Multivariate analysis of prognostic factors for survival following doxorubicin-eluting bead transarterial chemoembolization for hepatocellular carcinoma.

PURPOSE: To identify prognostic factors for survival in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization with doxorubicin-eluting beads (DEBs). MATERIALS AND METHODS: In a retrospective, single-center analysis, tumor- and patient-related factors were recorded for univariate and multivariate analyses via Kaplan-Meier and Cox regression. Infiltrative HCC phenotype and portal vein invasion (PVI) were correlated, and patients with either or both were classified as having radiographically advanced (RAdv) HCC. The primary endpoint was overall survival, which was calculated from the time of first DEB chemoembolization procedure. RESULTS: A total of 168 patients underwent 248 procedures, of which 215 (86.7%) were outpatient procedures. Mean length of stay was 0.33 days, and 25 patients (10.1%) were readmitted within 30 days. A total of 33 patients underwent liver transplantation and were excluded from survival analyses. A total of 130 had cirrhosis; 62, 50, and 18 had Child class A, B, and C disease, respectively. Forty-one patients had infiltrative HCC phenotype, 28 of whom also had PVI. Multivariate analysis of survival in all patients showed α-fetoprotein (AFP), performance status (PS), RAdv HCC, Child classification, albumin level, and ascites to predict survival. In patients without RAdv HCC, AFP, PS, Child classification, albumin level, and International Normalized Ratio were independent predictors. Increased bilirubin level was not an independent risk factor for death. CONCLUSIONS: Independent prognostic factors in patients with HCC undergoing DEB chemoembolization have been identified. Increased bilirubin level was not an independent risk factor. These data can be used in HCC patient selection and counseling for DEB chemoembolization.

Quality in colonoscopy reporting: an assessment of compliance and performance improvement.

BACKGROUND: An ASGE-ACG task force developed quality indicators (QI) for documenting quality endoscopic procedures. Acceptable compliance rates have not been determined. AIMS: To determine our degree of compliance to the intra-procedure colonoscopy QI prior to intervention, design an educational intervention to improve those with low compliance, and to compare the degree of compliance after intervention. METHODS: 300 patients undergoing colonoscopy in the pre-intervention time period followed by 300 patients after the educational intervention were reviewed. Endoscopists were instructed on the required QI and provided with their individual baseline compliance results. Dictated endoscopy reports were reviewed for compliance. RESULTS: Four QIs; documentation of bowel preparation adequacy, appendiceal orifice, photographs of cecum, and polyp shape, had low pre-intervention achievement (64%, 53%, 20%, and 15% respectively) and significant change was observed (83%, 68%, 63%, and 54% respectively, all p<0.001). Four QIs; documentation of ileocecal valve, polyp size description, polyp location description, and follow up recommendations, had high levels of achievement prior to intervention (92%, 98%, 97% and 81% respectively) and no significant change was observed (all p≥0.16). CONCLUSION: This study provides benchmarks for ASGE/QIs in colonoscopy cases in a large group practice model. It demonstrates that a quality improvement intervention can result in improved compliance.

Impact of neoadjuvant chemoradiation on the tumor burden before liver transplantation for unresectable cholangiocarcinoma.

The very early experience with liver transplantation (LT) for cholangiocarcinoma (CC) was dismal because of the poor survival outcomes and the high recurrence rates. However, LT for CC in conjunction with neoadjuvant chemoradiation recently has shown encouraging results, although the data are extremely limited. At our institution between 2001 and 2008, 22 CC patients underwent protocol orthotopic LT at a median age of 45 years (range = 24-63 years). At a median follow-up of 601.5 days (range = 111-1388 days), the median survival time of the cohort was 3.3 years. The 1-, 2-, and 3-year Kaplan-Meier survival probabilities were 90%, 70%, and 63%, respectively, whereas the historical 5-year survival rates were 0% to 18% for intrahepatic CC and 23% to 26% for extrahepatic CC when patients underwent transplantation without neoadjuvant therapy. These encouraging survival rates for patients with this type of tumor, which is difficult to diagnose and treat, are no less significant when they are compared to the national 1- and 3-year survival rates (86% and 68%, respectively) of patients undergoing deceased donor LT for malignant neoplasms of the liver (as reported by the United Network for Organ Sharing). In our series, disease recurrence was significantly associated with a larger residual tumor [6.3 versus 2.0 cm (mean values), P = 0.008] and with a shorter waiting time for LT after the chemoradiation protocol [18 versus 56 days (mean values), P = 0.04]. Our LT protocol for CC was found to be promising for patients with truly extrahepatic CC and for patients within stages I to IIB of the American Joint Committee on Cancer Staging system (100% survival at a median follow-up of 2.2 years), but the results were notably poor for patients with stage III extrahepatic CC (median survival = 1.2 years). These observations highlight the need for accurate preoperative staging of CC for ideal LT recipient selection and the importance of a low tumor burden and a longer wait after neoadjuvant therapy. More effective chemoradiation regimens for reducing the tumor burden and the appropriate timing of LT after neoadjuvant chemoradiation require further research.

