Remineralization effects of enamel binding peptide, WGNYAYK, on enamel subsurface demineralization in vitro. Enamel binding peptide, WGNYAYK effect remineralization of enamel

Objectives: We investigated remineralization effects of enamel binding peptide (EBP), WGNYAYK, on enamel subsurface demineralization in vitro.Methods: Bovine lower incisor crowns were used as subsurface enamel demineralization samples, and changes of EBP binding, remineraliztion rate, hardness and microstructure were investigated. Binding of EBP, remineralization rate, hardness and structural changes were investigated. Fluorescein isothiocyatate (FITC)-labeled EBPs (0.4 mM, 4.0 mM, and 7.0 mM) were applied to the samples for 30 min at 37 °C, with sample surfaces and cross-sections observed by confocal laser scanning microscope (CLSM). Mineralization analysis samples were divided into 4 experimental groups; distilled water (DW), EBP 0.4 mM, EBP 4.0 mM, and EBP 7.0 mM. Mineral density changes were measured by micro-CT with hardness measured by nano-indentation. Samples were also observed by scanning electron microscope (SEM) for surface and longitudinal microstructure.

Results

CLSM images indicated that increased fluorescence was observed in the surface layer and up to about 20 μm below the surface layer. The remineralization rate was significantly higher for EBP 7.0 mM compared to DW (p = 0.008). Enamel surface hardness was significantly higher in all EBP groups compared to DW (p < 0.05) and was highest in the 7.0 mM group. SEM images showed obscuring of the superficial columnar structure in the 7.0 mM EBP group, indicating subsurface crystalline structure recovery.

Conclusion

The results of this study suggest that EBP binds to demineralized enamel and promotes remineralization.

Material of choice for non-invasive treatment of dentin caries: An in vitro study using natural carious lesions

INTRODUCTION

In community settings with limited dental personnel and equipment, and in an era when the aerosol transmission of infectious agents is on the rise, a non-invasive approach to caries management is critical. To provide information on non-invasive material selection, the aim of this study was to compare the remineralization effect of commonly used fluoride-containing materials, adjunctive to the everyday use of fluoride toothpaste (F-toothpaste), on primary tooth natural dentin caries.

METHODS

Fifty-five specimens were randomly divided into five groups: 38% silver diamine fluoride (SDF), 5% fluoride varnish (F-varnish), glass-ionomer cement (GIC), deionized water (DW) with F-toothpaste slurry, and DW as a control group (n = 11). The lesion depth and mineral density were measured before and after bacterial pH-cycling using micro-computed tomography. The percentage of mineral density change (%MDchange) was quantified. The dependent t-test, Wilcoxon-Signed-Rank Test, and one way ANOVA with Bonferroni correction were used to analyse the data.

RESULTS

SDF application reduced lesion depth from 844.6 to 759.1 μm (p < 0.045) while increasing mineral density from 551.4 to 763.0 mgHA/cm3 (p < 0.003). Only mineral density rose from 600.2 to 678.4 mgHA/cm3 (p < 0.013) when GIC was used. The other groups showed no difference. The highest %MDchange was also found after SDF treatment (49.7%, p < 0.05), whereas GIC (17.2%, p < 0.05) presented a higher percentage than the F-varnish (2.0%), F-toothpaste (-1.1%) and no-treatment groups (-1.4%).

CONCLUSION

In this in vitro study, where the pH of cycling was almost neutral, using SDF as an adjunct to F-toothpaste resulted in the highest remineralization compared with other remineralizing materials.

Effects of bovine milk osteopontin on in vitro enamel remineralization as a topical application prior to immersion in remineralizing solutions with/without fluoride

The aim of the present study was to investigate the effects of bovine milk osteopontin (OPN) on enamel remineralization as a topical application prior to immersion in remineralizing solutions with/without fluoride. Bovine enamel blocks were demineralized then were divided into the following 3 groups: OPN (2.7 and 5.4 µM) solutions and deionized water (control). Each group was divided into 2 groups (remineralizing solution with or without 1 ppm of fluoride (F)). The specimens were analyzed by micro-CT and scanning electron microscope (SEM). The percentage of remineralization was higher in remineralization solution with than without F (p<0.05). The present results suggest that bovine milk OPN inhibits remineralization in solution without F, but 5.4 µM bovine milk OPN does not inhibit remineralization of the demineralized body using solution containing F by interrupting mineral deposition on the enamel surface.

