Publications by authors named "Nicholas N Nissen"

55 Publications

Increase in Alcoholic Hepatitis as an Etiology for Liver Transplantation in the United States: A 2004-2018 Analysis.

Transplant Direct 2020 Nov 8;6(11):e612. Epub 2020 Oct 8.

Division of Digestive and Liver Diseases, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Changing opinions on the alcohol abstinence requirement have led to increased liver transplantation (LT) for alcoholic hepatitis (AH). We aimed to determine the trend in LT for AH in the United States and overall and graft survival rates.

Methods: Adult liver-alone and liver-kidney registrations added to the Organ Procurement and Transplantation Network waiting list between 2004 and 2018 were divided into 3 periods (2004-2009, 2010-2013, 2014-2018). Kaplan-Meier survival models illustrated patient and graft survival.

Results: Between 2004 and 2018, 529 AH patients were registered for and 254 received LT. By periods, 116, 73, and 340 patients were registered for and 49, 17, and 188 patients received LT, respectively, indicating a increase in LT for AH from 2014 to 2018. Yearly registrants from 2014 to 2018 were 32, 47, 51, 70, and 140, and recipients were 16, 24, 24, 38, and 88, respectively, indicating increases of 338% and 450% in registrants and recipients, respectively, since 2014. AH patients had the highest 1- and 3-year posttransplant survival (93.2% and 87.3%, respectively) and graft survival (90.4% and 84.8%, respectively) comparing to other LT recipients.

Conclusions: LT for AH in the United States is at an all-time high with an increased overall patient and graft survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TXD.0000000000001051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546885PMC
November 2020

Factors Associated With Detection and Survival of T1 Hepatocellular Carcinoma in the United States: National Cancer Database Analysis.

J Natl Compr Canc Netw 2020 09;18(9):1210-1220

Samuel Oschin Comprehensive Cancer Institute, and.

Background: It remains unknown to what extent hepatocellular carcinomas (HCCs) are detected very early (T1 stage; ie, unifocal <2 cm) in the United States. The aim of this study was to investigate the trends and factors associated with very early detection of HCC and resultant outcomes.

Methods: Patients with HCC diagnosed from 2004 through 2014 were identified from the National Cancer Database. Logistic regression was used to identify factors associated with T1 HCC detection, and Cox proportional hazard analyses identified factors associated with overall survival among patients with T1 HCC.

Results: Of 110,182 eligible patients, the proportion with T1 HCC increased from 2.6% in 2004 to 6.8% in 2014 (P<.01). The strongest correlate of T1 HCC detection was receipt of care at an academic institution (odds ratio, 3.51; 95% CI, 2.31-5.34). Older age, lack of insurance, high Model for End-Stage Liver Disease (MELD) score, high alpha-fetoprotein, increased Charlson-Deyo comorbidity score, and nonsurgical treatment were associated with increased mortality, and care at an academic center (hazard ratio [HR], 0.27; 95% CI, 0.15-0.48) was associated with reduced mortality in patients with T1 HCC. Liver transplantation (HR, 0.27; 95% CI, 0.20-0.37) and surgical resection (HR, 0.67; 95% CI, 0.48-0.93) were independently associated with improved survival compared with ablation. This is the first study to examine the trend of T1 HCC using the National Cancer Database, which covers approximately 70% of all cancer diagnoses in the United States, using robust statistical analyses. Limitations of the study include a retrospective study design using administrative data and some pertinent data that were not available.

Conclusions: Despite increases over time, <10% of HCCs are detected at T1 stage. The strongest correlates of survival among patients with T1 HCC are receiving care at an academic institution and surgical treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.6004/jnccn.2020.7564DOI Listing
September 2020

Higher thresholds for the utilization of steatotic allografts in liver transplantation: Analysis from a U.S. national database.

PLoS One 2020 2;15(4):e0230995. Epub 2020 Apr 2.

Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, United States of America.

Background: Historically, liver allografts with >30% macrosteatosis (MaS) on donor biopsy have been associated with early allograft dysfunction and worse graft survival; however, successful outcomes have been reported in small cohorts. This study proposes an elevated MaS threshold for organ utilization without detriment to graft survival.

Methods: The UNOS Standard Transplant Analysis and Research database was evaluated for transplants between 2006-2015. Graft survival up to 1-year was evaluated by Kaplan-Meier (KM) survival analyses, and by univariate and multivariable logistic regression analyses, including donor and recipient characteristics. Odds ratios (OR) with 95% confidence intervals (CI) for risk of graft loss are reported.

Results: Thirty-day risk of graft loss was increased with MaS as low as 10-19% (OR [95% CI] 1.301 [1.055-1.605], p<0.0001) and peaked with MaS 50-59% (2.921 [1.672-5.103]). At 1-year, risk of graft loss remained elevated with MaS 40-49% (1.465 [1.002-2.142]) and MaS 50-59% (1.978 [1.281-3.056], p = 0.0224). Multivariable models were created for Lower and Higher MELD recipients and MaS cutoffs were established. In Lower MELD recipients, organs with ≥50% MaS had increased risk of graft loss at 30 days (2.451 [1.541-3.897], p = 0.0008) and 1-year post-transplant (1.720 [1.224-2.418], p = 0.0125). Higher MELD recipients had increased risk of graft loss at 30 days with allografts showing MaS ≥40% (4.204 [1.440-5.076], p = 0.0016). At 1-year the risk remained increased, but MaS was not significant predictor of graft loss.048 [1.131-3.710], p = 0.0616). In both MELD cohorts, organs with MaS levels below threshold had similar survival to those transplanted without a donor biopsy.

