Characteristics and Impacts of Venous Thromboembolism in Patients with Hepatocellular Carcinoma

INTRODUCTION

Venous thromboembolism (VTE) is a common complication in cancer patients, and is associated with worse prognosis in such population. Hepatocellular carcinoma (HCC) poses high risk for VTE; however, data is scarce regarding the characteristics and consequences of VTE in HCC patients.

METHOD

We retrospectively reviewed the electronic medical records (EMR) of 270 patients diagnosed with HCC from 2000 to 2015 in Cook County Health and Hospitals System. We report the cumulative incidence of VTE in the present cohort, and identified through multivariate logistic regression the independent risk factors of the development of VTE. Overall prognosis of patients with and without VTE were presented and compared.

RESULTS

Sixteen cases (5.93%) of VTE were documented in the present study. In multivariate analysis, obesity, Child B cirrhosis, intra-hepatic lesions more than 3, and multi-organ extrahepatic metastasis were significantly associated with VTE development (p < 0.05). The presence of VTE was an independent risk factor for mortality in multivariate analysis (HR = 3.62, p = 0.021), together with male gender, Child C cirrhosis, and extrahepatic metastasis.

CONCLUSIONS

Obesity, Child B cirrhosis, more intra-hepatic lesions, and multi-organ extrahepatic metastasis are associated with cancer-associated VTE. VTE will adversely affect the prognosis of patients with HCC; therefore, primary thromboprophylaxis may be warranted in such population.

Acute liver failure with amiodarone infusion: A case report and systematic review

WHAT IS KNOWN AND OBJECTIVE

Amiodarone, a commonly used class III antiarrhythmic agent notable for a relatively long half-life of up to 6 months and its pronounced adverse effect profile, is used for both acute and chronic management of cardiac arrhythmias. Chronic use of amiodarone has been associated with asymptomatic hepatotoxicity; however, acute toxicity is thought to be uncommon. There are only six reported cases of acute liver failure (ALF) secondary to amiodarone. In all these cases the outcome of death during the same hospitalization resulted. We aimed to report the only case of acute liver failure secondary to amiodarone infusion in the existing literature where the patient survived.

CASE SUMMARY

A 79-year-old woman admitted with atrial flutter was being treated with intravenous (IV) amiodarone when she abruptly developed coagulopathy, altered mental status and liver enzyme derangement. She was diagnosed with acute liver failure (ALF) secondary to an amiodarone adverse drug reaction, with a calculated score of seven on the Naranjo adverse drug reaction probability scale. Amiodarone was immediately withheld, and N-acetylcysteine (NAC) was initiated. Clinical improvement was seen within 48 hours of holding the drug and within 24 hours of initiating NAC. On post-hospital follow-up visit she was reported to have complete recovery.

WHAT IS NEW AND CONCLUSION

This report emphasizes the importance of monitoring liver enzymes and mental status while a patient is being administered IV amiodarone. N-acetylcysteine administration may have possibly contributed to the early and successful recovery from ALF in our patient. To date, she is the only patient in the existing literature who has been reported to survive ALF secondary to amiodarone administration.

Performance of Khorana Risk Score for Prediction of Venous Thromboembolism in Patients With Hepatocellular Carcinoma

Cancer-associated venous thromboembolism (VTE) is one of the leading causes of mortality and morbidity among patients with malignancy. The Khorana risk score (KRS) is currently the best validated risk assessment model to stratify risks of VTE development in ambulatory patients with cancer. In the current study, we assessed the performance of KRS in patients with hepatocellular carcinoma (HCC). We retrospectively analyzed patients with diagnosis of HCC (screened by International Classification of Diseases [ ICD-9] and ICD-10 code, confirmed with radiographic examination and/or histopathology) at a large public hospital over 15 years (January 2000 through July 2015). Cases with VTE were identified through radiographic examination and blindly adjudicated. Khorana risk score was calculated for each patient, and its association with VTE development and mortality was assessed. Among 270 patients with HCC, 16 (5.9%) cases of VTE were identified, including 7 (43.8%) pulmonary embolism, 4 (25%) peripheral deep vein thrombosis, and 6 (37.5%) intra-abdominal thrombosis. One hundred eighty-four (68.1%) patients had a KRS of 0 and 86 (31.9%) patients had a KRS >0. Most of the thrombotic (n = 9, 56%) events occurred in the low-risk group. In univariate analysis, only prechemotherapy leukocyte count equal to or greater than 11 000/μL was statistically significant in the prediction of VTE incidence. After adjusting for confounding factors in multivariate analysis, KRS >0 was not predictive of VTE (hazard ratio [HR] = 1.83, 95% confidence interval [CI] = 0.81-4.15, P = .15) or mortality (HR = 1.61, 95% CI = 0.92-2.81, P = .09). Khorana risk score did not predict VTE development or mortality in patients with HCC. Design of HCC-specific risk assessment model for VTE development is necessary.

