Risk of major liver resection in patients with underlying chronic liver disease: a reappraisal

OBJECTIVE

To explore the relation of patient age, status of liver parenchyma, presence of markers of active hepatitis, and blood loss to subsequent death and complications in patients undergoing a similar major hepatectomy for the same disease using a standardized technique.

SUMMARY BACKGROUND DATA

Major liver resection carries a high risk of postoperative liver failure in patients with chronic liver disease. However, this underlying liver disease may comprise a wide range of pathologic changes that have, in the past, not been well defined.

METHODS

The nontumorous liver of 55 patients undergoing a right hepatectomy for hepatocellular carcinoma was classified according to a semiquantitative grading of fibrosis. The authors analyzed the influence of this pathologic feature and of other preoperative variables on the risk of postoperative death and complications.

RESULTS

Serum bilirubin and prothrombin time increased on postoperative day 1, and their speed of recovery was influenced by the severity of fibrosis. Incidence of death from liver failure was 32% in patients with grade 4 fibrosis (cirrhosis) and 0% in patients with grade 0 to 3 fibrosis. The preoperative serum aspartate transaminase (ASAT) level ranged from 68 to 207 IU/l in patients with cirrhosis who died, compared with 20 to 62 in patients with cirrhosis who survived.

CONCLUSION

A major liver resection such as a right hepatectomy may be safely performed in patients with underlying liver disease, provided no additional risk factors are present. Patients with a preoperative increase in ASAT should undergo a liver biopsy to rule out the presence of grade 4 fibrosis, which should contraindicate this resection.

Risk of major liver resection in patients with underlying chronic liver disease: a reappraisal

OBJECTIVE

To explore the relation of patient age, status of liver parenchyma, presence of markers of active hepatitis, and blood loss to subsequent death and complications in patients undergoing a similar major hepatectomy for the same disease using a standardized technique.

SUMMARY BACKGROUND DATA

Major liver resection carries a high risk of postoperative liver failure in patients with chronic liver disease. However, this underlying liver disease may comprise a wide range of pathologic changes that have, in the past, not been well defined.

METHODS

The nontumorous liver of 55 patients undergoing a right hepatectomy for hepatocellular carcinoma was classified according to a semiquantitative grading of fibrosis. The authors analyzed the influence of this pathologic feature and of other preoperative variables on the risk of postoperative death and complications.

RESULTS

Serum bilirubin and prothrombin time increased on postoperative day 1, and their speed of recovery was influenced by the severity of fibrosis. Incidence of death from liver failure was 32% in patients with grade 4 fibrosis (cirrhosis) and 0% in patients with grade 0 to 3 fibrosis. The preoperative serum aspartate transaminase (ASAT) level ranged from 68 to 207 IU/l in patients with cirrhosis who died, compared with 20 to 62 in patients with cirrhosis who survived.

CONCLUSION

A major liver resection such as a right hepatectomy may be safely performed in patients with underlying liver disease, provided no additional risk factors are present. Patients with a preoperative increase in ASAT should undergo a liver biopsy to rule out the presence of grade 4 fibrosis, which should contraindicate this resection.

Hepatic nodules in Budd-Chiari syndrome: imaging features

PURPOSE

To analyze the imaging features of nodules associated with Budd-Chiari syndrome.

MATERIALS AND METHODS

The authors retrospectively studied images obtained in 23 patients with liver nodules who were being followed up for Budd-Chiari syndrome. Doppler ultrasonography was performed in all patients, computed tomography in 16, and magnetic resonance (MR) imaging in 20. The following lesion features were evaluated: location, number, size, vascularization, qualitative signal intensity at MR imaging, and homogeneity. Nodules were diagnosed on the basis of histopathologic findings or clinical and biologic data with no change at imaging during 2-year follow-up.

RESULTS

All patients had histopathologic features of chronic Budd-Chiari syndrome. Four patients had hepatocellular carcinoma (HCC), with one to three lesions. The mean diameter of the largest HCC lesion in each patient was 7.3 cm. All HCC lesions were heterogeneous and had high signal intensity on T2-weighted MR images. Nineteen patients had multiple benign regenerative nodules, most of which were smaller than 4 cm. Most nodules were homogeneous and hyperintense on T1- and T2-weighted images. In 15 patients, nodules were hypervascular in the arterial phase.

CONCLUSION

In patients with chronic Budd-Chiari syndrome, multiple (> 10) small (< 4-cm) lesions are suggestive of benignity.

