Airway evaluation in obstructive sleep apnea.

Cholangiocarcinoma (CCA) is the most common biliary tract malignancy. CCA is classified as intrahepatic, perihilar or distal extrahepatic; the individual subtypes differ in their biologic behavior, clinical presentation, and management. Throughout the last decades, CCA incidence rates had significantly increased. In addition to known established risk factors, novel possible risk factors (i.e. obesity, hepatitis C virus) have been identified that are of high importance in developed countries where CCA prevalence rates have been low. CCA tends to develop on the background of inflammation and cholestasis. In recent years, our understanding of the molecular mechanisms of cholangiocarcinogenesis has increased, thereby, providing the basis for molecularly targeted therapies. In its diagnostic evaluation, imaging techniques have improved, and the role of complementary techniques has been defined. There is a need for improved CCA biomarkers as currently used ones are suboptimal. Multiple staging systems have been developed, but none of these is optimal. The prognosis of CCA is considered dismal. However, treatment options have improved throughout the last two decades for carefully selected subgroups of CCA patients. Perihilar CCA can now be treated with orthotopic liver transplantation with neoadjuvant chemoradiation achieving 5-year survival rates of 68%. Classically considered chemotherapy-resistant, the ABC-02 trial has shown the therapeutic benefit of combination therapy with gemcitabine and cisplatin. The benefits of adjuvant treatments for resectable CCA, local ablative therapies and molecularly targeted therapies still need to be defined. In this article, we will provide the reader with an overview over CCA, and discuss the latest developments and controversies.

Cancer review: Cholangiocarcinoma.

Liver transplantation for hepatic malignancies has emerged as a well-documented and proven treatment modality. However, early unsatisfactory results emphasized that only a highly selected patient population would benefit from transplantation. Currently, 15% of all liver transplants performed are for hepatocellular carcinoma (HCC). There is no controversy about the fact that liver transplantation for HCC in the adult population yields good results for patients whose tumour masses do not exceed the Milan criteria. It remains to be determined whether patients with more extensive tumours can be reliably selected to benefit from the procedure. In patients with small HCC at an early stage and preserved liver function, liver resection provides an alternative to transplant. Liver resection may offer similar survival results to orthotopic liver transplantation (OLT) in the short term, and does not carry the long-term effects of immunosuppression; however, long-term and disease-free survival favours liver transplantation. Very promising results have been obtained for cholangiocarcinoma treated by aggressive combination therapies, including chemo- and radiotherapy followed by OLT. Survival rate in these selected patients can approach that of patients with cholestatic liver disease, and the role of transplantation now requires re-evaluation. Similarly, hepatoblastoma is an excellent indication in paediatric patients with unresectable or recurrent tumours. Epithelioid hemangioendothelioma is also an appropriate indication for liver transplantation, even in the presence of extrahepatic metastases, unlike angiosarcoma which is associated with a very poor survival and considered as a contraindication. And finally for metastatic liver disease from neuroendocrine tumours, liver transplantation can result in long-term survival and even cure in well selected patients. Conversely, the value of transplantation for colorectal liver metastases (currently a contraindication) requires further evaluation by well-designed trials.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1432-2277.2008.00735.x

Liver transplantation for primary and metastatic liver cancers

Objectives/Hypothesis: Although precise localization of obstruction sites in the upper airway during sleep is essential in subjects with obstructive sleep apnea syndrome (OSAS), no gold standard diagnostic method has been established. This study aimed to evaluate the dynamic collapse inside the upper airway by using cine magnetic resonance imaging (MRI), also called sleep MRI. Study Design: Cross-sectional study with retrospective data. Methods: The changes in the transverse and anteroposterior diameters of the retrolingual airway were studied during a respiratory cycle in 35 snoring subjects. The collapsibility of the airway was calculated by using axial images, and the actual obstruction sites were also identified by using sagittal images. Results: Airway collapse occurred in the retropalatal area in 13 (37.1%) of 35 subjects and in both the retropalatal and retrolingual regions in 20 subjects (57.1%). The respiratory disturbance index (RDI) and supine RDI were higher and the minimal oxygen saturation during sleep (MinSaO2) value was lower in subjects with both retropalatal and retrolingual obstruction than in those with only retropalatal obstruction. Airway collapse analyzed by using axial images was classified into four subgroups: patent group (five of 35, 14.2%), anteroposterior collapse group (one of 35, 2.9%), transverse collapse group (14 of 35, 40%) and circumferential collapse group (15 of 35, 42.9%). Supine RDI, MinSaO2, and age were significantly different between these four groups. In addition, anteroposterior, transverse, and circumferential collapses correlated well with MinSaO2. Significant correlation was also found between RDI/supine RDI and transverse collapse. Conclusions: Sleep MRI is a valuable method for evaluating dynamic obstruction during sleep and may be helpful in selecting the appropriate treatment approaches.