Effect of fluoride-releasing 4-META/MMA-TBB resin on enamel demineralization around orthodontic brackets: An in vitro µCT analysis

This study aimed to evaluate the impact of fluoride-releasing 4-META/MMA-TBB resin on the degree of enamel demineralization typically detected around orthodontic brackets using μCT. Enamel-dentin blocks were prepared from bovine teeth. Brackets were attached with either 4-META/MMA-TBB resin (SBC), fluoride-releasing 4-META/MMA-TBB resin (SBF), or fluoride-releasing RMGIC (FLC). The specimens were subjected to demineralization (pH 4.5, 21 days) and scanned by μCT (0, 7, and 21 days). Fluoride ion release under the experimental conditions was measured. The degree of demineralization detected in SBF and FLC was significantly lower than that in SBC; there were no significant differences in the degree of demineralization detected in SBF and FLC. The level of fluoride ion detected in FLC was significantly higher than that detected in SBC. Fluoride-releasing 4-META/MMA-TBB resin protected against enamel demineralization around orthodontic brackets when compared to the results from the fluoride-free resin.

In vitro remineralization of enamel with a solution containing casein and fluoride

The aim of the present study was to investigate the effects of casein in a remineralization solution on enamel remineralization. Bovine blocks were demineralized for 21 days, then, allocated into four groups. The specimens were remineralized for 21 days in the following artificial saliva solutions: 1) 0 µg/mL casein, 0 ppm fluoride (F) (C0-F0); 2) 0 µg/mL casein, 1 ppm F (C0-F1); 3) 10 µg/mL casein, 0 ppm F (C10-F0); and 4) 10 µg/mL casein, 1 ppm F (C10-F1). Micro-CT analyses were performed once a week. Specimens were characterized by scanning electron microscopy (SEM) and X-ray photoelectron spectroscopy (XPS). The present results suggest that casein by itself inhibits remineralization, whereas the coexistence of casein and F promotes the remineralization of caries bodies by interrupting mineral deposition on the enamel surface.

Micro-CT assessment of the effect of silver diammine fluoride on inhibition of root dentin demineralization

This study evaluated the ability of different types of silver diammine fluoride (SDF) to inhibit dentin demineralization using micro-focused X-ray computed-tomography (µCT). Dentin specimens were divided into five groups (n=10); no-treatment (control), 3.8% SDF (RC), 38% SDF, 38% SDF with potassium iodide (SDF/KI), and potassium fluoride (KF). The treated-dentin surfaces were subjected to demineralization for 7-days and assessed using µCT to determine mineral loss (ML) values. Specimens were also analyzed with scanning electron microscopy (SEM) and energy-dispersive X-ray spectroscopy (EDS). The ML values of the SDF and KF groups were significantly lower than those of the RC and SDF/KI groups. EDS detected fluoride ions in the SDF and KF groups but not in the RC and SDF/KI groups. It was concluded that 38% SDF demonstrated a high ability to inhibit dentin demineralization while additional application of KI may diminish the inhibitory effect of SDF. The amount of dentin demineralization with SDF treatments was material dependent.