Conclusions: In conjunction with recipient selection, organs with MaS up to 50% may be safely used without detriment to outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0230995PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7117730PMC
July 2020

An open-label, single-arm pilot study of EUS-guided brachytherapy with phosphorus-32 microparticles in combination with gemcitabine +/- nab-paclitaxel in unresectable locally advanced pancreatic cancer (OncoPaC-1): Technical details and study protocol.

Endosc Ultrasound 2020 Jan-Feb;9(1):24-30

Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Current treatment options for patients with unresectable locally advanced pancreatic cancer (LAPC) include chemotherapy alone or followed by chemoradiation or stereotactic body radiotherapy. However, the prognosis for these patients remains poor, with a median overall survival <12 months. Therefore, novel treatment options are needed. Currently, there is no brachytherapy device approved for pancreatic cancer treatment. Hereby, we present the protocol of a prospective, multicenter, interventional, open-label, single-arm pilot study (OncoPac-1, Clinicaltrial.gov-NCT03076216) aiming to determine the safety and efficacy of Phosphorus-32 when implanted directly into pancreatic tumors using EUS guidance, for patients with unresectable LAPC undergoing chemotherapy (gemcitabine ± nab-paclitaxel).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/eus.eus_44_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7038730PMC
November 2019

NASH Leading Cause of Liver Transplant in Women: Updated Analysis of Indications For Liver Transplant and Ethnic and Gender Variances.

Am J Gastroenterol 2018 11 8;113(11):1649-1659. Epub 2018 Jun 8.

Fatty Liver Program, Division of Digestive and Liver Diseases, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Biostatistics & Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Texas Liver Institute, San Antonio, TX, USA. Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA. These authors contributed equally: Mazen Noureddin, Aarshi Vipani.

Objectives: Chronic infection with hepatitis C virus (HCV) was previously the leading indication for liver transplant (LT) in the United States. However, since 2014 the use of direct-acting antivirals (DAAs) has decreased the chronic HCV burden, while the prevalence of nonalcoholic steatohepatitis (NASH) has risen substantially through the last decade. Both gender and ethnic disparities in indications for LT have been shown in the past but no data on this have been reported since the implementation of DAAs.

Methods: We assessed changes in etiologies for LT listing and in gender and ethnic differences in those listed for LT. Adult patients registered for LT in the United Network for Organ Sharing/Organ Procurement and Transplantation Network database between January 1, 2004 and December 31, 2016 were included. Multinomial logistic regression modeling was used to test for changes in waitlist or liver transplant rates.

Results: The study included 127,164 adult patients registered for LT. By 2016, alcoholic liver disease (ALD) was the leading etiology for waitlisting and LT; NASH was second; hepatocellular carcinoma (HCC) due to chronic HCV and chronic HCV alone were 3rd and 4th. NASH was the leading cause for LT for women and the 2nd leading cause for men (following ALD). NASH increased as the cause in all ethnic subgroups and was the leading cause in 2016 among Asian, Hispanic, and non-Hispanic white females. We also found that although the indication for liver transplant for hepatocellular carcinoma (HCC) due to HCV has increased over the years, this indication decreased for the first time between 2015 and 2016 in both males and females.

Conclusions: NASH is currently the second leading cause for LT waitlist registration/liver transplantation overall, and in females, the leading cause. Given the rate of increase, NASH will likely rise to become the leading indication for LT in males as well.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41395-018-0088-6DOI Listing
November 2018

The Clinicopathological Aspects of Primary Presacral Neuroendocrine Neoplasms: One Center Experience.

Pancreas 2018 01;47(1):122-129

Objectives: Presacral neuroendocrine neoplasms (NENs) are rare entities that are found at the presacral space. We report our experience in the diagnosis, management, and outcomes of primary presacral NENs.

Methods: This was an institutional review board-approved retrospective review of medical records and surgical pathology specimens of patients with a diagnosis of NENs at Cedars-Sinai Medical Center between January 2000 and April 2016.

Results: Ten patients were identified. The median age at presentation was 38 years (range, 20-77 years), and 8 were women. One patient presented with carcinoid-like symptoms, 2 were diagnosed incidentally, and 7 presented with symptoms related to mass effect. The median size of the tumor was 7.0 cm (range, 3-12 cm). On pathologic review, 3 of 10 were low-grade and well-differentiated, 5 of 10 were intermediate-grade and well-differentiated, 2 of 10 were grade 3 and classified as high-grade and poorly differentiated neuroendocrine tumors. Seven cases were metastatic on presentation with lymph node, liver, lung, or skeletal metastasis. Seven of 8 cases were detectable using Octreoscan. Eight patients were treated with a somatostatin analog and 5 patients were treated surgically.

Conclusions: Presacral NENs are clinically similar to gastroenteropancreatic tumors. Octreoscan imaging and somatostatin analog therapies were frequently applied. Further biologic characterization of this rare subtype is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0000000000000954DOI Listing
January 2018

Multifocality in Small Bowel Neuroendocrine Tumors.

J Gastrointest Surg 2018 02 8;22(2):303-309. Epub 2017 Nov 8.

Department of Surgery, Division of Surgical Oncology and Hepatobiliary Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: Neuroendocrine tumors (NETs) account for 30% of small bowel (SB) neoplasms. The objectives of this study were to evaluate the incidence of multifocality in primary small bowel neuroendocrine tumors (SBNETs) and to examine the associated outcomes.

Methods: Patients with multifocal SBNET were compared to those with a solitary lesion. Only patients who underwent diagnostic workup and surgical intervention at our institution were included in this study. The primary aim of our study was surgical outcomes and mortality and recurrence. The second aim of our study was to evaluate the utility of double-balloon enteroscopy (DBE) and capsule endoscopy.

