Research Spotlight

Horowitz, J. M., I. R. Kamel, H. Arif-Tiwari, S. K. Asrani, N. M. Hindman, H. Kaur, M. M. McNamara, R. B. Noto, A. Qayyum and T. Lalani (2017). “Acr appropriateness criteria(r) chronic liver disease.” J Am Coll Radiol 14(11s): S391-s405.

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Because liver fibrosis can be treated, it is important to diagnose liver fibrosis noninvasively and monitor response to treatment. Although ultrasound (grayscale and Doppler) can diagnose cirrhosis, it does so unreliably using morphologic and sonographic features and cannot diagnose the earlier, treatable stages of hepatic fibrosis. Transient elastography, ultrasound elastography with acoustic radiation force impulse, and MR elastography are modalities that can assess for hepatic fibrosis. Although all international organizations recommend ultrasound for screening for hepatocellular carcinoma, ultrasound is particularly limited for identifying hepatocellular carcinoma in patients with obesity, nonalcoholic fatty liver disease, and nodular cirrhotic livers. In these patient groups as well as patients who are on the liver transplant wait list, ultrasound is so limited that consideration can be made for screening for hepatocellular carcinoma with either MRI or multiphase CT. Additionally, patients who have been previously diagnosed with and treated for hepatocellular carcinoma require continued surveillance for recurrent hepatocellular carcinoma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Joshi, H. M., D. S. Keller and M. Chand (2017). “Utilization of indocyanine green to demonstrate lymphatic mapping in colon cancer.” J Surg Oncol: 2017 Oct [Epub ahead of print].

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The principles of oncologic resection for colon cancer are based on excising the primary tumor with its blood supply and associated lymph node basin. While resection of the tumor and its named vessel are relatively consistent, the extent of the mesenteric lymphadenectomy can be variable, which affects the quality of the specimen and nodal yield, and potentially the survival outcomes for the patient through under-staging. According to The Royal College of Pathologists and The College of American Pathologists, an adequate colonic oncological resection requires a minimum of 12 nodes to be removed but there is accumulating evidence this is still a substandard lymph node yield.[7] Proponents of complete mesocolic excision (CME) argue that performing more radical surgery with a larger mesenteric specimen results in a greater number of lymph nodes and potentially improved survival outcomes.[8] However, there is no current consensus for a CME approach, and there are concerns for increased morbidity after extended lymph node dissection.[9] In addition, while studies have shown value, the role of the sentinel lymph node biopsy is still undefined in colon cancer staging.[10]

Levitsky, J., R. N. Formica, R. D. Bloom, M. Charlton, M. Curry, J. Friedewald, J. Friedman, D. Goldberg, S. Hall, M. Ison, T. Kaiser, D. Klassen, G. Klintmalm, J. Kobashigawa, A. Liapakis, K. O’Conner, P. Reese, D. Stewart, N. Terrault, N. Theodoropoulos, J. Trotter, E. Verna and M. Volk (2017). “The american society of transplantation consensus conference on the use of hepatitis c viremic donors in solid organ transplantation.” Am J Transplant 17(11): 2790-2802.

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The availability of direct-acting antiviral agents for the treatment of hepatitis C virus (HCV) infection has resulted in a profound shift in the approach to the management of this infection. These changes have affected the practice of solid organ transplantation by altering the framework by which patients with end-stage organ disease are managed and receive organ transplants. The high level of safety and efficacy of these medications in patients with chronic HCV infection provides the opportunity to explore their use in the setting of transplanting organs from HCV-viremic patients into non-HCV-viremic recipients. Because these organs are frequently discarded and typically come from younger donors, this approach has the potential to save lives on the solid organ transplant waitlist. Therefore, an urgent need exists for prospective research protocols that study the risk versus benefit of using organs for hepatitis C-infected donors. In response to this rapidly changing practice and the need for scientific study and consensus, the American Society of Transplantation convened a meeting of experts to review current data and develop the framework for the study of using HCV viremic organs in solid organ transplantation.

Wilder, E. G., J. Frieder, S. Sulhan, P. Michel, J. D. Cizenski, J. M. Wright and M. A. Menter (2017). “Spectrum of orocutaneous disease associations: Genodermatoses and inflammatory conditions.” J Am Acad Dermatol 77(5): 809-830.

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The oral cavity and cutaneous organ systems share a close embryologic origin. Therefore, there are numerous dermatologic conditions presenting with concomitant oral findings of which the dermatologist must be aware. The second article in this continuing medical education series reviews inflammatory orocutaneous conditions and a number of genodermatoses. It is essential for dermatologists to be familiar with oral cavity manifestations associated with dermatologic diseases for prompt diagnosis, management, and appropriate referral to stomatology and dentistry.

Aguilar, P. R., D. Carpenter, J. Ritter, R. D. Yusen, C. A. Witt, D. E. Byers, T. Mohanakumar, D. Kreisel, E. P. Trulock and R. R. Hachem (2017). “The role of c4d deposition in the diagnosis of antibody-mediated rejection after lung transplantation.” Am J Transplant: 2017 Oct [Epub ahead of print].

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Antibody-mediated rejection (AMR) is an increasingly recognized form of lung rejection. C4d deposition has been an inconsistent finding in previous reports and its role in the diagnosis has been controversial. We conducted a retrospective single-center study to characterize cases of C4d-negative probable AMR and to compare these to cases of definite (C4d-positive) AMR. We identified 73 cases of AMR: 28 (38%) were C4d-positive and 45 (62%) were C4d-negative. The two groups had a similar clinical presentation, and although more patients in the C4d-positive group had neutrophilic capillaritis (54% vs. 29%, p = 0.035), there was no significant difference in the presence of other histologic findings. In spite of aggressive antibody-depleting therapy, 19 of 73 (26%) patients in the overall cohort died within 30 days, but there was no significant difference in freedom from chronic lung allograft dysfunction (CLAD) or survival between the two groups. We conclude that AMR may cause allograft failure, but the diagnosis requires a multidisciplinary approach and a high index of suspicion. C4d deposition does not appear to be a necessary criterion for the diagnosis, and although some cases may initially respond to therapy, there is a high incidence of CLAD and poor survival after AMR.