then managed by angioplasty with stent placement. SWE after angioplasty showed a gradual decrease in stiffness of the anterior segment, which was almost equal to the posterior segment at 2 weeks thereafter. Our experience suggested that SWE may be a noninvasive tool to assess alterations in liver stiffness secondary to hepatic venous congestion after liver transplantation.

Early postoperative spectral Doppler parameters of renal transplants: the effect of donor and recipient factors.

BACKGROUND: The objective of this study was to explore the donor and recipient factors related to the spectral Doppler parameters of the transplant kidney in the early posttransplantation period. METHODS: This retrospective study included 76 patients who underwent renal transplantation assessed using Doppler ultrasonography (US) on the first postoperative day. We compared spectral Doppler parameters (peak systolic velocity [PSV] and resistive index [RI]) of the segmental artery of the transplant kidney according to the type of renal transplant, level of serum creatinine (SCr) of donor prior to organ donation, and donor/recipient age. RESULTS: RI was significantly higher in deceased-donor kidney transplantation (DDKT) as compared with living-donor kidney transplantation (LDKT; 0.73 ± 0.10 vs 0.66 ± 0.11; P = .007). In the DDKT recipients, multivariate analysis showed donor SCr was the only factor affecting PSV (P = .023), whereas recipient age was the only factor affecting RI (P = .035). In the LDKT recipients, multivariate analysis showed recipient age was the only factor affecting both PSV (P = .009) and RI (P = .018). CONCLUSION: Spectral Doppler parameters in the early posttransplantation period are related to the type of renal transplant, donor renal function, and recipient age. These factors should be taken into consideration when interpreting the results of spectral Doppler US.

Results of kidney transplantation from high-terminal creatinine donors and the role of time-zero biopsy.

BACKGROUND: Deceased-donor kidney transplantation (DDKT) from high-terminal creatinine donors is associated with lower graft survival. These kidneys may be considered for discarding, worsening the organ shortage crisis. Using time-zero biopsy for histologic evaluation of these kidneys, we identified those organs eligible for transplantation, seeking to achieve better graft utility with comparable outcomes. METHODS: From April 2004 to April 2008, 55 patients underwent DDKT. A time-zero biopsy was used to examine glomerulosclerosis, interstitial fibrosis, tubular atrophy, and arteriolar narrowing. A scoring system was used to determine a discard. RESULTS: Twenty-five patients received DDKT from donors whose terminal creatinine levels were >2.0 mg/dL (high terminal creatinine, HTC group) and 30 from donors whose terminal creatinine levels were <2.0 mg/dL (low terminal creatinine, LTC group). Patients who accepted kidneys from HTC donors had shorter waiting times (P = .011) but a higher incidence of delayed graft function after transplantation (P < .001). Nonetheless, 5-year graft survival rates were similar between the two groups. CONCLUSIONS: With a time-zero biopsy for histologic evaluation, kidneys recovered from high-terminal creatinine donors can be transplanted to overcome the organ shortage while achieving reasonable graft survival.

Thromboelastography-guided transfusion decreases intraoperative blood transfusion during orthotopic liver transplantation: randomized clinical trial.

OBJECTIVE: To test in a prospective randomized study the hypothesis that use of thromboelastography (TEG) decreases blood transfusion during major surgery. MATERIAL AND METHODS: Twenty-eight patients undergoing orthotopic liver transplantation were recruited over 2 years. Patients were randomized into 2 groups: those monitored during surgery using point-of-care TEG analysis, and those monitored using standard laboratory measures of blood coagulation. Specific trigger points for transfusion were established in each group. RESULTS: In patients monitored via TEG, significantly less fresh-frozen plasma was used (mean [SD], 12.8 [7.0] units vs 21.5 [12.7] units). There was a trend toward less blood loss in the TEG-monitored patients; however, the difference was not significant. There were no differences in total fluid administration and 3-year survival. CONCLUSION: Thromboelastography-guided transfusion decreases transfusion of fresh- frozen plasma in patients undergoing orthotopic liver transplantation, but does not affect 3-year survival.

Changes in mitochondrial respiratory enzyme activity after ischemia-reperfusion injury in living-donor liver transplantation.