Results: Of 178 patients with SBNETs during the study period, 85 met inclusion criteria. The mean age was 61.0 ± 12.6 years and 44.7% were male. The ileum was the primary tumor site for 66 patients (77.7%). Of DBE patients, 28 (62.2%) had additional lesions identified, of which 23 (82.1%) had NET confirmed on pathology. Average tumor size was 1.8 cm and most were well differentiated (89.9%), with Ki-67 of ≥ 2% (65.8%); 74.4% had nodal metastases and 51% of patients had stage IV disease. Forty-six patients (54.1%) had multifocal disease, of whom 37 (80.5%) had an ileal primary. No differences in survival or recurrence were seen for multifocal versus solitary disease.

Conclusions: SBNETs have a high incidence of multifocality. DBE can be used in the preoperative assessment to detect multifocal NET. Multifocality has no impact on survival or recurrence outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11605-017-3586-8DOI Listing
February 2018

The Braden Scale, A standard tool for assessing pressure ulcer risk, predicts early outcomes after liver transplantation.

Liver Transpl 2017 09;23(9):1153-1160

Department of Medicine, Division of Gastroenterology, Oregon Health and Science University, Portland, OR.

The Braden Scale is a standardized tool to assess pressure ulcer risk that is reported for all hospitalized patients in the United States per requirements of the Center for Medicare and Medicaid Services. Previous data have shown the Braden Scale can predict both frailty and mortality risk in patients with decompensated cirrhosis. Our aim was to evaluate the association of the Braden Scale score with short-term outcomes after liver transplantation (LT). We performed a retrospective cohort study of deceased donor LT recipients at 2 centers and categorized them according to the Braden Scale at hospital admission as low (>18), moderate (16-18), or high risk (<16) for pressure ulcer. We created logistic and Poisson multiple regression models to evaluate the association of Braden Scale category with in-hospital and 90-day mortality, length of stay (LOS), nonambulatory status at discharge, and discharge to a rehabilitation facility. Of 341 patients studied, 213 (62.5%) were low risk, 59 (17.3%) were moderate risk, and 69 (20.2%) were high risk. Moderate- and high-risk patients had a greater likelihood for prolonged LOS, nonambulatory status, and discharge to a rehabilitation facility, as compared with low-risk patients. High-risk patients additionally had increased risk for in-hospital and 90-day mortality after LT. Multiple regression modeling demonstrated that high-risk Braden Scale score was associated with prolonged LOS (IRR, 1.56; 95% confidence interval [CI], 1.47-1.65), nonambulatory status at discharge (odds ratio [OR], 4.15; 95% CI, 1.77-9.71), and discharge to a rehabilitation facility (OR, 5.51; 95% CI, 2.57-11.80). In conclusion, the Braden Scale, which is currently assessed in all hospitalized patients in the United States, independently predicted early disability-related outcomes and greater LOS after LT. Liver Transplantation 23 1153-1160 2017 AASLD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/lt.24789DOI Listing
September 2017

A Clinicopathological Study of Malignant Insulinoma in a Contemporary Series.

Pancreas 2017 01;46(1):48-56

From the *Division of Endocrinology, Cedars-Sinai Medical Center; †Division of Endocrinology, UCLA David Geffen School of Medicine, ‡Department of Surgery, §Division of Hematology and Oncology, Cedars-Sinai Medical Center, Los Angeles, CA; ∥Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY; ¶Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China; and #Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA.

Objective: The aim of the study was to address the origin and natural history of malignant insulinoma.

Methods: Retrospective review of medical records of patients diagnosed with insulinoma at Cedars-Sinai Medical Center between 2000 and 2015 was conducted. Hormonal expression in tumor specimens was examined by immunostaining.

Results: All the 9 patients with malignant insulinoma (35% of 26 patients with insulinoma) already had liver metastasis at hypoglycemia presentation with bulky cumulative tumor burden. Six patients had de novo diagnosis, 2 had known metastatic nonfunctioning pancreatic neuroendocrine tumor, and 1 had a known pancreatic mass. Tumor grade at presentation was G1 in 4 patients, G2 in 4, and unknown in 1. Four patients died 2 to 32 months after presentation, all with extensive liver tumor involvement. Tumor expression of proinsulin and insulin was heterogeneous and overall infrequent. The proinsulin levels and proinsulin/insulin molar ratio in patients with malignant versus benign insulinoma were 334 versus 44 pmol/L and 2.1 versus 0.9, respectively.

Conclusions: Malignant insulinoma seems to arise from and behave like nonfunctioning pancreatic neuroendocrine tumor oncologically but with metachronous hyperinsulinemic hypoglycemia. High proinsulin levels and proinsulin/insulin molar ratio may suggest malignant insulinoma.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0000000000000718DOI Listing
January 2017

Cultured circulating tumor cells and their derived xenografts for personalized oncology.

Asian J Urol 2016 Oct 25;3(4):240-253. Epub 2016 Aug 25.

Uro-Oncology Research, Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Recent cancer research has demonstrated the existence of circulating tumor cells (CTCs) in cancer patient's blood. Once identified, CTC biomarkers will be invaluable tools for clinical diagnosis, prognosis and treatment. In this review, we propose culture as a rational strategy for large scale amplification of the limited numbers of CTCs from a patient sample, to derive enough CTCs for accurate and reproducible characterization of the biophysical, biochemical, gene expressional and behavioral properties of the harvested cells. Because of tumor cell heterogeneity, it is important to amplify all the CTCs in a blood sample for a comprehensive understanding of their role in cancer metastasis. By analyzing critical steps and technical issues in CTC culture, we developed a cost-effective and reproducible protocol directly culturing whole peripheral blood mononuclear cells, relying on an assumed survival advantage in CTCs and CTC-like cells over the normal cells to amplify this specified cluster of cancer cells.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ajur.2016.08.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5730836PMC
October 2016

Peribiliary hepatic cysts presenting as hilar cholangiocarcinoma in a patient with end-stage liver disease.