Cytolysis following chemoembolization for hepatocellular carcinoma

BACKGROUND

Lipiodolized chemoembolization of hepatocellular carcinoma (HCC) can induce fever and cytolysis, defined as an increase in serum levels of liver transaminases, which is frequently assumed to result from tumour necrosis. This study aimed to assess the causes of this syndrome, reviewing preoperative data, intraoperative findings, tumour necrosis and the status of non-tumorous liver.

METHODS

A retrospective study was undertaken of 29 patients treated by neoadjuvant lipiodolized chemoembolization before surgical resection of HCC. Tumour necrosis was assessed in the resected specimen and scored in four stages: absent, 50 per cent or less, more than 50 per cent, and complete. The status of non-tumorous liver parenchyma was classified as either fibrotic or cirrhotic.

RESULTS

Cytolysis occurred following chemoembolization in 16 patients and was associated with fever in 11. Postchemoembolization cytolysis with or without fever was more likely to develop in patients with minor fibrotic changes than in those with cirrhosis (14 of 21 with fibrosis versus two of four with cirrhosis, P < 0.05). In contrast, the extent of tumour necrosis did not correlate with the occurrence of symptoms.

CONCLUSION

These results suggest that fever and cytolysis following chemoembolization of HCC are an indication not of tumour necrosis but of injury to the non-tumorous liver.

[Intraductal papillary mucinous tumors of the pancreas: are there any preoperative clinical and laboratory factors predictive of degeneration. Results of a French-Belgium collective series]

Intraductal papillary and mucinous tumors are rare. We retrospectively analysed clinical, surgical and histological features and outcome of 41 operated patients (29 males, 12 females, mean age = 63 years). The commonest presenting manifestation was acute pancreatitis (41%). Tumor was located in only one pancreatic segment in 45% cases. Forty one per cent of patients had invasive carcinoma, 20% had tumor with severe dysplasia and 39% with minimal or moderate dysplasia. Only elevated age was significantly associated with invasive carcinoma. Eleven out of 17 patients with invasive carcinoma (65%) had a recurrence after surgery and 6 (35%) died. Among 24 patients with noninvasive tumor, 2 (8%) recurred without tumor-related death in the follow-up (48 months). This study underlines the need for early surgical resection in patients with intraductal papillary and mucinous tumor because of the high frequency of invasive carcinoma and the poor outcome of patients with invasive carcinoma.

Prognostic factors in patients with endocrine tumours of the duodenopancreatic area

BACKGROUND

The development of endocrine tumours of the duodenopancreatic area (ETDP) is thought to be slow, but their natural history is not well known. The aim of this study was to determine the factors that influence survival of patients with ETDP.

PATIENTS/METHODS

Eighty two patients with ETDP (44 non-functioning tumours, 23 gastrinomas, seven calcitonin-secreting tumours, four glucagonomas, three insulinomas, one somatostatinoma) followed from October 1991 to June 1997 were included in the study. The following factors were investigated: primary tumour size, hormonal clinical syndrome, liver metastases, lymph node metastases, extranodular/extrahepatic metastases, progression of liver metastases, local invasion, complete resection of the primary tumour, and degree of tumoral differentiation. The prognostic significance of these factors was investigated by uni- and multi-variate analysis.

RESULTS

Twenty eight patients (34%) died within a median of 17 months (range 1-110) from diagnosis. Liver metastases (p = 0.001), lymph node metastases (p = 0.001), progression of liver metastases (p < 0.00001), lack of complete resection of the primary tumour (p = 0.001), extranodular/extrahepatic metastases (p = 0.001), local invasion (p = 0.001), primary tumour size > or = 3 cm (p = 0.001), non-functioning tumours (p = 0.02), and poor tumoral differentiation (p = 0.006) were associated with an unfavourable outcome by univariate analysis. Multivariate analysis identified only liver metastases (risk ratio (RR) = 8.3; p < 0.0001), poor tumoral cell differentiation (RR = 8.1; p = 0.0001), and lack of complete resection of the primary tumour (RR = 4.8; p = 0.0007) as independent risk factors. Five year survival rates were 40 and 100% in patients with and without liver metastases, 85 and 42% in patients with and without complete resection of primary tumour, and 17 and 71% in patients with poor and good tumour cell differentiation respectively.

CONCLUSION

Liver metastases are a major prognostic factor in patients with ETDP. Progression of liver metastases is also an important factor which must be taken into account when deciding on the therapeutic approach. The only other independent prognostic factors are tumoral cell differentiation and complete resection of the primary tumour.