Resveratrol-induced inactivation of human gastric adenocarcinoma cells through a protein kinase C-mediated mechanism

Resveratrol, a polyphenolic phytochemical present in berries, grapes, and wine, has emerged as a promising chemopreventive candidate. Because there is scant information regarding natural agents that prevent, suppress, or reverse gastric carcinogenesis, the aim of the present study was to determine the chemopreventive potential of resveratrol against gastric cancer by investigating cellular and molecular events associated with resveratrol treatment of human gastric adenocarcinoma cells. We determined the action of resveratrol on cellular function and cellular integrity by measuring DNA synthesis, cellular proliferation, cell cycle distribution, cytolysis, apoptosis, and phosphotransferase activities of two key signaling enzymes, protein kinase C (PKC) and mitogen-activated protein kinases (ERK1/ERK2), in human gastric adenocarcinoma KATO-III and RF-1 cells. Resveratrol inhibited [3H]thymidine incorporation into cellular DNA of normally proliferating KATO-III cells and of RF-1 cells whose proliferation was stimulated with carcinogenic nitrosamines. Treatment with resveratrol arrested KATO-III cells in the G(0)/G(1) phase of the cell cycle and eventually induced apoptotic cell death, but had a minimal effect on cell lysis. Resveratrol treatment had no effect on ERK1/ERK2 activity but significantly inhibited PKC activity of KATO-III cells and of human recombinant PKCalpha. Results indicate that resveratrol has potential as a chemopreventive agent against gastric cancer because it exerts an overall deactivating effect on human gastric adenocarcinoma cells. Resveratrol-induced inhibition of PKC activity and of PKCalpha, without any change in ERK1/ERK2 activity, suggests that resveratrol utilizes a PKC-mediated mechanism to deactivate gastric adenocarcinoma cells.

Massive pelvic hemangioma in a patient with blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome (BRBNS) is a rare disorder characterized by gastrointestinal and cutaneous hemangiomas. Patients typically present with gastrointestinal bleeding and anemia. Management of gastrointestinal bleeding may be challenging, since these lesions may be diffusely distributed throughout the gastrointestinal tract. The most common location is the small bowel, and recurrence is common. We describe a patient with BRBNS and lower gastrointestinal bleeding resulting from a large pelvic hemangioma eroding into the rectal wall.

Cytoskeletal PKC and ERK/MAPK activation in response to N-nitrosamines and phorbol 12-myristate 13-acetate in gastric adenocarcinoma cells

Phorbol 12-myristate 13-acetate (PMA) exerts its tumor promotional action by targeting cellular PKC. Carcinogenic nitrosamines (NA) induce tumor formation in the absence of a tumor promoter, and have not been implicated as modulators of signal transduction events. We measured the distribution of PKC and ERK/MAPK activities between cytosol, plasma membranes and cytoskeleton of human gastric adenocarcinoma RF-1 cells after 60 minute and 24 hour treatments with 50 microM NA or 100 nM PMA. At 60 minutes, PMA caused translocation of PKC from cytosol to plasma membranes and increased plasma membrane ERK/MAPK activities; 24-hour treatment with PMA resulted in downregulation of membrane PKC and ERK/MAPK, but an increase in cytoskeletal PKC and ERK/MAPK. NA treatment targeted only cytoskeletal activities, producing a sharp increase in PKC at 60 minutes with further increase after 24 hours. Cytoskeletal ERK/MAPK was elevated only after 24 hours with NA. The converging action of NA and PMA on cytoskeletal PKC and ERK/MAPK activities suggests that both agents may focus on a common cellular target.

Giant pseudopolyps presenting as colocolic intussusception in Crohn's colitis

Bowel obstruction is a well-known complication of Crohn's disease and is usually a result of stricture formation. Intussusception due to giant pseudopolyps is a rare form of bowel obstruction even in Crohn's disease. These giant pseudopolyps rarely regress with medical management alone and often require surgical resection.

Multicentric primary adenocarcinomas of the midgut: the first case report

Multicentric adenocarcinomas of the midgut have not been described; even multiple adenocarcinomas limited to the small intestine are extremely uncommon, with only 14 cases reported in the literature. We report a case of multicentric synchronous involvement of the entire midgut with adenocarcinoma in a 52-yr-old Polish woman who had more than 30 lesions extending from duodenum to mid-transverse colon. There was no family history of cancer. Preoperative evaluation and intraoperative exploration were negative for primary malignancy of the lungs, breasts, ovaries, pancreas, and other parts of the gastrointestinal tract. Results of histopathological examination, immunohistochemical staining, and ras mutational analysis of the lesions uniformly support the diagnosis of multicentric poorly differentiated adenocarcinoma. The cause for this unusual presentation is unknown, although sporadic genetic alteration(s) of oncogene(s) might have been the precipitating event.