J Surg Case Rep 2016 Aug 10;2016(8). Epub 2016 Aug 10.

Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA

Peribiliary cysts are cystic dilatations of peribiliary glands in the liver. They are present in ~50% of cirrhotic patients, but are underrecognized because they are usually asymptomatic and rarely present as obstructive jaundice. A 63-year-old male with hepatitis C cirrhosis, awaiting liver transplantation, had a new finding of intrahepatic dilatation on magnetic resonance imaging. This was initially concerning for cholangiocarcinoma, but was ultimately diagnosed as peribiliary cysts. Peribiliary cysts can imitate cholangiocarcinoma on imaging. Therefore, awareness of this condition is essential because misdiagnosis may lead to inappropriate delay or denial for liver transplantation. The ideal imaging modalities to identify peribiliary cysts are magnetic resonance cholangiography and drip infusion cholangiographic computed tomography, though hepatic dysfunction may limit the usefulness of the latter. Peribiliary cysts should be considered in cirrhotic patients with cholestasis, biliary dilatations and negative biopsy of the biliary system for malignancy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/jscr/rjw130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979529PMC
August 2016

Impact of margin status and lymphadenectomy on clinical outcomes in resected pancreatic adenocarcinoma: implications for adjuvant radiotherapy.

J Gastrointest Oncol 2016 Apr;7(2):239-47

1 Department of Medicine, 2 Department of Radiation Oncology, 3 Department of Pathology, 4 Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: Adjuvant chemoradiotherapy (CRT) in the treatment of pancreatic ductal adenocarcinoma (PDA) is controversial. Minimal data exists regarding the clinical significance of margin clearance distance and lymph node (LN) parameters, such as extent of dissection and LN ratio. We assessed the impact of these variables on clinical outcomes to more clearly define the subset of patients who may benefit from adjuvant radiotherapy (RT).

Methods: We identified 106 patients with resected stage 1-3 PDA from 2007-2013. Resection margins were categorized as positive (tumor at ink), ≤1, or >1 mm. LN evaluation included total number examined (NE), number of positive nodes (NP), ratio of NP to NE (NR), extent of dissection, and positive periportal LNs. The impact of these variables was assessed on disease-free survival (DFS) and overall survival (OS) using multivariate cox proportional hazards modeling.

Results: In patients receiving adjuvant chemotherapy (CT) alone, greater margin clearance led to improved DFS (P=0.0412, HR =0.51). Range of NE was 4-37, with a mean of 19. NE was not associated with DFS or OS, yet absolute NP of 5 or more was associated with a significantly worse DFS (P=0.005). Whereas periportal lymphadenectomy did not result in improved DFS or OS, patients with positive periportal LN had worse clinical outcomes (DFS, P=0.0052; OS, P=0.023). The use of adjuvant CRT was associated with improved OS (P=0.049; HR=0.29).

Conclusions: In patients receiving adjuvant CT alone, there was a clinically significant benefit to clearing the surgical margin beyond tumor at ink. Having ≥5 NP and positive periportal LN led to significantly worse clinical outcomes. The addition of adjuvant RT to CT in resected PDA improved OS. A comprehensive evaluation of resection margin distance and LN parameters may identify more patients at risk for locoregional failure who may benefit from adjuvant CRT.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3978/j.issn.2078-6891.2015.109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783734PMC
April 2016

Differences and Similarities in the Clinicopathological Features of Pancreatic Neuroendocrine Tumors in China and the United States: A Multicenter Study.

Medicine (Baltimore) 2016 Feb;95(7):e2836

From the Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing (L-MZ, X-WQ, Y-LS, T-TS, C-ML, Y-JC); Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY (LT); Markey Cancer Center, University of Kentucky, Lexington, KY (EW); Department of Surgery (NNN); Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA (DD); Department of Gastroenterology, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou (JC); Department of Gastrointestinal Medical Oncology, Peking University School of Oncology, Beijing Cancer Hospital and Institute (LS); Department of Medical Oncology, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing (YC); Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University, Shanghai (Y-ZY, Q-WB); Department of Gastroenterology, the First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou (BL); Department of Endocrinology, the Third Hospital of Hebei Medical University, Shijiazhuang (Y-RZ); Department of Oncology (C-MB); Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing (JC); and Division of Endocrinology and Carcinoid and Neuroendocrine Tumor Center, Cedars-Sinai Medical Center, University of California Los Angeles, Los Angeles, CA (RY).

