Papers by Alessandro Cucchetti
Background: The benefit of surgical intervention for cancer should be estimated in relation to th... more Background: The benefit of surgical intervention for cancer should be estimated in relation to the life expectancy of the general population. The aim of this study was to provide a measure of relative survival after hepatectomy for hepatocellular carcinoma (HCC). Methods: Consecutive patients with liver cirrhosis and HCC who underwent hepatectomy were divided into age quartiles for analysis. Short-and mid-term survival rates were used to estimate survival until death for all patients, in relation to age and other co-variables. Years of life lost (YLL) were estimated using a reference cohort, derived from the general population matched for sex, age and year of diagnosis. Results: Some 919 patients were included in the study. The following age quartiles were identified: less than 60 years (229 patients), 60–66 years (230), 67–70 years (231) and over 70 years (229). Postoperative mortality rates were similar between age quartiles, as were survival rates up to 3 years (P = 0⋅404). A statistically significant reduction in 5–10-year survival rates was observed with ageing (P = 0⋅001). Relative survival calculation showed that the youngest age quartile (less than 60 years) experienced the longest entire postoperative lifespan (15⋅6 years) but also the greatest number of YLL (11⋅0 years). Patients aged over 70 years had the shortest entire postoperative lifespan (6⋅4 years) but also the smallest number of YLL (3⋅7 years). Conclusion: Although survival after liver resection for HCC is shortest in elderly patients, relative survival estimates suggest that hepatectomy can be of benefit in these patients, with a small loss of the entire individual lifespan.
Liver international : official journal of the International Association for the Study of the Liver, Jan 20, 2016
Indocyanine green retention test (ICG-r15) is a non-invasive marker of functional hepatic reserve... more Indocyanine green retention test (ICG-r15) is a non-invasive marker of functional hepatic reserve. Among patients with compensated cirrhosis, ICG-r15 correlates to the degree of portal hypertension (PH); however, its prognostic relationship with the occurrence of decompensation events still requires clarification. ICG-r15 was prospectively measured in 154 patients with compensated cirrhosis. Patients with hepatocellular carcinoma (HCC), Child-Pugh B-C, MELD>15, bilirubin>2mg/dL, INR>1.5 or portal vein thrombosis were excluded. All patients underwent laboratory tests, upper endoscopy and hepatic venous pressure gradient (HVPG). Decompensation, development of HCC, liver transplant and death were recorded and analyzed through competing risk analysis. The study group was composed of one hundred and thirty four patients who were followed for a median of 39 months. During follow-up, 46 patients (34.3%) developed liver decompensation. Hepatocellular carcinoma occurred in 18 patien...
Pancreas, Jan 5, 2015
The chance to improve survival from pancreatic adenocarcinoma relies on early diagnosis through s... more The chance to improve survival from pancreatic adenocarcinoma relies on early diagnosis through screening, but any screening program is subject to lead-time bias and no data are available in this regard. Aim of the present study was to evaluate the benefit obtainable from a screening program for early detection of pancreatic adenocarcinoma, considering screen-related biases. Monte Carlo simulation was performed using data from 1000 pancreatic cancer patients admitted in a tertiary referral hospital and from pertinent literature. Lead-time bias was assessed and subtracted from expected survival. Mean expected life expectancy was 13.0 months. Assuming a 20%, 30%, or 50% stage III/IV reduction with screening, pancreatic resections would increase from 217 to 290 in front of a 20% stage III/IV reduction to 324 in front of a 30% reduction and to 385 in front of a 50% reduction. After lead-time adjustment, life expectancies were 14.0, 14.6, and 15.9 months, respectively. The number-needed-...
Liver International, 2015
To develop an individual prognostic calculator for patients with unresectable hepatocellular carc... more To develop an individual prognostic calculator for patients with unresectable hepatocellular carcinoma (HCC) undergoing trans-arterial chemo-embolization (TACE). Data from two prospective databases, regarding 361 patients who received TACE as first-line therapy (2000 - 2012), were reviewed in order to refine available prognostic tools and to develop a continuous individual web-based prognostic calculator. Patients with neoplastic portal vein invasion were excluded from the analysis. The model was built following a bootstrap re-sampling procedure aimed at identifying prognostic predictors and by carrying out a 10-fold cross validation for accuracy assessment by means of Harrell's c-statistic. Number of tumours, serum albumin, serum total bilirubin, alpha-fetoprotein and maximum tumour size were selected as predictors of mortality following TACE with the bootstrap re-sampling technique. In the 10-fold cross-validation cohort, the model showed a Harrell's c-statistic of 0.649 (95%CI: 0.610 - 0.688), significantly higher than that of the Hepatoma Arterial-embolization Prognostic (HAP) score (0.589; 95%CI: 0.552 - 0.626; P=0.001) and of the modified HAP-II score (0.611; 95%CI: 0.572 - 0.650; P=0.005). Akaike's information criterion for the model was 2520; for the mHAP-II it was 2544 and for the HAP score it was 2554. A web-based calculator was developed for quick consultation at http://www.livercancer.eu/mhap3.html CONCLUSIONS: The proposed individual prognostic model can provide an accurate prognostic prediction for each patient with unresectable HCC following treatment with TACE without class stratification. The availability of an online calculator can help physicians in daily clinical practice. This article is protected by copyright. All rights reserved.