Ticlopidine induced colitis: a histopathological study including apoptosis

AIMS

To describe ticlopidine related microscopic colitis and to assess the occurrence of apoptosis in the colon epithelium.

METHODS

A series of colorectal biopsy samples from nine patients with ticlopidine related chronic diarrhoea were analysed. Biopsies were also taken from five of these patients between two and four months after ticlopidine withdrawal. The number of apoptotic cells in the crypts/mm2 (apoptotic index) was calculated using in situ labelling by terminal deoxyribonucleotidyl transferase (TdT) mediated dUTP-biotin nick end labelling (TUNEL). All specimens were matched to normal colorectal specimens from a control group of comparable age and sex distribution.

RESULTS

Histological examination of the colon biopsy specimens taken from all nine patients with ticlopidine related chronic diarrhoea showed characteristic features of microscopic colitis. The histology returned to normal when ticlopidine was withdrawn. Apoptotic cells were rarely found in controls, and the mean apoptotic index was 0.53. The apoptotic index was significantly higher (16.53) in ticlopidine related colitis, but decreased dramatically to control value when ticlopidine was withdrawn.

CONCLUSION

Microscopic colitis can be induced by ticlopidine and is accompanied by an increase in epithelial apoptosis. Hence, increased apoptosis might be related to drug injury or might be part of microscopic colitis.

Induction of nitric oxide synthase in vivo and cell injury in rat duodenal epithelium by a water soluble extract of Helicobacter pylori

1. Helicobacter pylori (Hp) infection, which involves the gastric antrum and duodenal mucosa, may be involved in peptic ulceration by stimulating the local release of cytoxic or pro-inflammatory factors. 2. Nitric oxide (NO) is known to be cytotoxic at high concentration. The aim of the present study was therefore to investigate the ability of a water soluble extract of Hp to induce NO synthase in duodenal mucosa and epithelial cells following its administration in vivo in rats and determine its association with cell damage. 3. Administration of Hp water extract (4 ml kg(-1)) led to the expression of the calcium-independent inducible nitric oxide synthase (iNOS) after 4 h in the duodenum, determined as [14C]-arginine conversion to citrulline. 4. This iNOS activity was not reduced by pretreatment with anti-neutrophil serum (0.4 ml kg(-1), i.p., 3 h before challenge). However, dexamethasone pretreatment (1 mg kg(-1), i.v., 2 h before the extract), or administration of the NO synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME, 5 mg kg(-1), i.v., 2.5 h after the extract) reduced this activity. 5. Furthermore, iNOS was expressed in duodenal isolated epithelial cells 4 h after the i.v. challenge with the extract, at a time when the cellular viability was also reduced, as assessed by trypan blue exclusion. 6. Dexamethasone pretreatment, administration of L-NAME, or pretreatment with polymyxin B (1 mg kg(-1), i.v.) which binds endotoxin, reduced both the iNOS activity and epithelial cell damage. 7. The induction of NO synthase by the Hp extract thus results in duodenal epithelial cell injury and such actions could play a role in pathogenesis of peptic ulcer disease.

Intraductal papillary and mucinous tumors of the pancreas: accuracy of preoperative computed tomography, endoscopic retrograde pancreatography and endoscopic ultrasonography, and long-term outcome in a large surgical series

BACKGROUND

Few data are available on the accuracy of preoperative imaging or on long-term outcome after surgery for intraductal papillary and mucinous tumors of the pancreas. The aims of this study were to assess the following: (1) the accuracy of preoperative computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography for determination of tumor invasion and pancreatic extension as compared with surgical findings; (2) the long-term outcome after surgery.

METHODS

Forty-seven patients who underwent surgery between 1980 and 1995 for pathologically diagnosed intraductal papillary and mucinous tumors were included in this study. The findings of available computed tomography (n = 25), endoscopic retrograde pancreatography (n = 29), and endoscopic ultrasonography (n = 21) were reviewed by experienced clinicians blinded to pathologic diagnosis to assess tumor invasion and pancreatic extension. Pathologic specimens were reviewed by experienced pathologists. Postoperative follow-up data were analyzed.

RESULTS

Histologic features of invasive carcinoma were found in 43% of patients, severe dysplasia in 21%, and mild or moderate dysplasia in 36%. The overall accuracy of computed tomography, endoscopic retrograde pancreatography, and endoscopic ultrasonography in distinguishing between invasive and noninvasive tumors were, respectively, 76%, 79%, and 76%. The overall 3-year disease-free survival rate was 63%, but it was 21% among patients with invasive carcinoma at surgery (p < 0.001).