The presentation, pathology, and prognosis of pancreatic neuroendocrine tumors (PNETs) in Asian patients have not been studied in large cohorts. We hypothesized that the clinicopathological features of PNETs of Chinese patients might be different from those of US patients. The objectives of this study were to address whether PNETs in Chinese patients exhibit unique clinicopathological features and natural history, and can be graded and staged using the WHO/ENETS criteria. This is a retrospective review of medical records of patients with PNETs in multiple academic medical centers in China (7) and the United States (2). Tumor grading and staging were based on WHO/ENETS criteria. The clinicopathological features of PNETs of Chinese and US patients were compared. Univariate and multivariate analyses were performed to find associations between survival and patient demographics, tumor grade and stage, and other clinicopathological characteristics. A total of 977 (527 Chinese and 450 US) patients with PNETs were studied. In general, Chinese patients were younger than US patients (median age 46 vs 56 years). In Chinese patients, insulinomas were the most common (52.2%), followed by nonfunctional tumors (39.7%), whereas the order was reversed in US patients. Tumor grade distribution was similar in the 2 countries (G1: 57.5% vs 55.0%; G2: 38.5% vs 41.3%; and G3: 4.0% vs 3.7%). However, age, primary tumor size, primary tumor location, grade, and stage of subtypes of PNETs were significantly different between the 2 countries. The Chinese nonfunctional tumors were significantly larger than US ones (median size 4 vs 3 cm) and more frequently located in the head/neck region (54.9% vs 34.8%). The Chinese and US insulinomas were similar in size (median 1.5 cm) but the Chinese insulinomas relatively more frequently located in the head/neck region (48.3% vs 26.1%). Higher grade, advanced stage, metastasis, and larger primary tumor size were significantly associated with unfavorable survival in both countries. Several clinicopathological differences are found between Chinese and US PNETs but the PNETs of both countries follow a similar natural history. The WHO tumor grading and ENETS staging criteria are applicable to both Chinese and US patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MD.0000000000002836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4998644PMC
February 2016

Visual Vignette.

Endocr Pract 2016 Jan 2;22(1):117. Epub 2015 Nov 2.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4158/EP151071.VVDOI Listing
January 2016

Surgery for gallbladder cancer in the US: a need for greater lymph node clearance.

J Gastrointest Oncol 2015 Oct;6(5):452-8

1 Department of Surgery, Stanford University, Stanford, CA, USA ; 2 Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Background: Gallbladder cancer (GBC) is a rare malignancy with a dismal prognosis. Often identified incidentally after laparoscopic cholecystectomy for presumably benign biliary disease, reoperation with partial hepatic resection and periportal lymph node dissection (LND) is frequently performed. The impact of lymph node (LN) clearance for GBC remains unclear.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database was queried for patients diagnosed with GBC between 1988 and 2009. Survival was calculated using Kaplan-Meier method and compared using log-rank test. Multivariate analysis was performed to identify predictors of survival.

Results: A total of 11,815 patients diagnosed with GBC were identified. Cancer-directed surgery was performed in 8,436 (71.3%) patients. Optimal LN clearance (defined as ≥4 LNs) is associated with young age, advanced T-stage, no radiation therapy, and radical surgery (all <0.001). Greater LND improves survival for all stages (P<0.001). After adjusting for confounding factors, multivariable analysis of patients with node-negative disease demonstrated that early stage, greater LND, and radical surgery were strong independent predictors of survival.

Conclusions: Extensive lymphadenectomy correlates with longer survival even in node negative patients. Extensive LND should be performed in patients with GBC as many patients in the USA are undertreated.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3978/j.issn.2078-6891.2015.062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570923PMC
October 2015

Can Transfusions Be Eliminated in Major Abdominal Surgery? Analysis of a Five-Year Experience of Blood Conservation in Patients Undergoing Pancreaticoduodenectomy.

Am Surg 2015 Oct;81(10):983-7

Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Pancreaticoduodenectomy (PD) has historically required perioperative blood transfusion in 40 to 60 per cent of cases. Growing data suggest that transfusions may be deleterious in the surgical patient. We recently initiated a minimal transfusion approach to PD consisting of limited postoperative blood draws, early iron supplementation, changes in surgical technique, and elimination of hemoglobin transfusion triggers. Predictors of perioperative transfusion were analyzed in 130 consecutive patients undergoing PD by a single surgeon between 2008 and 2013, divided into two eras with 65 patients each. Patients in each era were similar with respect to age, comorbidities, American Society of Anesthesiologists class, body mass index, and diagnosis. The transfusion rate for the entire group was 22 per cent. Nonsignificant predictors of perioperative transfusion include American Society of Anesthesiologists class ≥3 (P = 0.41), vascular resections (P = 0.56), body mass index ≥30 (P = 0.72), and intraoperative blood loss (P = 0.89). Significant predictors of transfusion include PD performed in Era 1 as well as preoperative hemoglobin levels <10 g/dL. In Era 1, 38 per cent of patients required transfusion compared with 6 per cent in Era 2 (P < 0.01). Shorter length of stay and a trend toward decreased pancreatic fistulae were seen in Era 2. Transfusions can be almost completely eliminated in PD and this may contribute to improved outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2015

Metastatic Periampullary Tumor from Hepatocellular Carcinoma Presenting as Gastrointestinal Bleeding.

Case Rep Gastrointest Med 2015 29;2015:732140. Epub 2015 Apr 29.

Department of Gastroenterology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA.

Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patient's hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2015/732140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4429209PMC
June 2015

Primary intra-aneurysmal surgical repair of a celiomesenteric trunk aneurysm.

J Vasc Surg Cases 2015 Mar 18;1(1):50-52. Epub 2015 Mar 18.

Section of Vascular Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.

We describe the surgical management of an asymptomatic 3-cm saccular aneurysm originating from a celiomesenteric trunk in a 45-year-old man. Surgical management was influenced by the location of the aneurysm, involving hepatic, splenic, and superior mesenteric arterial branches, by the young age of the patient, which made use of a synthetic graft less ideal, and by the lack of endovascular options.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvsc.2014.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6849929PMC
March 2015

Donation after cardiac death liver transplantation in primary sclerosing cholangitis: proceed with caution.