Preventive effect of experimental polymer-based desensitizers with NaF on demineralization of root dentin -observed using micro-CT

This study compared the effect of experimental polymer-based desensitizers with NaF and oxalic acid (OA) for preventing root demineralization via observation using micro-CT. Bovine root dentin surfaces were treated with coating materials: no treatment; MS0(+) (MS Coat One^®); MS3000(+) (MS Coat^®); MS0(-); MS3000(-); MS7000(+/-); fluoride gel (NaF9000). MS; MS polymer, 0-7000; NaF concentrations, (+/-); OA. The specimens were scanned using micro-CT before and after demineralization (pH4.5, 10 h). Following this, the mean mineral loss (ML) after demineralization was calculated, and the specimens were observed under a scanning electron microscope (SEM). The ML values of MS3000(+), MS7000(-), MS7000(+) and NaF9000 were significantly lower than the other groups (p<0.05). Under an SEM, a membrane structure was observed to have formed on the dentin surface in the presence of the MS, fluoride, and OA. The experimental polymer-based desensitizer with oxalic acid and a high concentration of fluoride is effective for preventing root demineralization.

Remineralization of enamel subsurface lesions using toothpaste containing tricalcium phosphate and fluoride: an in vitro µCT analysis

Background

This study aimed to compare the efficacies of experimental toothpastes containing functionalized tricalcium phosphate (fTCP) with and without fluoride for in vitro enamel remineralization under pH-cycling conditions.

Methods

To create artificial white spot lesions, 36 bovine enamel specimens were immersed in a demineralization solution for 10 days. During pH-cycling for 12 days, the specimens were divided into four groups based on the experimental toothpaste type used: (a) fTCP-free, fluoride-free (fTCP − F −); (b) fTCP-containing, fluoride-free (fTCP + F −); (c) fTCP-free, fluoride-containing (fTCP − F +); and (d) fTCP-containing, fluoride-containing (fTCP + F +). Micro-focus X-ray computed tomography (μCT) scans of all specimens were obtained before demineralization, after demineralization, and after pH-cycling. The mineral density and mineral loss (ΔZ) in the enamel subsurface lesions were measured and the percentage of remineralization (%R) was calculated from ΔZ after demineralization and pH-cycling. One-way ANOVA with Tukey’s test was used for statistical analysis of the %R values. The treated enamel surface was investigated via scanning electron microscopy (SEM).

Results

The fTCP − F − group presented with the lowest amount of mineral gain after pH-cycling. In contrast, the fTCP + F + group showed the highest degree of remineralization within all lesion parts. The %R was highest in the fTCP + F + group (38.2 ± 7.8, all P < 0.01). SEM revealed the presence of small crystals on the enamel rods in the fTCP + F − and fTCP + F + groups.

Conclusions

The experimental toothpaste containing fTCP and fluoride increased remineralization of the artificial enamel subsurface lesions during pH-cycling. Furthermore, fTCP and fluoride appear to act independently on the remineralization of enamel subsurface lesions, although they coexisted in one toothpaste type.

Trial registration: This is not a human subject research.

Adjunctive use of fluoride rinsing and brush-on gel increased incipient caries-like lesion remineralization compared with fluoride toothpaste alone in situ

Objective: The objective of this study was to compare the remineralizing effect of sodium fluoride (NaF) mouth rinse or NaF gel as an adjunct to NaF dentifrice on incipient caries-like lesions in an in situ cross-over design study, with three sessions of 30 days each. Materials and methods: Orthodontic brackets with artificial demineralized enamel slabs were attached to the upper first molars of 12 participants. A set of 3 test specimens from the same tooth was randomly assigned to each participant and allocated into three 30-day sessions: 1) brushing with 0.22% NaF dentifrice 2 times/day (F dentifrice), 2) brushing with 0.22% NaF dentifrice 2 times/day+ rinsing with 0.05% NaF before bedtime (F mouth rinse), 3) brushing with 0.22% NaF dentifrice 2 times/day + brushing with 1.1% NaF gel before bedtime (F brush-on gel). The mineral gain and lesion depth of the specimens were evaluated by micro-computed tomography. Results: The mean mineral gain from the NaF mouth rinse and the NaF brush-on gel was similar, but greater than that from the NaF dentifrice (p < .05). The NaF brush-on gel yielded the greatest mean depth of remineralization (168 µm), followed by the NaF mouth rinse (144 µm). Both depths were significantly greater than that of the NaF dentifrice (84 µm) (p < .05). Conclusions: Both 0.05% NaF mouth rinse and 1.1% NaF brush-on gel, used at bedtime, increased incipient caries-like lesion remineralization in situ in combination with brushing with NaF dentifrice twice a day.

