- Email: [email protected]
Predictive Factors Determining Survival in Ambulatory Cirrhotic HCC Patients & Survival Analysis Using ALBI & Child Score
2 months duration. Ascitic fluid analysis revealed non pleocytic low SAAG high protein ascites and negative for malignant cells. Routine blood chemistry were normal. Endoscopy and colonoscopy were normal. Contrast enhanced computed tomography (CECT) revealed heterogenously enhancing mass in the right hemithorax with liver metastasis, gross ascites, omental thickening and pelvic deposits. He underwent transesophageal EUS-FNA from lung mass as it was less than 1 cm from esophagus, transgastric EUS-FNA of peritoneal deposits. Both the samples revealed signet ring cell adenocarcinoma. He received 2 cycles of chemotherapy before succumbing to the illness. Patient B: A 83 year old female, diabetic for 10 years, presented with abdominal pain and significant weight loss for 1 month duration. Routine blood investigations, endoscopy and colonoscopy were normal. CECT abdomen revealed shrunken liver, mass lesion in the tail of pancreas and mild ascites. Transgastric EUS-FNA was done from the hypoechoic hard mass lesion in tail of pancreas using a 22G wilson cook FNA needle. Transrectal EUS FNA was done from omental deposits using another needle. Both the samples revealed adenocarcinoma. A diagnosis of metastatic carcinoma of pancreas was made and she received 6 cycles of chemotherapy before succumbing to the illness. Conclusion: Ability of EUS-FNA to adequately sample minimal ascites, pelvic or peritoneal deposits can be an useful modality for the standard metastatic workup.
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.140
Case Summary: Patient A: A 63 year old male diagnosed case of cryptogenic decompensated chronic liver disease presented with abdominal pain, pelvic abdominal mass and significant weight loss of 10 kg for 1 month duration. Contrast enhanced computed tomography (CECT) abdomen revealed 1–3 cm multiple lesions in both lobes of liver, 3–15 cm multiple enhancing pelvic deposits and moderate ascites. Alfa fetoprotein(AFP) levels were elevated—414 ng/mL (normal: <10 ng/mL). Transrectal endoscopic ultrasound revealed 7X5 cm heteroechoic pelvic mass with moderate ascites in pararectal area. Fine needle aspiration biopsy was done using 22 GuageWilson cook aspiration needle. On microscopy and immunohistochemistry (IHC) revealed hepatocyte paraffin (HepPar1), Alfa 1 anti-trypsin were negative, AFP and cytokeratin—CK 7 were positive and a diagnosis of clear cell variant of hepatocellular carcinoma (CHCC) was made. He was treated with sorafenib, but succumbed to illness after 4 months of diagnosis. Patient B: A 77year old male, diagnosed case of HCC BCLC stage D (diagnosed earlier based on CECT and AFP findings) on sorafenib for 4 months, under regular follow up with primary endoscopic variceal ligation schedule presented with hemetemesis and melena. Emergency endoscopy was performed which revealed small esophageal varices, diffusely hyperemic stomach with multiple submucosal hemorrhagic lesions with surface umbilication-biopsies were taken. Microscopy and IHC stains were diagnostic of metastatic HCC (positive for Hep Par 1 and negative for CK7, CDX-2). Conclusion: Due to improved short-term survival in HCC, uncommon metastasis to peritoneum and stomach might become common.
CONFLICTS OF INTEREST The authors have none to declare.
3 TWO UNCOMMON METASTASIS OF HEPATOCELLULAR CARCINOMA—A CASE REPORT Sanjeev Nagaruru ∗ , Avinash Balekudru, Kiran Reddiwari, L.V. Lokesh, B.S. Satyaprakash, Ravi Kiran M S Ramaiah Medical College, Bangalore, India
E-mail address: [email protected] (S. Nagaruru). Background: Hepatocellular carcinoma (HCC) constitutes more than 90% of primary liver cancers and extra hepatic spread are to lung, lymph nodes, bones and adrenals in decreasing order. We report 2 rare cases of metastatic HCC one each to peritoneum and stomach presenting with abdominal mass and gastrointestinal bleeding.
http://dx.doi.org/10.1016/j.jceh.2017.05.141
4 PREDICTIVE FACTORS DETERMINING SURVIVAL IN AMBULATORY CIRRHOTIC HCC PATIENTS & SURVIVAL ANALYSIS USING ALBI & CHILD SCORE Aniruddha P. Haripal Singh ∗ , Krishnadas Devadas, Srijaya Sreesh, Gaurav Kapur, Varun Tadkalkar, Rathan C. Joseph, Neehar Shanavas Medical College, Thiruvananthapuram, India
E-mail address: [email protected] (A.P. Haripal Singh).