Sleep magnetic resonance imaging as a new diagnostic method in obstructive sleep apnea syndrome.

Purpose of review Surgical resection is the primary modality of treatment for hilar and intrahepatic cholangiocarcinoma (HCCA-ICCA). For unresectable early-stage HCCA, excellent long-term tumor recurrence-free patient survival has been achieved using a strict regimen of preoperative staging and neoadjuvant chemoradiation treatment followed by orthotopic liver transplantation (OLT). However, in the case of unresectable ICCA, data on outcomes after OLT are limited. The present article reviews the current literature on the surgical treatment of ICCA focusing on the role of OLT in combination with neoadjuvant therapy and risk stratification of patients being considered for transplantation for unresectable ICCA. Recent findings Numerous studies reported poor survival outcomes after OLT for ICCA. Recent data using a combination of neoadjuvant therapy followed by OLT in appropriately selected patients with unresectable ICCA demonstrated promising disease recurrence-free survival. Summary Risk stratification for patient selection is crucial to optimize survival outcomes. Excellent long-term disease recurrence-free survival can be achieved in selected patients with unresectable ICCA using a combination of OLT and neoadjuvant therapy. Current data support the expansion of liver transplant criteria for treatment of unresectable ICCA.

Orthotopic liver transplantation in combination with neoadjuvant therapy: a new paradigm in the treatment of unresectable intrahepatic cholangiocarcinoma.

Introduction. Palliative treatment for nondisseminated irresectable hilar cholangiocarcinoma (HCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than that for other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for HCC and identify prognostic factors for survival. Methods. We retrospectively reviewed 36 patients undergoing OLT for HCC over 13 years. Results. The actuarial survival rate at 1, 3, and 5 years was 82%, 53%, and 30%, respectively. The main cause of death was tumor recurrence (53%). In the univariate analysis, the factors for a poor prognosis were vascular invasion (P .001) namely 0% survival at 3 years when present versus 63% and 35% at 3 and 5 years, respectively, when it was not; and stages III to IVA (P .05), namely 15% survival at 5 years versus 47% for stages I to II. Lymph node and perineural invasion also reduce survival. In the multivariate analysis, the factors for poor prognosis included vascular invasion (P .01) and stages III to IVA (P .01). Conclusions. OLT for nondisseminated irresectable HCC has higher survival rates at 3 and 5 years than palliative treatments, especially with initial stage tumors, which means that more information is needed to better select cholangiocarcinoma patients for transplantation.

Liver transplantation for hilar cholangiocarcinoma: Spanish experience.

Introduction Palliative treatment for nondisseminated unresectable peripheral cholangiocarcinoma (PCC) carries a 0% 5-year survival rate. The role of orthotopic liver transplantation (OLT) in these patients is controversial because the survival rate is lower than with other indications for transplantation and the lack of available donor organs. The aim of this paper was to review the Spanish experience in OLT for PCC to identify prognostic factors for survival. Methods We retrospectively reviewed 23 patients undergoing OLT in Spain for PCC over a period of 13 years. Results The actuarial survival rates were 77%, 65%, and 42% at 1, 3, and 5 years, respectively. The main cause of death was tumor recurrence (35%). Prognotic factors for an adverse outcome were pTNM classification (P Conclusions OLT for nondisseminated irresectable PCC displays higher survival rates at 3 and 5 years than palliative treatments, especially for tumors in the initial stages, which means that more information is needed to help better select PCC patients for transplantation.

http://www.biblioteca.uma.es/bbldoc/articulos/1664198x.pdf

Liver transplantation for peripheral cholangiocarcinoma: Spanish experience

Dynamic changes in the upper airway during sleep have been identified in patients with obstructive sleep apnea syndrome (OSAS). Fiberoptic nasopharyngoscopy with the Muller maneuver (FNMM) has been advocated as a practical, clinically useful, preoperative dynamic diagnostic method for assessing the site of collapse. The value of FNMM in predicting response to uvulopalatopharyngoplasty (UPPP) was assessed in patients with obstructive sleep apnea syndrome. Results indicate that preoperative FNMM can reliably enhance surgical success.

C Marín

Papers

Liver transplantation for hilar cholangiocarcinoma: Spanish experience.

Liver transplantation for peripheral cholangiocarcinoma: Spanish experience

Predictive value of the Müller maneuver in obstructive sleep apnea syndrome