MAPK activity is down-regulated in human colon adenocarcinoma: correlation with PKC activity

Cellular growth is regulated by a cascade of kinases, among which mitogen activated protein kinase (MAPK) is an integral member of the Ras-mediated pathway, while protein kinase C (PKC) is recognized as the intracellular receptor of tumor promoters. To assess the role of these two signal transduction enzymes in colonic carcinogenesis, we measured MAPK and PKC activities in cytosol and membrane compartments of: 1) normal colon, 2) colon adenocarcinoma, and 3) histologically normal colonic tissue taken from the margin of resection of neoplastic colon. Both MAPK and PKC activities were down-regulated in solubilized membranes from the cancers. MAPK activity was also down-regulated in the tissue adjacent to the cancer and designated as histologically normal (by routine histopathology). Therefore, MAPK activity appears to be more suitable than PKC as a marker for early detection of colonic transformation.

Protein kinase C activity is altered in HL60 cells exposed to 60 Hz AC electric fields

We examined the effects of electric fields (EFs) on the activity and subcellular distribution of protein kinase C (PKC) of living HL60 cells. Sixty Hertz AC sinusoidal EFs (1.5-1,000 mV/cm p-p) were applied for 1 h to cells (10(7)/ml) in Teflon chambers at 37 degrees C in the presence or absence of 2 microM phorbol 12-myristate 13-acetate (PMA). PMA stimulation alone evoked intracellular translocation of PKC from the cytosolic to particulate fractions. In cells that were exposed to EFs (100-1,000 mV/cm) without PMA, a loss of PKC activity from the cytosol, but no concomitant rise in particulate PKC activity, was observed. In the presence of PMA, EFs (33-330 mV/cm) also accentuated the expected loss of PKC activity from the cytosol and augmented the rise in PKC activity in the particulate fraction. These data show that EFs alone or combined with PMA promote down-regulation of cytosolic PKC activity similar to that evoked by mitogens and tumor promoters but that it does not elicit the concomitant rise in particulate activity seen with those agents.

Decreased MAP kinase activity in human gastric adenocarcinoma

We investigated the cellular signaling events involved in gastric cancer by examining the role of mitogen activated protein kinase (MAPK) in normal and transformed human gastric tissue. A significant loss in both MAPK abundance and activity was found in the membrane fractions of the adenocarcinomas when compared to the histologically normal gastric tissue, while no significant alteration in MAPK was seen in the cytosolic fractions from these two tissue types. These findings suggest that reduction in MAPK abundance and activity are associated with loss of normal growth control in human gastric adenocarcinoma.

Gastric syphilis: a disease with multiple manifestations

The resurgence of syphilis in the United States is effecting all areas of medical care. We describe a young female presenting with symptoms of peptic ulcer disease who failed to respond to H2-receptor antagonist therapy. After further evaluation, she was diagnosed with gastric syphilis and responded well to penicillin. Because gastric syphilis has no pathognomonic clinical findings, the clinician needs to be aware of this disease entity so as to make the correct diagnosis and institute the appropriate antibiotic therapy.

Small cell carcinoma of the esophagus. Report of three cases and review of the literature

Small cell carcinoma has been described in the lung, stomach, pancreas, small intestine, larynx, hypopharynx, thymus, kidney, prostate, breast, cervix, skin, and esophagus. Our three cases and review of the literature confirm that the clinical presentation and eventual evolution of small cell carcinomas of the esophagus appear to be basically similar to those of the far more frequently occurring squamous and glandular carcinomas. However, certain differences in age and sex distribution of cases should be noted. Although squamous cell carcinomas occur three to four times more commonly in males, the male-to-female ratio in SCC in 1.6. Squamous cell carcinomas of the esophagus reach a peak in the fifth and sixth decades of life; SCC cases occur a decade later. All of our patients had history of heavy smoking more than 50 pack-years, a factor that has also been implicated in predisposition to squamous cell carcinoma of the esophagus. History of smoking to this extent was also mentioned in three other patients. There are also some differences in the location of the tumor. SCC rarely occurs in the upper third of the esophagus. The most common location of this tumor is the lower third where APUD cells are most abundant. On the other hand, a majority of squamous cell carcinomas of the esophagus are localized to the middle third, the upper and lower third being involved in equal proportions of the cases. Despite the above reported differences in clinical symptoms and course of these two tumors, their gross appearance is similar. Mean survival of both diseases also seems to be similar.(ABSTRACT TRUNCATED AT 250 WORDS)