Micro-CT assessment of comparative radiopacity of adhesive/composite materials in a cylindrical cavity

This study was performed to evaluate the comparative radiopacity of adhesive/resin composite materials in cylindrical cavities using micro-computed X-ray tomography (μCT). The two-step self-etch adhesive systems, Clearfil SE Bond (SE) and FL-Bond II (FL), and flowable resin composites, Beautifil Flow F10 (BF) and Clearfil Majesty ES Flow High (MJ), were used. The radiopacity of bovine tooth structures and restorative materials was measured by μCT. In addition, cylindrical cavities prepared in bovine teeth were restored with the following adhesive/composite combinations: SE-BF, SE-MJ, FL-BF, and FL-MJ. The mean gray values of the composite restorations were calculated. The threshold values of the μCT images were evaluated using the Otsu's thresholding method. The current results show that the comparative radiopacity of the materials and tooth structure varied, which affected distinguishing the μCT images of the composite restorations in the cylindrical cavity. The proper combination of restorative materials should be considered when conducting in vitro μCT assessments of composite restorations.

Morphological Evaluation of the Adhesive/Enamel interfaces of Two-step Self-etching Adhesives and Multimode One-bottle Self-etching Adhesives

PURPOSE

To evaluate the acid-base resistant zone (ABRZ) at the adhesive/enamel interface of self-etching adhesives with or without prior phosphoric acid etching.

MATERIALS AND METHODS

Four adhesives were used in 8 groups: Clearfil SE Bond (SEB), Optibond XTR (XTR), Scotchbond Universal Adhesive (SBU), and Clearfil BOND SE ONE (ONE) without prior phosphoric-acid etching, and each adhesive with phosphoric acid etching for 10 s (P-SEB, P-XTR, P-SBU and P-ONE, respectively). After application of self-etching adhesives on ground enamel surfaces of human teeth, a flowable composite was placed. For observation of the acid-base resistant zone (ABRZ), the bonded interface was exposed to demineralizing solution (pH 4.5) for 4.5 h, followed by 5% NaOCl with ultrasonication for 20 min. After the acid-base challenge, morphological attributes of the interface were observed using SEM.

RESULTS

ABRZ formation was confirmed in all groups. The funnel-shaped erosion beneath the interface was present in SBU and ONE, where nearly 10 to 15 μm of enamel was dissolved. With phosphoric acid etching, the ABRZs were obviously thicker compared with no phosphoric acid etching.

CONCLUSION

Enamel beneath the bonding interface was more susceptible to acid dissolution in SBU and ONE. In the case of the one-bottle self-etching adhesives and universal adhesives that intrinsically have higher pH values, enamel etching should be recommended to improve the interfacial quality.

Silver diamine fluoride and glass ionomer differentially remineralize early caries lesions, in situ

OBJECTIVES

The aim of the present study was to evaluate the percent mean mineral density (MD) change of early caries lesions after the application of silver diamine fluoride (SDF) or glass ionomer cement (GIC).

MATERIALS AND METHODS

This double-blind, crossover study involved two experimental phases of 28 days each. Thirty-two pairs of enamel slabs were created from the proximal surfaces of 16 premolars. Each pair of artificial carious slabs was randomly divided into the control or test group (38 % SDF or GIC). The slabs were attached to orthodontic brackets and bonded to the maxillary first permanent molars of 16 subjects for 28 days. After a 7-day washout period between phases, the subjects received the other material for the second phase. The mean MD of the lesions was measured by microcomputed tomography.

RESULTS

SDF yielded a percent mean MD increase at a depth of 0-84 μm, although increase in the GIC group was observed at a depth of 24-108 μm. The percent mean MD changes of the SDF and GIC groups were similar (p = 0.100) and significantly higher than in control (p < 0.001, p = 0.003, respectively).

CONCLUSIONS

The two materials increased the percent mean MD change of early proximal caries lesions to a similar extent, but with different spatial patterns.