BACKGROUND: Ischemia-reperfusion (I-R) injury plays an important role in the immediate graft function in living-donor liver transplantation (LDLT). There is growing evidence that mitochondria play a pivotal role in I-R injury. Our aim was to evaluate changes in mitochondrial respiratory enzyme activities after I-R injury in LDLT. METHODS: Specimens from 8 donor recipient pairs enrolled in this study were obtained from the donor livers before harvest (before I-R injury) and after vascular anastomosis in the recipient (after I-R injury). Histidine-tryptophan-ketoglutarate solution was used to perfuse the organ during the cold ischemic period between harvesting and transplantation. We correlated changes in mitochondrial respiratory enzyme complex activity (succinate cytochrome c reductase [SCCR]; NADH cytochrome c reductase [NCCR]) after I-R injury with clinical data and graft status. RESULTS: NCCR and SCCR activities did not uniformly decrease after I-R injury. Two of 8 recipients experienced graft dysfunction after transplantation. The decrease in neither NCCR nor SCCR activity correlated with graft dysfunction in these 2 patients. Among the clinical factors, grafts from older donors tended to show decreased NCCR activity after I-R injury. CONCLUSIONS: In this study, changes in mitochondrial respiratory enzyme activity failed to predict the severity of I-R injury in LDLT. The organ preservation solution may play a protective role on mitochondrial respiratory enzymes during I-R injury.

HBsAg(+) donor as a kidney transplantation deceased donor.

BACKGROUND: The organ shortage and high prevalence of hepatitis B (HB) infection in the general population are important issues in Taiwan. It is difficult for us to abandon HBsAg(+) donors. Hereby we present our experience transplanting kidneys from deceased donors with HB virus infection. METHODS: From November 1977 to March 2007, 21 patients with end-stage renal disease received kidney grafts from 12 HBsAg(+) deceased donors (3.92% of 306 donors). One of the 12 donors was hepatitis Be antigen (HBeAg) (+), and 5 displayed antibody to hepatitis core antigen (anti-HBc) (+). Four of the 21 recipients were HBsAg(+) before transplantation. RESULTS: Four HBsAg(+) recipients remained surface antigen positive after transplantation. One of them died of an intracranial hemorrhage. Two (11.76%) of the other 17 HBsAg(-) recipients became HBsAg(+), 1 of whom died of hepatic failure and the other of sepsis. The other 15 HBsAg(-) recipients (88.23%) remained HBsAg(-) after transplantation. They displayed normal serum levels of aspartate aminotransferase/alanine aminotransferase during the follow-up period. The 5-year patient and graft survivals were 85.15% and 61.14%, respectively. CONCLUSION: Although the number of patients is relatively small, it does suggest that a kidney allograft from an HBsAg(+) deceased donor transplanted to an HBsAg(+) or (-) recipient is safe. This strategy shortens the waiting time. Additional prophylactic HB immunoglobulin and antiviral medications are also suggested. Frequent surveillance after transplantation is essential.

Evaluation of cortical perfusion in renal transplants: application of quantified power Doppler ultrasonography.

Perfusion of renal transplants may be altered by various pathological conditions. This study assessed cortical perfusion of renal transplants during acute rejection episodes using power Doppler quantification. Forty-eight renal transplant patients with clinical indications for biopsy were included in this study. Power Doppler ultrasonography (US) of these renal transplants was performed prior to biopsy. Power Doppler image intensity in the proximal outer cortex of renal transplants was quantified by image analysis software. The results of power Doppler quantification were compared with the clinical data and histological findings. Biopsies were classified into three groups based on Banff diagnostic categories: group 1 (no acute rejection; 26 patients), group 2 (acute cell-mediated rejection alone; 12 patients), and group 3 (acute antibody-mediated rejection with/or without acute cell-mediated rejection; 10 patients). The power Doppler intensity of the outer renal cortex was 1.98 +/- 1.50 dB for group 1, 1.38 +/- 0.86 dB for group 2, and 0.81 +/- 0.66 dB for group 3. Statistically, there was a significant difference between group 1 and group 3 (1.98 vs 0.81 dB, P = .01) but not between group 1 and group 2 (1.98 vs 1.38 dB, P = .34). In conclusion, the status of cortical perfusion of renal transplants can be determined noninvasively by quantified power Doppler US. Accordingly, acute antibody-mediated rejection is associated with significantly decreased cortical perfusion, which, we propose, is due to this distinct pathological process.