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S77
NEOPLASMS
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
NEOPLASMS
Table 1 Multivariate Cox Regression Analysis. Variable ALBI Grade CHILD PUGH STATUS Serum creatinine Serum Albumin INR Serum Bilirubin Platelet
HR 2.423 1.37 1.519 0.353 3.454 1.11 1
P-value 0.002 0.05 0.055 0.000 0.000 0.001 0.015
CI 1.368–4.291 0.991–2.328 0.991–2.328 0.212–0.588 1.854–6.436 1.043–1.182 1–1
CONFLICTS OF INTEREST The authors have none to declare. Figure 1. Kaplain Meir Survival curve of ALBI & Child-Pugh grades.
NEOPLASMS
Background and Aim: Identifying accurate prognostic indicators of overall survival (OS) in Hepatocellular carcinoma (HCC) allows care provider to counsel Individual patients and utilize optimum resources. In this study we aim to find out predictive factors determining survival in ambulatory cirrhotic HCC patients & further assess survival using ALBI & CHILD Score. Methods: In this observational study at MCH Thiruvananthapuram, All patients with diagnosis of HCC from January 2011 to December 2016 were studied who received standard of care and predictors of survival were studied with parameters measured before any treatment and within 6 weeks of diagnosis. A total of 202 were included and predictive factors in terms of OS were studied. Results: In our cohort of 202 cirrhotic patients, 164 were males and 38 were females. 43% were HBV related, 20% NASH and 17% Ethanol related. 36% CHILD A, 33% CHILD B and 30% CHILD C. 11%, 55% and 34% were ALBI grade 1, 2 and 3 respectively calculated using an online calculator by Stanford university, 13%, 27%, 28%, 31% were BCLC A, B, C and D respectively. 88% died on follow up. On Multivariate regression ALBI grade, CHILD status, Serum creatinine, serum albumin, INR, Serum Bilirubin, Platelet count, % Neutrophils were identified as factors affecting OS in HCC patients. Visual Inspection of the resulting Kaplain Meir survival curves shows equal good discrimination between the 3 ALBI groups & the CHILD grades. Median survival was 17, 6.6, 1.6 months in ALBI grade 1, 2 and 3 respectively & 10, 5, and 2 months in CHILD A, B and C respectively. Conclusion: ALBI grade offers a simple, evidencebased, objective, and discriminatory method of assessing liver function in HCC that has been extensively tested in an international setting (Figure 1 and Table 1).