Tumori
Focal nodular hyperplasia (FNH) is an infrequent benign tumor of the liver that is generally beli... more Focal nodular hyperplasia (FNH) is an infrequent benign tumor of the liver that is generally believed to have no potential for malignant transformation; the coexistence of FNH and hepatocellular carcinoma (HCC) has seldom been reported. Here we describe an exceptional case of simultaneous FNH and HCC in the same patient and discuss the clinical and therapeutic management of FNH on the basis of a review of the literature.
Hepato-gastroenterology
ABSTRACT
World Journal of Surgery, 2015
Hepato-gastroenterology
An aggressive surgical approach in the management of gallbladder cancer (GBC) has improved surviv... more An aggressive surgical approach in the management of gallbladder cancer (GBC) has improved survival significantly in recent years. The aim of this retrospective study is to evaluate the long-term results of surgical treatment of GBC reassessed following the TNM staging system of the AJCC-2002. The present series considers 118 patients with GBC treated between 1982 and 2003. Seventy-four cases (63%) were females and 44 (37%) males; overall age was 63 years (range 38-91). Among the 118 patients with GBC, 35 (36%) underwent radical surgery: 3 pTNM IA [3 cholecystectomy (CT)], 10 IB [3CT, 3 CT + hepatic resection (HR), 4 HR], 3 IIA (3 HR), 7 IIB (3 CT+HR+ bile duct resection (BDR), 3 HR, 1 hepatopancreatoduodenectomy +CT), 10 III [4 CT+HR, 5 extensive HR (eHR), 1 HR+right colectomy+BDR+total gastrectomy], 2 IV (2 eHR). Overall 1-, 3-, 5-year survival was 67%, 46%, 34% respectively for stage IA-IB; 63%,12%, 12% for IIA-IIB; 50%, 30%, 30% for III-IV (p=ns); in particular, 1-, 3-, 5-year s...
Introduction: Liver resection remains the gold standard in the treatment of colorectal metastases... more Introduction: Liver resection remains the gold standard in the treatment of colorectal metastases. Aim: To evaluate if there is any difference in clinical characteristics and outcome in the last 10 years compared to previously, in resected patients for colorectal metastases. Methods: Clinico-pathologic characteristics were compared between 342 resected patients before 1999 and 310 resected patients after 2000. Results: There was no difference in term of sex, age, mean tumor diameter and synchronous vs metachronous between the 2 groups. The median number of resected metastases/ patient was significantly increased after 2000 (1.7 (plus or minus) 1 vs 2.4 (plus or minus) 2, respectively). Postoperative mortality was similar (1.2 vs 2.3%), but morbidity increased from 19% up to 27.1%. There was a tendency to perform less number of major hepatectomies after 2000 (61.7% vs 55.2%, respectively). Blood transfusion was required in 44.7% of patients in the first group, and in only 23.9% after...
Background: Nowadays, liver transplantation (LT) for hepatocellular carcinoma (HCC) on cirrhosis ... more Background: Nowadays, liver transplantation (LT) for hepatocellular carcinoma (HCC) on cirrhosis is the best treatment in term of disease free survival. Owing the organ shortage, the aim of this study is to determine risk factors for HCC recurrence to better select patients to submit to OLT. Methods: Since 1986 until 2009, at University of Bologna 340 patients affected by HCC were transplanted. Among 340 patients transplanted, 288 (85%) were male and 52 (15%) were female.Mean MELD score was 17.05 (plus or minus) 7.06 (6-45), recipient age was 54.3 (plus or minus) 7.7 (11-67), donor age was 55.8 (plus or minus)19.67 (10-95). Mean waiting time was 291(plus or minus)310 days (1-2474), mean cold ischemia time was 423.89(plus or minus)165.63 min. (150-1860) and red blood cells infused were 2681 (plus or minus) 2769 cc. (0-18986).Considering pathologic features of the HCC, 107 (32%) resulted Edmonson G3 and number of nodules was 2.08(plus or minus)1.68 (1-9). Results: Post-operative morta...