Late spontaneous kidney graft decapsulation after administration of sirolimus in a recipient with chronic hepatitis B and C infection: a case report.

Late spontaneous kidney graft decapsulation with fluid collection is a rare condition with only a few cases reported in the literature. Common causes of renal allograft rupture include acute rejection, acute tubular necrosis, renal vein thrombosis, and trauma. Sirolimus related late spontaneous decapsulation has not been reported in the past. Interestingly, sirolimus may promote lymphocele formation in renal transplant recipients, including those presenting with chronic hepatitis B or C. Herein, we report a case of late spontaneous decapsulation with subcapsular hematoma formation developing 12 years after receipt of a cadaveric allograft. The patient was infected with both hepatitis B and C viruses. Cyclosporine was replaced by sirolimus for maintenance therapy because of chronic rejection and acute deterioration of renal function. He presented to the hospital at 9 months after sirolimus inception because of a sudden onset of pain and swelling over the kidney graft. Magnetic resonance imaging found the capsule to be stripped from the kidney by a collection of liquefied hematomas. A laparoscopic fenestration was performed by creation of a peritoneal window adjacent to the renal allograft. When patients have chronic hepatitis, tacrolimus might be a better choice than sirolimus.

Hepatocellular carcinoma after renal transplantation: the long-term impact of cirrhosis on chronic hepatitis B virus infection.

Hepatocellular carcinoma (HCC) is the most common posttransplantation malignancy in hepatitis B virus (HBV) endemic areas. The aim of this study was to review the significant effect of liver cirrhosis on the outcome of renal allograft recipients with chronic hepatitis B. We performed a retrograde analysis of the clinical presentations of 66 hepatitis B surface antigen-positive kidney allograft recipients during the past 25 years with a mean follow-up of 76 months. Seven patients were diagnosed with HCC. The patients were subgrouped into cirrhotic versus noncirrhotic liver cohorts. Among renal allograft recipients with HBV infection, patients with cirrhotic livers had a higher risk of HCC (P = .003) and mortality (P = .025) than those with a noncirrhotic liver. The outcome was poor among the cirrhotic liver group. Pretransplantation liver biopsy may be indicated for the recipient candidate with HBV infection. Liver cirrhosis may be an exclusion criterion for the renal transplant waiting list due to the high incidence of HCC and the poor patient survival.

ENDO-GIA staplers for side-to-side anastomosis of veins.

OBJECTIVE: To study the application of ENDO-GIA staplers for the side-to-side anastomosis of veins. MATERIALS AND METHODS: An animal study was conducted. Five dogs received side-to-side anastomosis of allograft IVC by ENDO-GIA staplers (Group 1). In addition, five received the same operation with right renal vein reimplantation to allograft IVC (Group 2). Five dogs, receiving the same operation as in Group 1 using polypropylene sutures (control group, Group 3). An autopsy was performed if the dogs survived more than 8 weeks. RESULTS: The IVC anastomosis remained patent in four subjects (80%) for Group 1, in five subjects (100%) for Group 2 and in four subjects (80%) for Group 3. CONCLUSIONS: From the results of our experiment, ENDO-GIA staplers can be considered for use in the side-to-side anastomosis of large veins such as piggyback cavacaval side-to-side anastomosis in cadaveric orthotopic liver transplantation (OLT) or side-to-side splenorenal shunt in portal hypertension.

Antioxidant supplementation may improve renal transplant function: a preliminary report.