CLINICAL RELEVANCE

Due to deeper level of GIC remineralization, the refractive index of the GIC applied enamel might be closer to sound enamel. Hence, GIC is recommended for remineralization of anterior teeth. SDF staining makes it unsuitable for use in anterior teeth; thus, it is reserved for use in posterior teeth.

Study on the influence of leucine-rich amelogenin peptide (LRAP) on the remineralization of enamel defects via micro-focus x-ray computed tomography and nanoindentation

Regeneration of severely damaged enamel (e.g. deep demineralized lesions) is currently not possible, because the structural units of enamel crystal construction are removed after its maturation. The aim of this in vitro study was to evaluate the effect of surface impregnation by leucine-rich amelogenin peptide (LRAP) on the remineralization of eroded enamel using micro-focus x-ray computed tomography (µCT). Fifteen bovine enamel blocks were embedded in resin and three zones (sound, demineralization, and remineralization) were defined on each specimen. Lesions were prepared by immersing the samples in demineralization solution for 7 d. The samples were soaked in distilled water or 60 or 120 µg mL(-1) solution of LRAP in water for 30 min. After the surface treatment, specimens were incubated in artificial saliva for either 5 or 10 d at 37 °C. The amount of mineral gain (dΔZ%) and the relative changes in the lesion depth (dLD%), obtained from µCT, were used to evaluate the effect of LRAP on the remineralization of lesions. The effects of LRAP on cross-sectional integrated hardness ΔINH were studied after 10 d using nanoindentation. ANOVA test was used to determine the effect of time and/or LRAP concentration on dΔZ%, dLD% and ΔINH mean values. Tukey's analysis was used for multiple comparison testing (α = 0.05). Analysis of µCT data showed significant effect of time and LRAP concentration on the dΔZ% (p = 0.013, p = 0.003) and the dLD% (p  <  0.001, p = 0.002) mean values. The nanoindentation hardness was significantly improved by 120 µg mL(-1) LRAP (p = 0.02). Also, the peptide treatment affected the mineral distribution throughout the lesion by inhibiting of superficial deposition. This study showed that the treatment of eroded lesions in enamel by LRAP can improve and regulate the pattern of remineralization in vitro.

Casein phosphopeptide-amorphous calcium phosphate and glass ionomer show distinct effects in the remineralization of proximal artificial caries lesion in situ

This study aimed to compare the ability of casein-phosphopeptide amorphous-calcium-phosphate (CPP-ACP) and glass-ionomer (GI) in remineralizing proximal artificial caries lesions (ACLs). Molar enamel-slabs were divided into: original-lesion control, intra-oral controls, and experimental (CPP-ACP or GI) groups. Specimens received ACLs and were bonded on subject maxillary first molars. After 4-weeks, mineral density (MD) was analyzed by μCT. Compared to control, CPP-ACP increased MD at 0-38/68-84 microns and the GI group had an increase at 0-68 microns, with a greater increase in MD compared to the CPP-ACP group from 0-53 microns. The mean percent remineralization (%R) showed differences between the GI, CPP-ACP groups and their paired controls. GI tended to increase remineralization more than CPP-ACP. In conclusion, CPP-ACP and GI demonstrated distinct remineralizing ability. GI induced greater remineralization in the superficial lesion, while CPP-ACP remineralized the lesion body. Their effects on percent remineralization and reducing lesion depth of proximal ACLs were similar.

Assessment of natural enamel lesions with optical coherence tomography in comparison with microfocus x-ray computed tomography