CONCLUSIONS

This study emphasizes the need for early surgical resection in patients with suspected intraductal papillary and mucinous tumors of the pancreas because of the high frequency of invasive carcinoma and the inadequacy of preoperative imaging for assessing malignancy.

[Results of the surgical treatment of cancer of the cardia]

OBJECTIVES

In the curative treatment of the adenocarcinoma of the cardia (AC), the extent of the esogastrectomy and the need for lymph node dissection are still debated. The palliative treatment of AC is now currently non-surgical. The aim of this study was (a): to assess early results of palliative surgery; and (b) to evaluate the results of curative resection with reference to the influence of the extent of gastrectomy and lymph node dissection on early results and long-term survival. Methods. From 1979 to 1989, 179 patients (mean age = 60 +/- 12 years) with AC had 45 palliative resections (mean age = 56 +/- 15) and 134 curative resections (mean age = 61 +/- 12). Thirty-eight proximal subtotal esogastrectomy (PSOG) and 7 total esogastrectomy (TOG) were palliative; 72 PSOG and 62 TOG extended to the spleen were curative and associated with lymphadenectomy.

RESULTS

The operative mortality rate was 8.9% regardless of the palliative or curative intent of resection. After palliative resection, the mortality rate was 2.6% (1/38) after PSOG and 42.9% (3/7) after OGT = (p = 0.01); the median survival was 8 months. After curative resection, the mortality rate was 12.5% (9/72) after PSOG and 4.8% (3/62) after extended TOG (p = 0.2); actuarial 5-year survival rate was 42% after PSOG and 39% after extended TOG.

CONCLUSIONS

These results suggests that: (a) palliative PSOG for AC can be performed with a low mortality; and (b) resection with extensive lymphadenectomy allows substantial survival regardless of the extent of gastrectomy.

Evidence for the polyclonal nature of focal nodular hyperplasia of the liver by the study of X-chromosome inactivation

Focal nodular hyperplasia (FNH) of the liver is a benign tumor commonly considered as a reactive disorder related to a pre-existing vascular malformation. However, the pathogenesis of this lesion has been recently discussed. To determine whether FNH is a polyclonal or a clonal lesion, we investigated the inactivation pattern of the X chromosome, using molecular genetic analysis of the DNA methylation pattern at a polymorphic site on the human androgen receptor gene (HUMARA). Fifteen FNH were studied, and results were compared with those obtained from 7 hepatic adenomas (HA) and 2 hepatocellular carcinomas (HCC). DNA was extracted from both lesional and nonlesional livers, fixed, and paraffin-embedded. To assess the methylation pattern, we used a quantitative fluorescent polymerase chain reaction (PCR) procedure that allows for the accurate measurement of the peak intensities of each allele. Three patients were noninformative because they were homozygous at the HUMARA locus. According to the threshold for monoclonality established by a titration curve, all FNH showed a random pattern of X-chromosome inactivation consistent with a polyclonal lesion. In contrast, all but 1 hepatic adenoma and all hepatocellular carcinomas were clonal, as shown by the nonrandom pattern of X-chromosome inactivation observed in these cases. In conclusion, these results suggest that FNH should be considered as a reactive disorder rather than as a tumoral proliferation. Discordant results recently observed in the literature could be at least in part explained by methodological differences in the PCR procedure.

Intrahepatic cholangiocarcinoma: MRI and pathologic correlation in 14 patients

PURPOSE

Our goal was to determine the MR features of intrahepatic cholangiocarcinoma and to correlate them with pathologic findings in a surgical series.

METHOD

MRI in 14 patients with intrahepatic cholangiocarcinoma who had undergone resection was reviewed. All patients had T1- and T2-weighted SE sequences. Contrast-material-enhanced MRI was performed in 12 cases. Comparison between findings at MRI and pathologic examination was made.