Background: Primary transplantation offers longer lifeexpectancy in comparison to hepatic resecti... more Background: Primary transplantation offers longer lifeexpectancy in comparison to hepatic resection for hepatocellular carcinoma (HCC); however, the improved diagnostic and interventional techniques have greatly improved the survival after partial hepatectomy. Aim of the study was to compare the observed survival of transplantable patients submitted to resection to their predicted survival in case of liver transplantation. Methods: Clinical data and survivals of 123 transplantable patients (within Milan criteria) resected for HCC were reviewed and their predicted survival after listing for liver transplantation was calculated using a Markov model simulation based on literature data or estimated from the United Network for Organ Sharing (UNOS) database. Results: The mean observed 5-years life-expectancy after resection (33.7 (plus or minus) 18.9 months) was significantly lower than the predicted life-expectancy in case of listing for transplantation (37.4 (plus or minus) 12.1 months;...
Cancer, 2015
A patient can be considered statistically cured from a specific disease when their mortality rate... more A patient can be considered statistically cured from a specific disease when their mortality rate returns to the same level as that of the general population. In the current study, the authors sought to assess the probability of being statistically cured from intrahepatic cholangiocarcinoma (ICC) by hepatic resection. A total of 584 patients who underwent surgery with curative intent for ICC between 1990 and 2013 at 1 of 12 participating institutions were identified. A nonmixture cure model was adopted to compare mortality after hepatic resection with the mortality expected for the general population matched by sex and age. The median, 1-year, 3-year, and 5-year disease-free survival was 10 months, 44%, 18%, and 11%, respectively; the corresponding overall survival was 27 months, 75%, 37%, and 22%, respectively. The probability of being cured of ICC was 9.7% (95% confidence interval, 6.1%-13.4%). The mortality of patients undergoing surgery for ICC was higher than that of the general population until year 10, at which time patients alive without tumor recurrence can be considered cured with 99% certainty. Multivariate analysis demonstrated that cure probabilities ranged from 25.8% (time to cure, 9.8 years) in patients with a single, well-differentiated ICC measuring ≤5 cm that was without vascular/periductal invasion and lymph nodes metastases versus <0.1% (time to cure, 12.6 years) among patients with all 6 of these risk factors. A model with which to calculate cure fraction and time to cure was developed. The cure model indicated that statistical cure was possible in patients undergoing hepatic resection for ICC. The overall probability of cure was approximately 10% and varied based on several tumor-specific factors. Cancer 2015. © 2015 American Cancer Society.
Liver Transplantation, 2015
A moral liver allocation policy must be fair. Consider a two-step, two-principle allocation syste... more A moral liver allocation policy must be fair. Consider a two-step, two-principle allocation system called "age-mapping". Its first principle, equal opportunity, ensures that candidates of all ages have an equal chance of getting an organ. Its second principle, prudential lifespan equity, allocates younger donor grafts to younger candidates and older donors to older candidates in order to increase the likelihood that all recipients achieve a "full lifespan". Data from 2476 candidates and 1371 consecutive adult liver transplants (1999-2012) were used to determine whether age mapping can reduce the gap in years of life lost (YLL) between younger and older recipients. A parametric Weibull prognostic model was developed to estimate total life-expectancy after transplantation using survival of the general population matched by sex and age as reference. Life-expectancy from birth was calculated by adding age at transplant and total life-expectancy after transplantation. In multivariate analysis, recipient age, Hepatitis C status, Model for End-stage Liver Disease (MELD) score at transplant >30 and donor age were significantly related to prognosis after surgery (P<0.05). The mean (and standard deviation) number of years of life from birth, calculated from the current allocation model, for various age groups were: recipients 18-47 years (n=340) =65.2 (3.3); 48-54 years (n=387) =72.7 (2.1); 55-60 years (n=372) =74.7 (1.7) and for recipients >60 years (n=272) =77.4 (1.4). The total number of YLL equaled 523 years. Re-distributing liver grafts, using an "age-mapping" algorithm, reduces the lifespan gap between younger and older candidates by 33% (from 12.3% to 8.3%), and achieves a 14% overall reduction of YLL (73 years) compared to baseline liver distribution. In conclusion, deliberately incorporating age into an allocation algorithm promotes fairness and increases efficiency. This article is protected by copyright. All rights reserved.