S78
http://dx.doi.org/10.1016/j.jceh.2017.05.142
5 INFANTILE HEMANGIOENDOTHELIOMA PRESENTING AS NEONATAL CHOLESTASIS SYNDROME: AN UNCOMMON PRESENTATION OF A VERY RARE CAUSE Sajan Agarwal ∗ , Madhur Jain, Raj K. Gupta SMS Medical College, Jaipur, India
E-mail address: [email protected] (S. Agarwal). Case Summary: 30-day-old female baby, born by full term delivery, admitted with complaints of noticed yellowish discoloration of eye and urine for last 15 days with diaper staining and ambiguous stool. On examination, baby had deep icterus with hemangioma like lesion over anterior abdominal wall and firm hepatosplenomegaly. In work up, there was severe anemia with thrombocytopenia and LFT showed high conjugated hyperbilirubinemia with high GGT. USG abdomen showed multiple hypoechoic lesion with hyperechoic rim (largest lesion 22 mm × 13 mm) noted in both lobes of liver and portal vein thrombosis with lesion communicating with left portal vein. CECT Abdomen with triple phase was also done for further confirmation which confirmed the USG findings with peripheral rim enhancement of lesions. Based on above details, final diagnosis of Infantile Hemangioendothelioma with obstructive jaundice, portal vein thrombosis, and consumption coagulopathy (KasabachMerritt syndrome) was made. Baby was managed medically with steroid and propanolol therapy. On Day 4 of therapy, there was drastic fall in jaundice with improvement in coagulopathy and reduction in lesion size. Baby was discharged on same therapy after parent’s persistent request (Figure 1). Conclusion: Infantile hemagioendothelioma can present with NCS and it should also be kept in differential diagnosis of NCS. © 2017, INASL
CONFLICTS OF INTEREST The authors have none to declare. http://dx.doi.org/10.1016/j.jceh.2017.05.140
Case Summary: Patient A: A 63 year old male diagnosed case of cryptogenic decompensated chronic liver disease presented with abdominal pain, pelvic abdominal mass and significant weight loss of 10 kg for 1 month duration. Contrast enhanced computed tomography (CECT) abdomen revealed 1–3 cm multiple lesions in both lobes of liver, 3–15 cm multiple enhancing pelvic deposits and moderate ascites. Alfa fetoprotein(AFP) levels were elevated—414 ng/mL (normal: <10 ng/mL). Transrectal endoscopic ultrasound revealed 7X5 cm heteroechoic pelvic mass with moderate ascites in pararectal area. Fine needle aspiration biopsy was done using 22 GuageWilson cook aspiration needle. On microscopy and immunohistochemistry (IHC) revealed hepatocyte paraffin (HepPar1), Alfa 1 anti-trypsin were negative, AFP and cytokeratin—CK 7 were positive and a diagnosis of clear cell variant of hepatocellular carcinoma (CHCC) was made. He was treated with sorafenib, but succumbed to illness after 4 months of diagnosis. Patient B: A 77year old male, diagnosed case of HCC BCLC stage D (diagnosed earlier based on CECT and AFP findings) on sorafenib for 4 months, under regular follow up with primary endoscopic variceal ligation schedule presented with hemetemesis and melena. Emergency endoscopy was performed which revealed small esophageal varices, diffusely hyperemic stomach with multiple submucosal hemorrhagic lesions with surface umbilication-biopsies were taken. Microscopy and IHC stains were diagnostic of metastatic HCC (positive for Hep Par 1 and negative for CK7, CDX-2). Conclusion: Due to improved short-term survival in HCC, uncommon metastasis to peritoneum and stomach might become common.
CONFLICTS OF INTEREST The authors have none to declare.
3 TWO UNCOMMON METASTASIS OF HEPATOCELLULAR CARCINOMA—A CASE REPORT Sanjeev Nagaruru ∗ , Avinash Balekudru, Kiran Reddiwari, L.V. Lokesh, B.S. Satyaprakash, Ravi Kiran M S Ramaiah Medical College, Bangalore, India
E-mail address: [email protected] (S. Nagaruru). Background: Hepatocellular carcinoma (HCC) constitutes more than 90% of primary liver cancers and extra hepatic spread are to lung, lymph nodes, bones and adrenals in decreasing order. We report 2 rare cases of metastatic HCC one each to peritoneum and stomach presenting with abdominal mass and gastrointestinal bleeding.
http://dx.doi.org/10.1016/j.jceh.2017.05.141
4 PREDICTIVE FACTORS DETERMINING SURVIVAL IN AMBULATORY CIRRHOTIC HCC PATIENTS & SURVIVAL ANALYSIS USING ALBI & CHILD SCORE Aniruddha P. Haripal Singh ∗ , Krishnadas Devadas, Srijaya Sreesh, Gaurav Kapur, Varun Tadkalkar, Rathan C. Joseph, Neehar Shanavas Medical College, Thiruvananthapuram, India
E-mail address: [email protected] (A.P. Haripal Singh).