RESULTS

MRI depicted all the lesions but one satellite nodule of 2 cm diameter. All lesions were hypointense relative to the liver on T1-weighted images. On T2-weighted images, the tumors were predominantly isointense or slightly hyperintense relative to liver parenchyma in nine cases (64%) and were strongly hyperintense in five cases (36%). Central hypointense areas or bands were seen in eight cases. No capsule was detected. On contrast-enhanced MR studies, all lesions had progressive and concentric filling with contrast material. Associated findings such as vascular encasement, focal liver atrophy, or dilatation of intrahepatic bile ducts were observed in 10 cases (71%). Comparison with pathologic examination revealed that lesion signal intensity on T2-weighted MR images was due mostly to the amount of fibrosis, necrosis, and mucous secretion within the lesion. The nine isointense or slightly hyperintense lesions contained abundant fibrosis and had a low content of mucous secretion or necrosis, whereas the five hyperintense lesions contained low or moderate fibrosis and prominent mucous secretion and/or necrosis.

CONCLUSION

Our study suggests that the MR features of intrahepatic cholangiocarcinoma are well correlated with pathologic findings, but are nonspecific. Associated findings may strengthen the diagnosis of intrahepatic cholangiocarcinoma at MRI.

Fibrolamellar carcinoma of the liver: composition of the extracellular matrix and expression of cell-matrix and cell-cell adhesion molecules

We have analyzed the composition of the tumor stroma and the expression of cell-matrix and cell-cell adhesion molecules in 11 cases of fibrolamellar carcinoma of the liver (FLC), in comparison with 34 cases of hepatocellular carcinoma and 8 cases of focal nodular hyperplasia. Fibrolamellar carcinoma was characterized by the presence of large amounts of tenascin in tumor stroma and by the scarce expression of basement membrane components at the contact of neoplastic clusters. Like normal hepatocytes, neoplastic cells constantly expressed the alpha1 integrin chain, lacked the beta4 integrin chain, and coexpressed E-cadherin and the hepatocyte N-related cadherin. Abnormalities in the expression of cell adhesion molecules, including altered cadherin expression, alphaV integrin chain induction, and CD44 expression, were detected in the majority of cases. The composition of the tumor stroma and the pattern of expression of cell adhesion molecules in fibrolamellar carcinoma were reminiscent of those observed in grade III and grade IV hepatocellular carcinomas. Our results therefore show that, despite its slow local growth and good prognosis, fibrolamellar carcinoma expresses many characteristics usually associated with clinically aggressive malignancies. Further studies are needed to identify the factors responsible for the apparent dissociation between clinical behavior and biological characteristics in this tumor.

Expression of cadherins and alpha-catenin in primary epithelial tumors of the liver

BACKGROUND & AIMS

Cadherins and their associated molecules, such as alpha-catenin, have been shown recently to play a pivotal role in epithelial carcinogenesis.

METHODS

The expression of E-cadherin, N-cadherin, and alpha-catenin in 10 normal samples, 28 focal nodular hyperplasias, 9 liver cell adenomas, 65 hepatocellular carcinomas, and 9 cholangiocarcinomas was studied by immunohistochemistry and Western blotting.

RESULTS

In the normal liver, hepatocytes expressed E-cadherin and a 129-kilodalton cadherin identified by the anti-N-cadherin antibody GC4. The expression level of alpha-catenin was low. Bile duct cells expressed only E-cadherin and showed high levels of alpha-catenin. The expression of cadherins and alpha-catenin was preserved in focal nodular hyperplasia. In liver cell adenomas, cadherins and alpha-catenin were heterogeneously expressed. In hepatocellular carcinomas, cadherin and alpha-catenin expression was frequently reduced or absent. Alterations in cadherin expression correlated with large tumor size, low grade of histological differentiation, and occurrence of capsular and vascular invasion. In cholangiocarcinomas, neoplastic cells inconstantly expressed E-cadherin and alpha-catenin.

CONCLUSIONS

Alterations of cadherin and alpha-catenin expression are frequent in liver cell adenomas and primary liver carcinomas. Their incidence in hepatocellular carcinomas is of prognostic significance.

Absence of human papillomavirus DNA detected by polymerase chain reaction in French patients with esophageal carcinoma

BACKGROUND & AIMS

Recent studies have suggested that esophageal human papillomavirus infection could be a risk factor for esophageal squamous cell carcinoma. The aim of this study was to evaluate the prevalence of human papillomavirus DNA sequences in the esophagus of French patients with esophageal squamous cell carcinoma.

METHODS

Multiplex polymerase chain reactions with consensus primers directed to the L1 gene or specific primers for human papillomavirus types 6, 11, 16, 18, 31, and 33 directed to E6 gene (40 cycles followed by restriction mapping of the amplified products) were used to determine the presence of human papillomavirus DNA sequences in esophageal squamous cell carcinoma (n = 75), normal adjacent mucosa (n = 49), and metastatic lymphadenopathies (n = 5). As an internal control, a target located in the embryonic myosin heavy-chain gene was used in each reaction.