Transplantation 2015 May;99(5):973-8

1 Division of Gastroenterology and Comprehensive Transplant Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA. 2 Department of Internal Medicine, University of California at Los Angeles School of Medicine, Los Angeles, CA. 3 Samuel Oschin Comprehensive Cancer Center, Cedars-Sinai Medical Center, LosAngeles, CA. 4 Department of Surgery and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA.

Background: Primary sclerosing cholangitis (PSC) patients suffer from comorbidities unaccounted for by the model for end-stage liver disease scoring system and may benefit from the increased donor organ pool provided by donation after cardiac death (DCD) liver transplantation. However, the impact of DCD transplantation on PSC graft outcomes is unknown.

Methods: We studied 41,018 patients using the United Network for Organ Sharing database from 2002 through 2012. Kaplan-Meier analysis and Cox regression were used to evaluate graft survival and risk factors for graft failure, respectively.

Results: The PSC patients receiving DCD livers (n=75) showed greater overall graft failure (37.3% vs. 20.4%, P = 0.001), graft failure from biliary complications (47.4% vs. 13.9%, P = 0.002), and shorter graft survival time (P = 0.003), compared to PSC patients receiving donation after brain death organs (n=1592). Among DCD transplants (n=1943), PSC and non-PSC patients showed similar prevalence of graft failure and graft survival time, though a trend existed toward increased biliary-induced graft failure among PSC patients (47.4 vs. 26.4%, P = 0.063). Cox modeling demonstrated that PSC patients have a positive graft survival advantage compared to non-PSC patients (hazard ratio [HR]=0.72, P < 0.001), whereas DCD transplantation increased risk of graft failure (HR = 1.28, P < 0.001). Furthermore, the interaction between DCD transplant and PSC was significant (HR = 1.76, P = 0.015), indicating that use of DCD organs impacts graft survival more in PSC than non-PSC patients.

Conclusion: Donation after cardiac death liver transplantation leads to significantly worse outcomes in PSC. We recommend cautious use of DCD transplantation in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/TP.0000000000000447DOI Listing
May 2015

Increasing age and survival after orthotopic liver transplantation for patients with hepatocellular cancer.

J Am Coll Surg 2014 Mar 5;218(3):431-8. Epub 2013 Dec 5.

Division of Surgical Oncology, Department of Surgery, City of Hope Comprehensive Cancer Center, Duarte, CA.

Background: Orthotopic liver transplantation (OLT) is the gold standard treatment for patients with early hepatocellular carcinoma (HCC). There are concerns about the efficacy of OLT for HCC in older patients, who we hypothesized might have poorer outcomes. Therefore, we sought to examine advanced age and its impact on OLT outcomes.

Study Design: The United Network for Organ Sharing database was queried for patients who underwent OLT for HCC from 1987 to 2009. Patients were divided into 3 age groups: 35 to 49 years old, 50 to 64 years old, and 65 years or older, and patient characteristics were compared. Univariate and multivariate analyses were performed to assess the impact of age on OLT outcomes.

Results: Of 10,238 patients with OLT for HCC, 16.5% (n = 1,688) of patients were 35 to 49 years old, 67.8% (n = 6,937) were 35 to 49 years old, and 15.8% (n = 1,613) were 65 years and older. By Kaplan-Meier method, the 50- to 64-year-old age group had the highest overall survival, despite having one of the highest rates of hepatitis C positivity (70%), but this group also had the lowest rate of diabetes mellitus (8.7%). The lowest overall survival was observed in the 65-year or older age group (p < 0.001). Finally, there was no difference in disease-specific survival among the age groups (p = 0.858), and patients aged 65 years and older had the highest rate of death from nonhepatic causes (17.5%).

Conclusions: Although OS was prolonged in younger patients who underwent OLT for HCC, there was no observed difference in disease-specific survival among the age groups. Our results suggest that carefully selected patients 65 years of age and older can derive equal benefit from OLT for HCC when compared with their younger counterparts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2013.12.001DOI Listing
March 2014

Exocrine pancreas hyperplasia without dysplasia in glucagon receptor knockout mice.

Pancreas 2014 Jan;43(1):143-5

Division of Endocrinology Cedars-Sinai Medical Center Los Angeles, CA Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA Department of Pathology Cedars-Sinai Medical Center Los Angeles, CA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0b013e3182a5dc77DOI Listing
January 2014

Surgical management of advanced adrenocortical carcinoma: a 21-year population-based analysis.

Am Surg 2013 Oct;79(10):1115-8

Hepatobiliary Surgery and Liver Transplantation, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Adrenocortical carcinoma (ACC) is a rare endocrine malignancy with a dismal prognosis. When diagnosed in advanced stages of the disease, the outcomes of surgical resection are not well understood. The objective of this study is to determine the impact of surgery in patients with advanced ACC. Using the Surveillance, Epidemiology and End Results database, we identified patients diagnosed with Stage III and IV ACC between 1988 and 2009. A total of 320 patients with Stage III and IV disease were included in our analysis. In patients treated with surgical resection, the Stage III 1- and 5-year survival rates were 77 and 40 per cent, respectively, whereas the Stage IV 1- and 5-year survival rates were 54 and 27.6 per cent, respectively. Patients treated without surgery had poor survival at 1 year for both Stage III (13%) and Stage IV (16%) (P < 0.01 compared with the surgical groups). Lymph node dissection was performed in 26 per cent of the patients with advanced ACC and was associated with improved survival in univariate analysis of Stage IV patients. Overall, our results indicate that favorable survival outcomes can be achieved even in patients with Stage III and IV disease and surgery should be considered in patients with advanced ACC.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2013

Outcomes of vascular resection in pancreaticoduodenectomy: single-surgeon experience.