Dysfunction of the renal graft may not only be due to rejection but also other causes such as ischemia and reperfusion injury and calcineurin inhibitor nephrotoxicity. Antioxidant free radical scavengers may decrease oxidative stress and lipid peroxidation. Previous animal studies suggest that vitamins C (ascorbic acid) and E (alpha-tocopherol) are both strong antioxidants, that decrease oxidative stress caused by ischemia-reperfusion injury and calcineurin inhibitor nephrotoxicity. But there have been only limited reports about clinical efficacy. We report five cases supplemented with vitamin C (500 mg per day), vitamin E (500 mg per day), or both. After a 1- to 3-month prescription, the serum creatinine level decreased more than 20% from the original value. Interestingly, one patient had this experience: he ceased vitamin E for 1 month due to noncompliance. The serum creatinine level increased more than 50%. When he took vitamin E again, his serum creatinine level declined and returned to the previous level. From our limited experience, antioxidant supplementation with vitamin C or E may improve renal transplant function, especially in grafts donated from marginal donors.

Recurrent hepatocellular carcinoma after hepatic resection: prognostic factors and long-term outcome.

AIM: The prognosis of patients with recurrent hepatocellular carcinoma (HCC) after hepatic resection varies widely. This study analyzed long-term survival and prognostic factors of patients with recurrent HCC after hepatectomy. METHODS: From July 1991 to December 2000, 623 patients underwent hepatic resection for HCC. Of those, 347 (56.5%) patients had tumour recurrence, and 286 patients with follow-up time more than 24 months after recurrence were enrolled. Twenty-seven clinicopathologic factors underwent both univariate and multivariate analysis. RESULTS: Of these 286 patients, survival times after tumour recurrence were mean 672+/-619 days; median 468 days; and, range 10-3753 days. The overall 1-, 3-, 5-, and 10-year post-recurrence survival rates were 61.5, 33.4, 18.2, and 9.0%, respectively. Seventy (24.5%) patients were alive at the time of study, and 10 of the 34 patients who underwent re-resection were disease-free. By Cox regression analysis, multiple initial tumours (relative risk (RR) 1.428), recurrent multiple (RR 1.372), extrahepatic recurrence (RR 2.434), recurrent tumour size >2 cm (RR 1.926), post-hepatectomy period until recurrence <1 year (RR 1.769), and non-resectional treatment of recurrent tumours (RR 3.527) were independent prognostic factors for post-recurrent survival rates. CONCLUSIONS: In patients with recurrent HCC after hepatectomy, both initial and recurrent tumour factors influenced their prognosis. Early detection of recurrent tumours is important. Re-resection correlated with better post-recurrent survival rates.

Reliability of contemporary radiology to measure tumour size of hepatocellular carcinoma in patients undergoing resection: limitations and clinical implications.

BACKGROUND: Preoperative radiology has been widely used to detect and measure hepatocellular carcinoma (HCC). However, its accuracy and reliability are unclear. This study aimed to assess the ability of current radiology to measure tumour size in patients undergoing resection. METHODS: We evaluated 212 HCC patients undergoing curative resection. Tumour size measured in the pathological examination was correlated with that obtained in preoperative ultrasound (US) and contrast-enhanced dynamic computed tomography (CT). Accuracy and association with tumour recurrence were investigated. RESULTS: The mean size of the tumour was 4.5 +/- 2.6 cm and was accurate in both US and CT in only 6 (3%) patients. Cirrhosis (P = 0.015), absence of tumour stain (P = 0.002) and small (< or = 4 cm) tumour (P < 0.001) were the significant factors associated with size deviation using both US and CT. Ninety-four (44%) patients developed tumour recurrence within 17 +/- 11 months of resection. Recurrence rate was 52%, 52% and 67% in patients with underestimation in US (relative risk [RR]: 2.0, 95% confidence interval [CI]: 1.2-3.4, P = 0.01), CT (RR: 2.1, 95% CI: 1.1-4, P = 0.022) and both modalities (RR: 2.5, 95% CI: 1.4-4.2, P = 0.001), respectively, compared to 30% recurrence in patients with accurate estimation of tumour size. CONCLUSION: The accuracy of radiology in measuring tumour size was poor, and may lead to inappropriate treatment. The finding that underestimation of tumour size was associated with a higher tumour recurrence rate is consistent with the hypothesis that HCC may recur from pre-existing tumour foci which could not be identified from the current imaging modalities.