RESULTS

Human papillomavirus DNA sequences could not be detected in any of the tumoral samples, the normal adjacent mucosa, or the metastatic lymphadenopathies.

CONCLUSIONS

Human papillomavirus seems not to be implicated in esophageal carcinogenesis, at least in French patients, because the viral genomes are not associated with esophageal squamous cell carcinomas.

[Variety of pancreatic lesions observed in von Hippel-Lindau disease. Apropos of 8 cases]

Von Hippel-Lindau's disease is a rare genetic disease, with an autosomal dominant mode of inheritance, characterised by the development of several tumours, such as haemangioblastoma of the central nervous system and retina, renal cysts or carcinoma and pheochromocytoma. Several pancreatic lesions, mainly represented by multiple cysts, are also encountered. We report here 8 cases of pancreatic involvement in patients affected with von Hippel-Lindau's disease. It consisted of multiple cysts (3 cases), serous cystadenoma (2 cases), endocrine tumour (1 case), haemangioblastoma (1 case) and ductal adenocarcinoma (1 case). Diagnosis of a rare lesion of the pancreas (multiple cysts, serous cystadenoma or vascularized tumour) in a young patient may lead to search the other lesions of von Hippel-Lindau's disease and to undergo a familial inquiry in order to propose a multidisciplinary approach for patients affected by the disease.

Focal nodular hyperplasia of the liver: composition of the extracellular matrix and expression of cell-cell and cell-matrix adhesion molecules

We studied by immunohistochemistry 25 cases of focal nodular hyperplasia (FNH) to evaluate the composition of the extracellular matrix and the expression and distribution of endothelial cell-cell adhesion molecules and integrin receptors. The extracellular matrix of FNH retained the overall organization of that of normal liver. The matrix of central scars resembled that of portal tracts. The main difference was the presence of large vitronectin deposits, which might indicate the existence of local hemodynamic disturbances. The matrix lining the sinusoid-like vessels running in the hyperplastic parenchyma retained characteristic features of the normal perisinusoidal matrix, such as the presence of tenascin. In the zone surrounding the central scars, it contained large amounts of laminin, von Willebrand factor, and thrombospondin, suggesting the development of perisinusoidal fibrosis. Laminin deposition was accompanied by the induction of cell-cell adhesion molecules on adjacent endothelial cells and by the up-regulation of specific integrin receptors on both hepatocytes and sinusoidal endothelial cells. In conclusion, our study: (1) reinforces the hypothesis that FNH is merely a hyperplastic response of liver parenchyma to local vascular abnormalities, and (2) shows that the lesions of perisinusoidal fibrosis associated with FNH are accompanied by the induction of integrin receptors on hepatocytes and sinusoidal endothelial cells.

Structure and expression of the cyclin A gene in human primary liver cancer. Correlation with flow cytometric parameters

BACKGROUND/AIMS

The cyclin A gene plays an important role in both the S and G2-M phases of the cell cycle, and has been identified at a site of hepatitis B virus DNA integration in a human liver cancer. We analyzed tumorous and non-tumorous samples from patients with primary liver cancer to determine whether a) the cyclin A gene is rearranged in liver tumors and b) the cyclin A transcript level correlates with the percentage of proliferating cells.

METHODS

Samples from 43 patients were analyzed by Southern blot. Cyclin A RNA accumulation was evaluated in 18 cases by slot blot and correlated with the percentage of cells in S plus G2-M phases defined by flow cytometry.

RESULTS

No rearrangement of the cyclin A gene was found in tumorous compared to non-tumorous tissue. A very strong positive correlation was found between the cyclin A RNA level and the cumulative percentage of cells in S plus G2-M phases (r = 0.99; p < 0.0001).

CONCLUSIONS

This in vivo study shows that the expression of cyclin A RNA correlates with the percentage of proliferating cells in primary liver cancer. Thus, cyclin A is a new potential liver tumor cell proliferation index.

Preoperative cyst fluid analysis is useful for the differential diagnosis of cystic lesions of the pancreas

BACKGROUND/AIMS

It has been suggested that activity of pancreatic enzymes and concentrations of tumoral markers in cyst fluid may help to distinguish pseudocyst, serous, and mucinous cystadenomas. The aim of this study was to prospectively assess the reliability of preoperative biochemical and tumor marker analysis in cyst fluids obtained by fine-needle aspiration for pathological diagnosis.

