Jan Nicolaas Maria Ijzermans

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Endoscopic retrograde cholangio-pancreatography (ERCP) with plastic stent placement is the standard pertaining preoperative biliary drainage for resectable perihilar cholangiocarcinoma (pCCA). Uncovered self-expanding metal stents (ucSEMS) have shown better outcomes in palliative settings. This pilot study aimed to assess the feasibility and safety of direct ucSEMS placement via ERCP for resectable pCCA. In this single-centre pilot study, ten patients with presumed resectable pCCA (without prior drainage) underwent ERCP aiming to place an ucSEMS directly across the papilla into the future liver remnant (FLR). If the opposing liver segment was cannulated or had contrast injected, a stent was placed here too. Primary outcome was feasibility, defined as ucSEMS placement in the targeted liver segment without the need for additional drainage, with adequate bilirubin decrease according to the TOKYO criteria. Secondary outcomes included ERCP adverse events (AE) and successful stent removal during surgery. In 5 of the 10 included patients, direct ucSEMS placement in the FLR was technically successful, but one required additional intervention, resulting in 40% feasibility. All patients experienced ERCP-AE (five mild, five severe). Only two patients underwent hepatectomy, one after unsuccessful ERCP and one with successful ucSEMS removal during hepatectomy. Other patients did not proceed to hepatectomy due to ERCP-related AE (n = 3), disease progression (n = 2), or unresectability upon staging (n = 3). Direct placement of ucSEMS for resectable pCCA showed limited feasibility and high AE rates. Its routine use is not justified without further refinement and larger studies to reduce AE and improve outcomes.

Liver transplantation is the most successful treatment for limited-stage HCC. The waiting time for liver transplantation (LT) can be a critical factor affecting the oncological prognosis and outcome of patients with HCC. Efficient strategies to optimize waiting time are essential to maximize the benefits of LT and to reduce the harm of delay in transplantation. The ever-increasing demand for donor livers emphasizes the need to improve the organization of the waiting list for transplantation and to optimize organ availability for patients with and without HCC. Current progress in innovations to expand the donor pool includes the implementation of living donor LT and the use of grafts from extended donors. By expanding selection criteria, an increased number of patients are eligible for transplantation, which necessitates criteria to prevent futile transplantations. Thus, the selection criteria for LT have evolved to include not only tumor characteristics but biomarkers as well. Enhancing our understanding of HCC tumor biology through the analysis of subtypes and molecular genetics holds significant promise in advancing the personalized approach for patients. In this review, the effect of waiting time duration on outcome in patients with HCC enlisted for LT is discussed.

Background and objectives: Urological complications after kidney transplantation, due to the ureteroneocystostomy, are associated with significant morbidity, prolonged hospital stay and even mortality. Ureteral stents can minimize the number of complications but are not consistently used, as previous studies were retrospective in nature. We aim to prospectively determine the most effective stenting approach. Methods: We performed a non-blinded single-centre randomised controlled trial in an academic hospital. Kidney transplant recipients were randomised to either a Single-J stent or a Double-J stent, removed according to respective protocols. Primary outcome was PCN placement within six months. Secondary outcomes encompassed urinary tract infections, cost-effectiveness, and hospital admission time. The study was conducted from November 2018 to August 2023, during which 300 recipients were included with complete follow-up. Results: PCN was performed in 14.5% in the Single-J group (21/145) and 4.5% in the Double-J group (7/155), p = 0.003. Multivariable logistic regression, corrected for recipient age, BMI, sex, and donor type, showed an OR of 0.26 [0.10, 0.61] (OR [95%CI]). To prevent PCN in one recipient, 10 would have to receive the Double-J. All secondary outcomes were comparable, whereas hospital admission time and cost-effectiveness analysis heavily favoured Double-J stenting. An important limitation was that Single-J participants were unable to leave, even if their recovery allowed earlier discharge. Conclusion: This trial showed that Double-J stenting consistently reduced urological complications from 14.5% to 4.5%, while being highly cost-effective. Transplant surgeons should favour Double-J stenting to minimise the risk of complications.

