Oskar Hemmingsson

Background: Sub-Saharan Africa carries a disproportionate burden of hepatocellular carcinoma (HCC), yet clinical guidelines used on the African subcontinent are extrapolated from high-income countries (HICs). The presentation, treatment, and outcomes of HCC were compared between liver referral centres in South Africa and Sweden to examine the limitations of applying HIC-derived guidelines to sub-Saharan Africa. Methods: This was a comparative cohort study of adult patients with HCC treated from 2012 to 2023 in a referral centre in South Africa and in a referral centre in Sweden. The main and secondary outcomes were overall survival (OS) and treatment-specific survival respectively. Results: Of 959 patients included, 455 and 504 were treated in South Africa and Sweden respectively. Patients in South Africa were younger (median 50 versus 71 years, P < 0.001) and predominantly had hepatitis B virus (HBV)-related HCC (60% versus 3.6%, P < 0.001). They presented with more advanced liver dysfunction, more frequent metastases, and more advanced Barcelona Clinic Liver Cancer (BCLC) stage. Curative-intent therapies (ablation, liver resection, or liver transplantation) were offered to 9.2% and 42.5% of patients respectively (P < 0.001). OS rates at 1 year, 3 years, and 5 years were 17.8%, 7.7%, and 5.3% versus 59.3%, 35.3%, and 27.0% respectively (P < 0.001). Survival was consistently lower for the patients in South Africa when comparing treatment-specific cohorts. Conclusion: Marked disparities in disease presentation, access to treatment, and survival were observed between regions. Tailored regional guidelines are urgently needed to address these inequities and improve outcomes.

Breast cancer (Bc) is the leading cause of cancer-related death in women. In many patients, BC liver metastases (BCLM) are associated with short survival. The aims of this study were to investigate the risk of and time to BCLM in each BC surrogate subtype, and to determine the incidence of BCLM in a population-based setting. The Swedish national breast cancer registry identified patients with Bc in a regional cohort from 2009 to 2018. The cohort was followed until January 2023. Cox regression analysis was used to determine the risk of BCLM for each subtype. Kaplan-Meier estimates determined the probability of BCLM for each subtype over time. In all, 7292 patients with Bc were included in the study. Distant metastases developed in 755 patients (10.4%); of these, 345 (45.7%) developed BCLM. The BCLM incidence rate was 8 per 1000 person-years. Only 13 patients had oligometastases isolated to the liver. Triple-negative, non-luminal human epidermal growth factor receptor 2 (HER2)-positive and luminal B cancers had the highest risk of BCLM. T category, nodal status, and Nottingham histological grade III were also strongly associated with BCLM. The median time from Bc diagnosis to BCLM was 36 months. Patients with HER2-positive BC subtypes developed BCLM early, at a median of only 9 months. Bc subtype is correlated to the risk and timing of BCLM development. BCLM are common in advanced Bc, but isolated oligometastases are rare.

Background and purpose: Real-world data on management and outcomes of patients with simultaneously diagnosed synchronous colorectal liver and lung metastases are limited. This national study evaluated referral patterns, treatment strategies, and survival in a population-based cohort.Patient/material and methods: This retrospective cohort study used Swedish national registries to identify patients with synchronous liver and lung metastatic colorectal cancer (CRC), defined as metastases detected within 6 months of CRC diagnosis between 2008 and 2016. Medical record review provided additional information on diagnosis confirmation, multidisciplinary team (MDT) referral, metastatic burden, and treatment. Logistic regression identified factors associated with MDT referral and curative treatment, and Cox regression with a time-varying covariate assessed survival.Results: Among 2703 registry-identified patients, medical records were accessible for 855. After exclusion of extrahepatic, non-pulmonary metastases, 556 remained for analysis. A total of 189 patients (34%) were discussed at a liver MDT conference. Referred patients were younger, had lower metastatic burden, and better performance status than non-referred. Median survival was 24 months (95% CI [confidence interval] 21–28) for referred versus 10 months (95% CI 7–12) for non-referred patients. Curative local treatment of liver and/or lung metastases was performed in 101 patients (18%), and complete metastasectomy in 34 (6%), conferring superior survival compared with liver-only intervention (hazard ratio 0.34, 95% CI 0.18–0.61). The main reason for non-referral was presumed non-resectability.Interpretation: Referral to an MDT and subsequent local treatment were associated with improved survival, although this may partly reflect favorable patient and tumor characteristics influencing referral and treatment decisions. Patients with adequate physiological reserve should routinely be evaluated in an organ-specific MDT for potential curative treatment.