Journal of Clinical and Experimental Hepatology July 2017 Vol. 7 No. S2
S77
NEOPLASMS
JOURNAL OF CLINICAL AND EXPERIMENTAL HEPATOLOGY
NEOPLASMS
Table 1 Multivariate Cox Regression Analysis. Variable ALBI Grade CHILD PUGH STATUS Serum creatinine Serum Albumin INR Serum Bilirubin Platelet
HR 2.423 1.37 1.519 0.353 3.454 1.11 1
P-value 0.002 0.05 0.055 0.000 0.000 0.001 0.015
CI 1.368–4.291 0.991–2.328 0.991–2.328 0.212–0.588 1.854–6.436 1.043–1.182 1–1
CONFLICTS OF INTEREST The authors have none to declare. Figure 1. Kaplain Meir Survival curve of ALBI & Child-Pugh grades.
NEOPLASMS
Background and Aim: Identifying accurate prognostic indicators of overall survival (OS) in Hepatocellular carcinoma (HCC) allows care provider to counsel Individual patients and utilize optimum resources. In this study we aim to find out predictive factors determining survival in ambulatory cirrhotic HCC patients & further assess survival using ALBI & CHILD Score. Methods: In this observational study at MCH Thiruvananthapuram, All patients with diagnosis of HCC from January 2011 to December 2016 were studied who received standard of care and predictors of survival were studied with parameters measured before any treatment and within 6 weeks of diagnosis. A total of 202 were included and predictive factors in terms of OS were studied. Results: In our cohort of 202 cirrhotic patients, 164 were males and 38 were females. 43% were HBV related, 20% NASH and 17% Ethanol related. 36% CHILD A, 33% CHILD B and 30% CHILD C. 11%, 55% and 34% were ALBI grade 1, 2 and 3 respectively calculated using an online calculator by Stanford university, 13%, 27%, 28%, 31% were BCLC A, B, C and D respectively. 88% died on follow up. On Multivariate regression ALBI grade, CHILD status, Serum creatinine, serum albumin, INR, Serum Bilirubin, Platelet count, % Neutrophils were identified as factors affecting OS in HCC patients. Visual Inspection of the resulting Kaplain Meir survival curves shows equal good discrimination between the 3 ALBI groups & the CHILD grades. Median survival was 17, 6.6, 1.6 months in ALBI grade 1, 2 and 3 respectively & 10, 5, and 2 months in CHILD A, B and C respectively. Conclusion: ALBI grade offers a simple, evidencebased, objective, and discriminatory method of assessing liver function in HCC that has been extensively tested in an international setting (Figure 1 and Table 1).
S78
http://dx.doi.org/10.1016/j.jceh.2017.05.142
5 INFANTILE HEMANGIOENDOTHELIOMA PRESENTING AS NEONATAL CHOLESTASIS SYNDROME: AN UNCOMMON PRESENTATION OF A VERY RARE CAUSE Sajan Agarwal ∗ , Madhur Jain, Raj K. Gupta SMS Medical College, Jaipur, India
E-mail address: [email protected] (S. Agarwal). Case Summary: 30-day-old female baby, born by full term delivery, admitted with complaints of noticed yellowish discoloration of eye and urine for last 15 days with diaper staining and ambiguous stool. On examination, baby had deep icterus with hemangioma like lesion over anterior abdominal wall and firm hepatosplenomegaly. In work up, there was severe anemia with thrombocytopenia and LFT showed high conjugated hyperbilirubinemia with high GGT. USG abdomen showed multiple hypoechoic lesion with hyperechoic rim (largest lesion 22 mm × 13 mm) noted in both lobes of liver and portal vein thrombosis with lesion communicating with left portal vein. CECT Abdomen with triple phase was also done for further confirmation which confirmed the USG findings with peripheral rim enhancement of lesions. Based on above details, final diagnosis of Infantile Hemangioendothelioma with obstructive jaundice, portal vein thrombosis, and consumption coagulopathy (KasabachMerritt syndrome) was made. Baby was managed medically with steroid and propanolol therapy. On Day 4 of therapy, there was drastic fall in jaundice with improvement in coagulopathy and reduction in lesion size. Baby was discharged on same therapy after parent’s persistent request (Figure 1). Conclusion: Infantile hemagioendothelioma can present with NCS and it should also be kept in differential diagnosis of NCS. © 2017, INASL