Purpose: To evaluate dosimetry, dose–response and dose-toxicity relationships for holmium-166 (¹⁶⁶Ho) radioembolisation in patients with hepatocellular carcinoma (HCC). Methods: Thirty-one patients with hepatocellular carcinoma were included in the HEPAR Primary study (NCT03379844, registered on December 20th, 2017) and underwent ¹⁶⁶Ho-microspheres radioembolisation. Linear mixed models assessed the association between tumour absorbed doses and response based on mRECIST both on tumour and patient level. Preliminary tumour absorbed dose thresholds were estimated based on predictive value. Linear regression models assessed the association between non-tumour absorbed dose and Common Terminology Criteria for Adverse Events version 4.03. Results: Median tumour absorbed dose (tumour level) was 95.5 Gy (range 44—332 Gy). Median non-tumour absorbed dose based on whole liver volume was 19 Gy (range 3 – 48 Gy) and based on target liver volume was 30 Gy (range 13 – 54 Gy). There was a significant association between non-tumour absorbed dose and toxicity. Tumours with partial response/complete response (PR/CR, responders) received a 41% higher absorbed dose than tumours with progressive disease/stable disease (PD/SD, non-responders) (95%CI: 2%-93%, p = 0.04). A predictive value of 90% for tumour response was observed at a tumour absorbed dose threshold of 155 Gy, 100% predictive value was achieved at 184.5 Gy. Conclusion: This study confirms a positive relationship between tumour absorbed dose and response and between non-tumour absorbed dose and toxicity. Dose thresholds found in this study can serve as a basis for personalized dosimetry in HCC patients treated with ¹⁶⁶Ho-microspheres.

Background: Hepatocellular adenoma is a rare benign liver tumor. Typically, hepatocellular adenomas are solitary and are found in young women who use estrogen-containing contraceptives. The occurrence of multiple hepatocellular adenoma has been linked to higher body mass index, and as the prevalence of overweight increases, multiple hepatocellular adenomas are seen more often. An hepatocellular adenoma does not always necessitate treatment, as they can regress under conservative strategies. In incidental cases, an adenoma presents owing to bleeding, which is mostly self-limiting. If it is not, embolization of hepatic involved vessels is indicated. Case presentation: In this case report, we discuss a 42-year old Caucasian woman with multiple hepatocellular bleeds, treated by multiple endovascular procedures. After the first embolization of an adenoma in the right liver lobe, a second bleed occurred in the left lobe, necessitating additional endovascular intervention. During admittance, treatment was complicated by pulmonary embolism and a pneumonia. During follow-up, our patient was diagnosed with antiphospholipid syndrome. Conclusion: Hepatocellular adenoma is a rare diagnosis that requires centralized expertise. This particular case illustrates the complexity of treatment strategies for associated intra-abdominal bleeding and possible complications. Although liver adenoma is often an incidental finding, it can also result in significant morbidity. Centralization of treatment leads to expertise in managing complex treatment strategies.

Purpose: Recently introduced hybrid 2-[18 F]-fluoro-2-deoxy-D-glucose (18 F-FDG) Positron Emission Tomography (PET) combined with Magnetic Resonance Imaging (MRI) may aid in proper diagnosis and staging of perihilar cholangiocarcinoma (pCCA). The aim of this study is to assess the effect of 18 F-FDG PET/MRI on diagnosis and clinical decision making in the pre-operative work up of pCCA. Methods: In this single-centre pilot study patients with presumed resectable pCCA underwent state-of-the-art 18 F-FDG hybrid PET/MRI using digital silicone photomultiplier detectors integrated within a 3-Tesla bore. Data were collected on several baseline and imaging characteristics. The primary outcome measure was the added diagnostic information and the effect on clinical decision making. Secondary aim was to correlate quantitative PET signal intensity to patient- and tumour characteristics. High and low SUVmax subgroups related to the mean value were made. Significance of lesion- and patient characteristics with the high and low SUVmax subgroups, as well as TLR and TBR, was evaluated with Fisher’s exact test or Mann-Whitney-U test. Results: In total 14 patients were included (mean age 62.4 years, 64% male). Final diagnosis was pCCA in 10 patients (71.4%), follicular lymphoma in one patient (7.1%) and benign disease in the remaining three patients. FDG-PET/MRI added valuable diagnostic information in six (43%) patients and affected clinical decision making in two of these patients (14%) by increasing confidence for malignancy which lead to the decision for surgery on short term. High SUVmax values were seen in half of cases with pCCA and half of cases with non-cancerous lesions. In addition, high SUVmax values were directly associated with primary sclerosing cholangitis when present (p = 0.03). Conclusion: Simultaneous 18 F-FDG-PET/MRI added diagnostic information in six of fourteen patients and influenced clinical decision making in two patients (14%) with presumed resectable pCCA.