Interobserver agreement on the endosonographic features of lymph nodes in aerodigestive malignancies.

BACKGROUND: Endoscopic ultrasound (EUS) is used to locally stage aerodigestive malignancies. Endosonographic features are used to predict malignant lymph nodes (MLN). Interobserver agreement on the endosonographic features of MLN has not been described. AIMS: To evaluate the interobserver agreement among endosonographers on the EUS features of MLN in aerodigestive malignancies along with the specific feature used to make this distinction. METHODS: A total of 760 procedures of suspected LN were reviewed. Cases were selected based on cytology-proven malignant or benign LN involvement by FNA with correspondent photodocumentation. Images of each LN were de-identified and distributed to three expert endosonographers. The experts recorded the LN's echogenicity (hypoechoic or other), shape (round or other), border (sharp or fuzzy) and subjective diagnosis (benign or malignant). The relationship between the endosonographers' subjective as well as the pathological diagnosis and LN's endosonographic features were analyzed using logistic regression analysis. Pair-wise comparison between endoscopist and interobserver agreement (kappa statistics) were performed. RESULTS: Images of 41 malignant and 35 benign LN were evaluated. There was fair agreement on shape, Κ = 0.35 (95% CI 0.2-0.5), and moderate agreement on echogenicity and borders, Κ = 0.46 (95% CI 0.31-0.61) and 0.43 (95% CI 0.27-0.58) respectively. The agreement on malignant LN was good, Κ = 0.65 (95% CI 0.5-0.8). The overall diagnostic predictive accuracy ranged from 70 to 77% among the three endoscopists.Two of the three endoscopists assessed shape as the most predictive feature of malignancy (OR 39.4, 95% CI 3.29-470.96). CONCLUSION: The inter-observer agreement on the individual lymph node features as obtained by EUS is moderate with good overall agreement on the diagnosis. Round shape was the feature most strongly associated with a diagnosis of MLN.

Risk of lymphoma in primary biliary cirrhosis.

BACKGROUND & AIMS: A number of immunosuppressive therapies have not been associated with clinical benefit in primary biliary cirrhosis (PBC). The use of more potent immunomodulatory therapies, however, could raise concerns over the risk of adverse effects such as the development of lymphoma. Therefore, we sought to describe the frequency, clinical spectrum, and outcomes among patients with PBC and a concomitant diagnosis of lymphoma. METHODS: Patients with PBC evaluated at the Mayo Clinic between January 1, 1976-December 31, 1997 comprised the study cohort. Medical records were abstracted for demographic and clinical information including the temporal relationship between diagnoses and potential risk factors for lymphoma. RESULTS: From a total of 2192 patients, the frequency of lymphoma was observed at 0.6% (13 cases). The majority of patients (54%) had PBC before they were diagnosed with lymphoma, whereas 23% of cases were diagnosed in conjunction with PBC. Non-Hodgkin's lymphoma (69%) was observed in most cases with disease involvement above the diaphragm (38%). Treatment in the form of chemotherapy (n = 3), radiation (n = 2), and surgery (n = 6) was provided for 11 patients. Seven (54%) patients did not have evidence for recurrent disease, whereas 3 (23%) patients died of progressive lymphoma. CONCLUSIONS: The baseline risk for lymphoma in patients with PBC is estimated at <1%. Clinical trials with potent immunosuppressive therapies for PBC should not be prohibited on the basis of concerns regarding a baseline predisposition for lymphoma in this population.