The aim was to determine the frequency of altered receptor expression between primary breast cancer and liver metastases, and to examine the impact of receptor expression on survival. The conversion frequency of estrogen- (ER), progesterone- (PgR) and human epidermal growth factor receptor 2 (HER2) was investigated. The prognostic value of the receptor status in the primary tumor versus the metastases was estimated. Data on a population-based regional cohort of 7292 breast cancer patients from 2009 to 2018 were collected from the National Breast Cancer Register. Biomarker expression and intrinsic subtype was studied among those who developed liver metastases with available histopathological records. The study included 311 patients with liver metastases. Conversion of ER, PgR and HER2 occurred in 16%, 47% and 12% of patients, respectively. The subtype converted in 26%. HER2 amplification in the primary tumor or metastases was associated with improved survival. Positive ER and PgR in breast cancer and positive ER in liver metastases were beneficial for survival. A combined primary tumor and metastasis receptor evaluation had the highest prognostic value. Receptor conversion from primary tumor to liver metastases is common. HER2 amplification and positive ER or PgR are associated with improved survival. Accordingly, luminal HER2 positive tumors have improved survival compared to other intrinsic subtypes. To personalize treatment for each patient, a liver biopsy is warranted at diagnosis of breast cancer liver metastases.

Background: Acute cholecystitis is a common complication of gallstone disease. Although early laparoscopic cholecystectomy is recommended, some patients do not undergo early surgery and remain at risk of recurrent disease. This study investigated whether early cholecystectomy for recurrent cholecystitis is associated with higher complication rates versus first-time cholecystitis. Methods: A retrospective population-based cohort study was conducted using data from the Swedish Registry of Gallstone Surgery. Patients undergoing early cholecystectomy for acute cholecystitis in Sweden between 1 January 2006, and 31 December 2020, were included. Patients with recurrent cholecystitis were compared to those with a first episode. The primary outcome was the total 30-day complication rate. Secondary outcomes included open surgery, prolonged surgery (≥ 120 minutes), bile duct injury, and specific complications such as intestinal injury, bleeding, reoperation, abscess, and 30-day mortality. Multivariable logistic regression was used to calculate odds ratios (OR), adjusting for age, sex, American Society of Anesthesiologists (ASA) grade, and time from admission to surgery as confounders. Results: Among 34 925 patients, 3384 had recurrent cholecystitis and 31 541 had first-time cholecystitis. The recurrent cholecystitis group had a higher complication rate (20.2 versus 13.8%) and an increased risk of bile duct injury (OR 2.44; 95% confidence interval (c.i.) 1.67 to 3.56), intestinal perforation (OR 2.54; 95% c.i. 1.51 to 4.25), prolonged surgery (OR 1.64; 95% c.i. 1.53 to 1.67), and open surgery (OR 1.76; 95% c.i. 1.64 to 1.92). However, patients with recurrent cholecystitis were older and had a higher ASA grade. Conclusion: Early cholecystectomy for recurrent cholecystitis is associated with increased complication rates compared with first-time cholecystitis. These findings support early surgical intervention during the first episode to reduce the risk of adverse outcomes associated with recurrent disease.

Background and objective: Breast cancer liver and lung metastases are common and associated with poor prognosis. Personalized medical treatment of advanced breast cancer, based on established predictive factors, has improved survival during the last decades. In contrast, there is no consensus regarding indications for surgery. The aim of this narrative review is to summarize the current knowledge on the outcome of surgical treatments for breast cancer liver and lung metastases. Method: A narrative review of existing evidence for diagnosis and treatment of breast cancer liver and lung metastases. Results: There are no randomized trials to evaluate surgery as an adjunct to medical treatment. In this review, data are reported from case–control studies and meta-analyses on surgery for liver and lung metastases. Selected patients have an improved survival after surgery compared to those who only received medical treatment. The survival benefit is, however, uncertain when adjusting for prognostic factors, and prospective trials are warranted. Anecdotal cases have long-term survival and surgery is safe. Conclusion: Surgery for breast cancer liver and lung metastases may be considered in selected cases within prospective studies.

Supplementary methods and figure legends

Manual scoring of vulval induction in the ST65 strain.

Automated scoring of vulval induction and percent larvae in the ST65 strain.

Z-factors for automated scoring protocols in the ST65 strain.