Internal and Emergency Medicine, 2015
Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which h... more Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which have a challenging preoperative diagnosis. Early identification allows better surgical management. Contrast-enhanced computed tomography (ceCT) is the current diagnostic gold standard. Contrast-enhanced ultrasonography (CEUS) is a promising tool for the diagnosis of gallbladder perforation, but data from the literature concerning efficacy are sparse. The aim of the study was to evaluate CEUS findings in pathologically proven complicated cholecystitis (gangrenous, perforated gallbladder, pericholecystic abscess). A total of 8 patients submitted to preoperative CEUS, and with subsequent proven acute complicated cholecystitis at surgical inspection and pathological analysis, were retrospectively identified. The final diagnosis was gangrenous/phlegmonous cholecystitis (n. 2), phlegmonous/ulcerative changes plus pericholecystic abscess (n. 2), perforated plus pericholecystic abscess (n. 3), or perforated plus pericholecystic biliary collection (n. 1). Conventional US findings revealed irregularly thickened gallbladder walls in all 8 patients, with vaguely defined walls in 7 patients, four of whom also had striated wall thickening. CEUS revealed irregular enhancing gallbladder walls in all patients. A distinct wall defect was seen in six patients, confirmed as gangrenous/phlegmonous cholecystitis at pathology in all six, and in four as perforation at macroscopic surgical inspection. CEUS is a non-invasive easily repeatable technique that can be performed at the bedside, and is able to accurately diagnose complicated/perforated cholecystitis. Despite the limited sample size in the present case series, CEUS appears as a promising tool for the management of patients with the clinical possibility of having an acute complicated cholecystitis.
World journal of gastroenterology : WJG, Jan 7, 2015
The urea cycle is the final pathway for nitrogen metabolism. Urea cycle disorders (UCDs) include ... more The urea cycle is the final pathway for nitrogen metabolism. Urea cycle disorders (UCDs) include a variety of genetic defects, which lead to inefficient urea synthesis. Elevated blood ammonium level is usually dominant in the clinical pattern and the primary manifestations affect the central nervous system. Herein, we report the case of a 17-year-old girl who was diagnosed with UCD at the age of 3. Despite a controlled diet, she was hospitalized several times for acute attacks with recurrent life risk. She came to our attention for a hyperammonemic episode. We proposed an orthotopic liver transplant (OLT) as a treatment; the patient and her family were in complete agreement. On February 28, 2007, she successfully received a transplant. Following the surgery, she has remained well, and she is currently leading a normal life. Usually for UCDs diet plays the primary therapeutic role, while OLT is often considered as a last resort. Our case report and the recent literature data on the q...
Minerva chirurgica, 2009
The aim of this study was to evaluate the role of surgery in the treatment of non-colorectal, non... more The aim of this study was to evaluate the role of surgery in the treatment of non-colorectal, non-neuroendocrine (NCRNNE) liver metastases. One hundred and thirty-four patients undergoing curative liver resection for NCRNNE liver metastases were retrospectively analyzed. Perioperative results (blood transfusion, hospital stay, morbidity and mortality), 3 and 5-year overall and disease-free survival were evaluated. The following prognostic factors were analyzed: age (cut-off 50 year old), single vs. multiple nodules, diameter (cut-off 5 cm), disease-free interval less vs. more than one year, type of primary tumor, blood transfusion, major hepatectomy vs. minor hepatectomy. Survival of patients undergoing liver resection for metastatic colorectal cancer was also analyzed to compare the results with the study population. Mortality and morbidity rate were 3% and 23.1%, respectively. The 3 and 5-year survival were 56.5% and 40%, respectively. The 3 and 5-year disease-free survival were 4...
Tumori
Focal nodular hyperplasia (FNH) is an infrequent benign tumor of the liver that is generally beli... more Focal nodular hyperplasia (FNH) is an infrequent benign tumor of the liver that is generally believed to have no potential for malignant transformation; the coexistence of FNH and hepatocellular carcinoma (HCC) has seldom been reported. Here we describe an exceptional case of simultaneous FNH and HCC in the same patient and discuss the clinical and therapeutic management of FNH on the basis of a review of the literature.
Transplantation Proceedings, 2014
Kidney function usually deteriorates after intestinal transplant, with prevalence of renal failur... more Kidney function usually deteriorates after intestinal transplant, with prevalence of renal failure almost 20% after 5 years. We report our results on adults from single institution over >10 years. Forty-six patients were transplanted with 22 survivors; we divided them in 2 groups: Group 1, recipients with creatinine>1.2 mg/dL (normal, 0.50-1.2) and Group 2, normal creatinine. Group 1 included 12 patients (9 males) with a mean age of 42.8 years; all lived at home, with normal creatinine at transplant (apart from 1 patient with a creatinine of 1.6 mg/dL), and were mainly transplanted for short bowel syndrome. One underwent retransplantation. Immunosuppression was based on alemtuzumab (8 recipients) plus tacrolimus (FK). Group 2 included 10 patients (6 males) with a mean age of 34.7 years; all lived at home, had normal creatinine at transplantation, and were mainly transplanted for short bowel syndrome. Immunosuppression was mainly based on alemtuzumab (8 recipients) plus FK. There were no relevant differences between the 2 groups regarding number of recipients, sex, baseline creatinine at transplant, reason for transplantation, retransplantation, immunosuppression, antifungal or antiviral therapy, hospitalization, total parenteral nutrition (or fluids), or stoma. The only relevant difference was age (P=.04); patients with deteriorated kidney function or altered creatinine were found to be older.
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Papers by Alessandro Cucchetti