METHODS

Cyst fluid was obtained preoperatively by fine-needle aspiration, and biochemical and tumoral marker values were measured. The diagnosis of cystic tumors (7 serous cystadenomas and 12 mucinous tumors) was established by surgical specimen analysis. Thirty-one pancreatic pseudocysts complicating well-documented chronic pancreatitis were also studied.

RESULTS

Carbohydrate antigen 19.9 levels of > 50,000 U/mL had a 75% sensitivity and a 90% specificity for distinguishing mucinous tumors from other cystic lesions. Carcinoembryonic antigen levels of < 5 ng/mL had a 100% sensitivity and an 86% specificity for distinguishing serous cystadenomas from other cystic lesions. Amylase levels of > 5000 U/mL had a 94% sensitivity and a 74% specificity for distinguishing pseudocysts from other cystic lesions.

CONCLUSIONS

High carbohydrate antigen 19.9, low carcinoembryonic antigen, and high amylase levels in cyst fluid are very indicative of mucinous tumors, serous cystadenomas, and pseudocysts, respectively.

PML nuclear bodies are general targets for inflammation and cell proliferation

Acute promyelocytic leukemia is associated with a t(15;17) translocation that generates a fusion product between PML and the retinoic acid receptor alpha. Recently, PML was shown to concentrate within subnuclear domains, referred to as nuclear bodies, that are disorganized in acute promyelocytic leukemia cells. This observation provided the first evidence that alteration of a nuclear structure may play a role in human pathogenesis. In an attempt to clarify the role of PML and, more generally, of the associated nuclear bodies, we used immunohistochemistry to explore the expression of PML in normal, inflammatory, and neoplastic human tissues. With the exception of endothelial cells and macrophages that contain a high amount of PML protein, a weak speckled labeling pattern was observed in the nucleus of all cell types analyzed. By contrast to normal tissues, the level of PML expression was considerably enhanced in inflammatory tissues, predominantly around the mononuclear cell infiltrate, as well as during either normal or pathological proliferative states, in particular in tumoral pathology. Surprisingly, in most hepatocellular carcinoma, a cytoplasmic delocalization of PML was observed. Finally, the number of PML nuclear bodies increased up to twice their normal value as quiescent cultured cells were stimulated to grow upon serum addition. Altogether these results strongly suggest that the PML-associated nuclear bodies are implicated both in the inflammatory process and in cell growth control.

[Diagnosis of cystadenomas and cystadenocarcinomas of the pancreas. Study of 35 cases]

OBJECTIVES

The aims of this study were to assess the circumstances of diagnosis and accuracy of imaging procedures in patients with cystic pancreatic tumours.

METHODS

Thirty-five consecutive patients with cystic pancreatic tumours (serous cystadenomas: n = 19, mucinous cystadenomas: n = 9, cystadenocarcinomas: n = 7) were studied from 1988 to 1993. Respective diagnostic values of ultrasonography, endoscopic ultrasonography, CT scan and analysis of cyst fluid were evaluated.

RESULTS

The circumstances of diagnosis were abdominal pain (74%), weight loss (23%), jaundice (8%), abdominal mass (6%), asymptomatic (6%). Initial diagnosis of cystadenoma was correctly made by ultrasonography, CT scan and endoscopic ultrasonography in 63%, 77% and 84%, and the type of cystadenoma was correctly diagnosed in 20%, 51% and 55%. A pseudocyst was falsely diagnosed in 28%, 12% and 3%, respectively. After blind review of CT scans and endoscopic ultrasonography records, the type of cystadenoma was correctly diagnosed in 82% by both procedures. Cytological examination of cyst fluid of 18 cystic tumours gave correct diagnosis in 10 cases with sufficient material. A low CEA (P < 0.002), Ca 19.9 (P < 0.003) and absence of mucins (P < 0.002) in cyst fluid was evocative of serous cystadenoma.

CONCLUSIONS

Abdominal pain was the main circumstance of diagnosis in cases of pancreatic cystadenomas. The type of cystadenoma was correctly diagnosed in 82% by CT scan and endoscopic ultrasonography. Cytological examination, tumoural marker and mucin levels in cyst fluid were helpful for an accurate diagnosis of cystic tumours.

