Expanding Indications for Liver Transplant: Tumor and Patient Factors.

During the past few decades, liver transplant has developed from a high-mortality procedure to an almost routine procedure with good survival outcomes. The development of living donor liver transplant has increased the availability of liver grafts, and the scope of indications for liver transplant has been expanding ever since. The aim of this review is to provide an overview of such an expansion of scope. Various criteria have been proposed to expand the eligibility of patients with hepatocellular carcinoma exceeding the Milan criteria for liver transplant. Furthermore, liver transplant is increasingly performed as a treatment modality for cholangiocarcinoma, neuroendocrine liver metastasis and colorectal liver metastasis. The number of elderly patients receiving liver transplant is on the rise. Combined organ transplantation has also been adopted to treat patients with multiple organ failure. Going forward, further development of preoperative noninvasive predictors in tumor, patient and even donor factors is needed to identify patients at risk of poor outcomes and hence optimize patient management.

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Update in management of hepatocellular carcinoma in Eastern population.

Hepatocellular carcinoma (HCC) is one of the commonest malignant tumours in the East. Although the management of HCC in the West is mainly based on the Barcelona Clinic for Liver Cancer staging, it is considered too conservative by Asian countries where the number of HCC patients is huge. Scientific and clinical advances were made in aspects of diagnosis, staging, and treatment of HCC. HCC is well known to be associated with cirrhosis and the treatment of HCC must take into account the presence and stage of chronic liver disease. The major treatment modalities of HCC include: (1) surgical resection; (2) liver transplantation; (3) local ablation therapy; (4) transarterial locoregional treatment; and (5) systemic treatment. Among these, resection, liver transplantation and ablation therapy for small HCC are considered as curative treatment. Portal vein embolisation and the associating liver partition with portal vein ligation for staged hepatectomy may reduce dropout in patients with marginally resectable disease but the midterm and long-term results are still to be confirmed. Patient selection for the best treatment modality is the key to success of treatment of HCC. The purpose of current review is to provide a description of the current advances in diagnosis, staging, pre-operative liver function assessment and treatment options for patients with HCC in the east.

Evaluating the incidence, clinical significance and predictors for vocal cord palsy and incidental laryngopharyngeal conditions before elective thyroidectomy: is there a case for routine laryngoscopic examination?

BACKGROUND: Routine preoperative laryngeal examination remains controversial. We aimed to assess the utility of preoperative routine flexible laryngoscopy (FL) by looking at the incidence, clinical significance and predictors for preoperative vocal cord paresis (VCP) and incidental laryngopharyngeal conditions (LPC) in our consecutive cohort. METHODS: A total of 302 patients underwent laryngeal examination by an independent otorhinolaryngologist and were specifically asked about voice/swallowing symptoms suggestive of VCP 1 day before surgery. As well as vocal cord (VC) mobility, the naso-pharynx and larynx were examined using FL. Any VCP and/or LPC was recorded. VCP was defined as reduced or absent movement in one or more VC. An LPC was considered clinically significant if the ensuing thyroidectomy was changed or deferred. RESULTS: Seven (2.3 %) patients had preoperative VCP, while an additional seven patients had an incidental LPC. Of the seven VCPs, five were caused by previous thyroidectomy, while two were caused by a benign goitre. The incidence of asymptomatic VCP in a previously non-operated cohort was 1/245 (0.41 %). Voice/swallowing symptoms (p = 0.033) and previous thyroidectomy (p < 0.001) were the two significant predictors for VCP. The seven incidental LPCs were vallecular cyst (n = 1), VC scar and polyp (n = 2), nasopharyngeal cyst and polyp (n = 3) and redundant arytenoid mucosa (n = 1); however, as they were benign, all seven patients proceeded to thyroidectomy as planned. CONCLUSIONS: Given the low incidence (0.41 %) of asymptomatic VCP in a previously non-operated cohort and that none of the seven LPCs were considered clinically significant, routine preoperative laryngoscopic examination should be reserved for those with previous thyroidectomy and/or voice/swallowing symptoms.

Clinicopathologic predictors for early and late biochemical hypothyroidism after hemithyroidectomy.

BACKGROUND: Biochemical hypothyroidism (BH) after hemithyroidectomy is an under-recognized complication with a reported incidence of 9% to 43%. This study aimed to identify potential clinicopathologic risk factors associated with early (<12 months after hemithyroidectomy) and late-onset (≥12 months after hemithyroidectomy) BH. METHODS: From 2005 to 2008 there were 263 postsurgical patients who were eligible for analysis. Serum thyroid stimulating hormone (TSH) level was checked regularly after surgery. Postoperative TSH reaching a level higher than 5.5 mIU/L was defined as BH. The overall median follow-up period was 21 months (range, 3-62 mo). Any clinicopathologic factors significantly associated with BH in the univariate analysis were entered into multivariate analysis. A further analysis was performed comparing factors between early and late-onset BH. RESULTS: There were 38 patients who developed subsequent BH, 33 of these cases developed within 2 years. Those patients with BH were significantly older (P = .037), had a higher preoperative TSH level (P < .001), longer follow-up period (P < .001), more frequent thyroiditis on histology (P = .043), lighter resected tissue weight (P = .001), and were more likely to have positive antimicrosomal antibodies (P = .043) than those without BH. However, in the multivariate analysis after adjusting for different follow-up periods in the 2 groups, only lighter resected tissue weight (P = .036) and concomitant thyroiditis on histology (P = .005) turned out to be independent factors for BH. Thyroiditis on histology was also the only significant risk factor for developing early onset BH. CONCLUSIONS: Patients with lighter resected tissue weight and concomitant thyroiditis on histology were particularly at risk for subsequent BH. Although not all patients with thyroiditis developed BH, in those who did develop BH it occurred within the first 11 months.