Am Surg 2013 Oct;79(10):1064-7

Hepatobiliary and Pancreatic Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Extension of pancreatic adenocarcinoma into adjacent vasculature often necessitates resection of the portal vein (PV) and/or superior mesenteric vein (SMV) during pancreaticoduodenectomy (PD). The vein is reconstructed primarily by end-to-end anastomosis of vein remnants or venoplasty or by use of autologous or synthetic vein grafts. The objective of this study was to review outcomes in patients undergoing PD for pancreatic adenocarcinoma, specifically comparing the short- and long-term outcomes between the patients undergoing vascular resection and those undergoing standard PD. All patients undergoing PD for pancreatic adenocarcinoma by a single surgeon between 2007 and 2012 were reviewed. Of the 61 patients identified, 18 patients underwent vascular resection of the PV (four patients), SMV (10 patients), or both (four patients). The remaining 43 patients had standard PD. Demographic, perioperative, pathological, and long-term outcomes data were collected and both vascular and standard groups were compared. Both groups had similar demographics. The vascular group had significantly longer operative times (529 vs 406 minutes; P < 0.01) with a trend to greater estimated blood loss (0.64 vs 0.53 L; P = 0.06). Pathological analysis showed no difference between the two groups with regard to lymph node status/ratio and rate of R0 resection (94 vs 91%; P = 0.57); however, the size of the tumor was significantly greater in the vascular group (4.2 vs 3 cm; P < 0.01). Short-term outcomes were similar in the vascular group and standard group, respectively, with no difference in pancreatic fistula rate (6 vs 7%; P = 1.0), transfusion rate (44 vs 35%; P = 0.57), and median length of stay (8 vs 7 days; P = 0.10), and there was no 30-day mortality in either group. Based on Kaplan-Meier methods, the median recurrence-free survival was 18 versus 23 months (P = 0.37) in the vascular and standard groups, respectively, and the overall survival was almost identical in both groups, each with a median of 31 months (P = 0.91). In our experience, mesenteric and PV resection during PD was performed safely and without compromise of short- or longer-term outcomes. It can be performed safely and patients have no significant difference in perioperative outcomes or overall survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2013

Unsuspected fluorodeoxyglucose positron emission tomography (FDG-PET)-positive pancreatic lesions: prevalence and significance.

Pancreas 2013 Oct;42(7):1191-3

Division of Endocrinology, Cedars-Sinai Medical Center Los Angeles, CA Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA Department of Imaging Cedars-Sinai Medical Center Los Angeles, CA Division of Endocrinology, and Carcinoid and Neuroendocrine Tumor Center Cedars-Sinai Medical Center Los Angeles, CA

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0b013e318287d06eDOI Listing
October 2013

Hepaticojejunostomy using short-limb Roux-en-Y reconstruction.

JAMA Surg 2013 Mar;148(3):253-7; discussion 257-8

Division of Transplantation, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.

Importance: When performing biliary reconstruction, one of the long-standing tenets of surgery is that Roux-en-Y (RY) reconstruction should use a long hepatic limb to decrease the risk for postoperative cholangitis. However, this practice is not well supported and may also make postoperative biliary endoscopy difficult. While some authors recommend Roux limbs of up to 75 cm, we have routinely used a Roux length of 20 cm to facilitate possible postoperative endoscopic access.

Objective: To review our experience with short-limb RY hepaticojejunostomy (HJ) and examine the short-term and long-term outcomes following this procedure, as well as the success of future biliary interventions.

Design: Retrospective medical record review of all patients who underwent short-limb RYHJ by 2 surgeons (N.N.N. and S.D.C.).

Setting: Tertiary care, university-affiliated teaching hospital.

Participants: One hundred patients who underwent RYHJ were identified, with 30 of those patients being excluded owing to creation of an RYHJ to intrahepatic bile ducts with concomitant liver resection.

Main Outcomes And Measures: Patient records were reviewed to determine the incidence of postoperative cholangitis and biliary stricture. Secondary outcomes were the need for postoperative biliary endoscopy and success rates for endoscopic biliary interventions. RESULTS Seventy patients underwent short-limb RYHJ over an 11-year period (2001-2012). Indications included benign stricture (n = 18), malignant stricture (n = 12), choledochal cyst (n = 5), choledocholithiasis (n = 3), idiopathic cholangitis (n = 2), and deceased donor or live donor liver transplant (n = 30). Seven patients, including 4 liver transplant patients, developed clinical or radiographic evidence of postoperative biliary stricture, and all patients underwent successful endoscopic cholangiography. Four of these patients required dilation and/or stone extraction, which were accomplished endoscopically in all cases.

Conclusions And Relevance: Short-limb RYHJ is safe and associated with a low incidence of postoperative complications. In addition, biliary intervention, when indicated, can be performed endoscopically with a high degree of success. In the absence of any evidence demonstrating longer limbs to be superior, we recommend using short-limb RY reconstruction for HJ.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2013.601DOI Listing
March 2013

Mixed acinar-endocrine carcinoma of the pancreas: new clinical and pathological features in a contemporary series.

Pancreas 2013 Apr;42(3):429-35

Division of Endocrinology, Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.

Objective: The objective of this study was to characterize the novel clinical and pathological features of mixed acinar-endocrine carcinoma of the pancreas.

Methods: This was a retrospective review of medical records and surgical pathology specimens of patients with a diagnosis of mixed acinar-endocrine carcinoma of the pancreas at Cedars-Sinai Medical Center between 2005 and 2011. Additional immunohistochemistry was performed on the specimens of some patients.