Association of multiple liver cell adenomas with spontaneous intrahepatic portohepatic shunt

The association of multiple liver cell adenomas containing foci of focal nodular hyperplasia with a spontaneous intrahepatic portohepatic venous shunt is reported in a 13-year-old male patient. At least eight nodules less than 10 cm in diameter were recognized and proved by means of surgical resection or surgical biopsies. These lesions were heterogeneous and hypodense on precontrast computed tomographic (CT) scans, and were slightly enhanced after injection of contrast medium. At magnetic resonance (MR) imaging, the signal intensity of these nodules varied. It was either hyperintense or hypointense on T1-weighted SE images. Sonography and angiography demonstrated a portohepatic venous shunt and hepatic arterialization was observed. These findings emphasize the hypothesis that hepatic arterialization may cause the development of liver cell adenomas. Moreover, it is suggested that liver cell adenoma and focal nodular hyperplasia have a common pathogenesis.

Mechanism of the abnormal vitamin K-dependent gamma-carboxylation process in human hepatocellular carcinomas

BACKGROUND

An important marker for hepatocellular carcinoma is the presence of des-gamma-carboxy (abnormal) prothrombin. However, the molecular basis for the reduced carboxylation of prothrombin is unknown.

METHODS

Two groups of patients were defined according to the absence (Group I, n = 7) or presence (Group II, n = 8) of des-gamma-carboxy prothrombin. The enzymatic activity of gamma-carboxylase and the total microsomal prothrombin concentration were determined in all tumors. The kinetic parameters for the synthetic peptide Phe-Leu-Glu-Glu-Leu (FLEEL) were measured in eight tumors. The gamma-carboxylase mRNA expression was evaluated by Northern blot analysis in 12 of 15 tumors. In addition, the total vitamin K content (K1, K1 epoxide, and menaquinones 4-10) in 10 tumors was investigated by high performance liquid chromatography.

RESULTS

Concentrations of menaquinones 4-10 were normal in the nontumorous part of the liver but significantly decreased (P = 0.02) in all the tumors (Groups I and II). This decrease was more severe in Group II (P = 0.02). The tumors in Group I had normal or increased gamma-carboxylase activity and increased mRNA expression (P < 0.02) as compared with their nontumorous counterparts. The tumors in Group II were heterogeneous. Five tumors displayed low gamma-carboxylase activity, associated with low mRNA expression in two, whereas two others had high gamma-carboxylase activity and mRNA expression. The concentration of FLEEL at half-maximal velocity was normal in all the tumors examined (Groups I and II), and a relation was found between the level of expression of gamma-carboxylase and the maximal velocity for FLEEL carboxylation in the tumors in Group II (r = 0.98; P < 0.01). The microsomal content of normal prothrombin was within normal limits in all tumors (Groups I and II).

CONCLUSIONS

Tumor vitamin K content has a critical role in the synthesis of des-gamma-carboxy prothrombin. Furthermore, the gamma-carboxylase defect, which is observed in some secreting tumors, is the result of the defective gene expression of a normal enzyme and not the consequence of the presence of a competitive inhibitor. It is possible that a 75% reduction in gamma-carboxylase gene expression could take a part in the secretion of des-gamma-carboxy prothrombin, but this mechanism is not predominant.

Associated primary esophageal and lung carcinoma: a study of 39 patients

From 1979 to 1992, of 1,294 patients with esophageal squamous cell carcinoma, 39 patients (3.2%) (38 male patients, 1 female patient; mean age, 58 years) had associated primary lung carcinoma. Criteria for the diagnosis of primary lung carcinoma were: (1) non-squamous cell carcinoma tumors, (2) tumors existing before the esophageal squamous cell carcinoma, and (3) solitary squamous cell carcinoma presenting with endobronchial involvement. The two tumors were observed synchronously in 22 patients (56%) and metachronously in 17, with a mean tumor-free interval of 46 months (range, 18 to 77 months). In patients with synchronous disease, 10 underwent nonoperative treatment or a palliative surgical procedure, and 12 (55%) underwent a curative operation. In patients with metachronous disease, a curative operation was performed in all for the first tumor and in 9 (53%) for the second tumor. The overall postoperative mortality rate was 15%. Two patients (10%) died after the curative operation. None of the patients died who underwent curative esophagectomy combined with lobectomy. For the patients with synchronous disease, the 5-year survival rate was 11% in those who underwent a curative operation, and the longest survival in those who received palliative treatment was 18 months. For the patients with metachronous disease, the 5-year survival rates from the date of the diagnosis of the second tumor were 17% for those who had a curative operation and 11% for those who received palliative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)