Results: Five patients were identified. The median age at presentation was 74 years (range, 59-89 years), and all patients were male. The presenting symptoms were all related to tumor mass effects. The median size of the tumor was 10 cm (range, 3.9-16 cm). Preoperative clinical diagnosis aided by fine-needle aspiration biopsy was incorrect in all 5 cases. Most tumors (3/5) exhibited predominantly endocrine differentiation without hormonal production. Only 10% to 30% of cells were truly amphicrine, whereas most were differentiated into either endocrine or acinar phenotype. The clinical behavior ranged from moderate to aggressive with postoperative survival from 2.5 months to more than 3 years. Four patients received neoadjuvant or adjuvant chemotherapy with variable responses.

Conclusions: Mixed acinar-endocrine carcinoma of the pancreas appears to be not uncommon in men, may harbor predominantly endocrine component, is often misdiagnosed by cytology, and exhibits variable clinical behavior. Mixed acinar-endocrine carcinoma of the pancreas should be considered in older patients with sizable pancreatic mass and may warrant aggressive surgical resection and chemotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MPA.0b013e318264d073DOI Listing
April 2013

Universal multifunctional HD video system for minimally invasive, [corrected] open and microsurgery.

Surg Endosc 2013 Mar 9;27(3):782-7. Epub 2012 Oct 9.

Liver Transplant and Hepatobiliary Surgery, Department of Surgery, Cedars-Sinai Medical Center, 8635 W Third Street, Suite 590W, Los Angeles, CA 90048, USA.

Background: Laparoscopy has familiarized most surgeons with the benefits of a surgical video system, including the ability to magnify fine structures, to display the operative field on a monitor for improved intraoperative communication, and to capture video footage for documentation and education. Use of intraoperative video systems during open surgery is far less common and the potential benefits of this have not been well explored. In this report we describe a simple video system that is applicable to both laparoscopic and open surgery.

Methods: We employed a standard laparoscopic HD camera (1080p) and telescope for initial laparoscopy. In cases requiring laparotomy, a mechanical arm is attached to the operating table and the camera is mounted without the telescope; this provides video display of the open surgical field. In cases requiring dissection or anastomosis of minute structures, a prototype telescope made for open cases is attached to the same camera; this provides improved magnification and illumination for the surgeon. Microsurgical components can then proceed with the surgeon working off the video monitor at a more convenient posture and with the benefits of video display.

Results: This multifunctional HD video system for open abdominal surgery has been utilized in 98 complex hepatopancreaticobiliary surgeries. Clear benefits include (1) improved intraoperative communication, (2) improved teaching of bystanders, (3) improved visualization of minute structures, and (4) improved capture and utilization of surgical video and images for education. In an analysis of patients who underwent pancreaticoduodenectomy (PD) with this system, there was a trend toward fewer pancreatic leaks and shorter length of stay but slightly longer operative time compared to PD prior to implementation of this system.

Conclusions: This system can be employed with little added cost over a standard laparoscopy setup and has the potential to be widely utilized in surgical education programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-012-2552-5DOI Listing
March 2013

A simple algorithm for drain management after pancreaticoduodenectomy.

Am Surg 2012 Oct;78(10):1143-6

Department of Surgery, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.

Pancreatic fistula (PF) continues to be the Achilles' heel of pancreaticoduodenectomy (PD) with both morbidity and mortality linked to its occurrence. The optimal drain management strategy after PD remains unclear. We evaluated drain amylase (DA) levels on postoperative Day (POD) 0 to 5 in 76 consecutive patients undergoing PD to determine the patterns associated with PF. Of these 76 patients, eight patients (11%) developed Grade A, B, or C PF by International Study Group of Pancreatic Fistula criteria. POD 1 DA levels correlated closely with PF rates when high (greater than 5000 U/L, 100% PF rate) and low (less than 100 U/L, 2% PF rate). In patients with intermediate POD 1 DA (100 to 5000 U/L), 42 and 74 per cent had low DA levels on POD 3 and 5, respectively, and the PF rate was four of 31 (13%). Overall, the temporal pattern of decreasing DA levels after PD correlates closely with the risk of PF, and only two patients (5%) developed PF after early DA levels had normalized. Based on these data, we propose an algorithm of monitoring DA daily with drain removal when the level is less than 100 U/L. In our patient group drain removal would have occurred on a mean of 1.8 days and median 1 day after surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
October 2012

Novel syndrome of four-limb proximal fragility fractures associated with HIV infection, cholestatic liver failure, and histiocytic infiltration of bone marrow.

Hormones (Athens) 2012 Apr-Jun;11(2):203-6

Division of Endocrinology, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Los Angeles, CA 90048, USA.

We report a syndrome of four-limb proximal fragility fractures associated with HIV infection, cholestatic liver failure, and histiocytic infiltration of bone marrow in a 40-year-old African American man. The patient presented with multiple fractures in the proximal humeri and femurs without osteopenia in the vertebrae. His right humerus appeared normal on chest X-ray film 3 years before presentation when he was first diagnosed with HIV infection and abnormal liver functions. At presentation, the patient had vitamin D deficiency, hypogonadism, and low IGF- 1 levels, but did not have hyperparathyroidism. Bone biopsy showed diffuse foamy histiocytic infiltration of bone marrow at all fracture sites without evidence of infectious or neoplastic processes. Exhaustive search did not identify any similar cases in the English literature. Our case likely represents a novel syndrome, the etiology of which is probably multifactorial and includes HIV infection, cholestatic liver failure, immobility, and endocrine abnormalities. The case further calls for the need for monitoring of bone health in patients with HIV infection or liver disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14310/horm.2002.1348DOI Listing
June 2013