A technology to characterize early enamel lesions is needed in dentistry. Optical coherence tomography (OCT) is a noninvasive method that provides high-resolution cross-sectional images. The aim of this study is to compare OCT with microfocus x-ray computed tomography ([Formula: see text]) for assessment of natural enamel lesions in vitro. Ten human teeth with visible white spot-like changes on the enamel smooth surface and no cavitation (ICDAS code 2) were subjected to imaging by μCT (SMX-100CT, Shimadzu) and 1300-nm swept-source OCT (Dental SS-OCT, Panasonic Health Care). In [Formula: see text], the lesions appeared as radiolucent dark areas, while in SS-OCT, they appeared as areas of increased signal intensity beneath the surface. An SS-OCT attenuation coefficient based on Beer-Lambert law could discriminate lesions from sound enamel. Lesion depth ranged from 175 to [Formula: see text] in SS-OCT. A correlation between [Formula: see text] and SS-OCT was found regarding lesion depth ([Formula: see text], [Formula: see text]) and also surface layer thickness ([Formula: see text], [Formula: see text]). The images obtained clinically in real time using the dental SS-OCT system are suitable for the assessment of natural subsurface lesions and their surface layer, providing comparable images to a laboratory high-resolution [Formula: see text] without the use of x-ray.

Effect of different desensitizers on inhibition of bovine dentin demineralization: micro-computed tomography assessment

This study evaluated the effect of two desensitizers on inhibition of dentin demineralization, after immersion in artificial saliva using micro-computed tomography (μCT). Dentin blocks cut from bovine incisors were treated with deionized water (DW, a negative control) or one of three desensitizers: a fluoride varnish (Duraphat, a positive control), a calcium phosphate desensitizer (Teethmate Desensitizer), and a fluoro-alumino-calcium silicate-based desensitizer (Nanoseal). After each treatment, the specimens in Duraphat, Nanoseal, and Teethmate Desensitizer groups were pre-immersed in artificial saliva (pH 6.5) for either 1 d or 1 wk. The mineral loss of the specimens after demineralization (pH 5.0, 3 h) was evaluated by μCT. The treated surface was investigated with scanning electron microscopy. Mineral loss in all treatment groups was significantly lower than that in DW. Duraphat was the most effective treatment against demineralization, followed by Nanoseal. Nanoseal showed significantly better reduction in mineral loss following immersion for 1 wk in artificial saliva than for 1 d. However, Teethmate Desensitizer and Duraphat did not exhibit enhanced inhibition of demineralization over a longer period of immersion in artificial saliva. Scanning electron microscopy images showed deposition of particles on the dentin in both Teethmate Desensitizer. The application of Teethmate Desensitizer and Nanoseal to the exposed dentin surface resulted in inhibition of demineralization, with Nanoseal resulting in improved inhibition after prolonged immersion in artificial saliva.

Sodium fluoride mouthrinse used twice daily increased incipient caries lesion remineralization in an in situ model

OBJECTIVES

To investigate the remineralizing effects of fluoride mouthrinses used at different times and frequency in addition to fluoride toothpaste.

METHODS

A randomized crossover single blinded study comprised 4 experimental phases of 21 days each. Twelve orthodontic volunteers were fixed with an orthodontic bracket containing an artificial carious enamel slab, which was from the same tooth in all 4 phases, and were randomly assigned to the following groups: (1) brushing with F toothpaste 2× per day (F- brush), (2) F- brush+rinsing with 0.05% NaF (F- rinse) after lunch, (3) F- brush+F-rinse before bedtime, and (4) F- brush+F- rinse 2× per day. Mean mineral gain after each phase was determined from mineral density profiles obtained using Micro-CT.

RESULTS

The mean mineral gain in all treatments with F- brush and F-rinse were significantly greater than those in F- brush (p<0.05). Moreover F- rinse 2× per day increased lesion remineralization more than F- rinse once a day.

CONCLUSIONS

The twice-daily use of 0.05% NaF mouthrinse combined with twice-daily regular use of fluoride toothpaste resulted in the greatest remineralization of incipient caries. These data indicate that rinsing frequency is a factor affecting the effectiveness of fluoride mouthrinse.

CLINICAL SIGNIFICANCE

The rinsing frequency of NaF mouthrinse, when used with fluoride toothpaste, also affects the remineralization. This finding, if confirmed by a clinical study, would lead to a new recommendation for fluoride mouthrinse used in high caries risk patients who could benefit from using it twice a day.

Non-destructive characterization of voids in six flowable composites using swept-source optical coherence tomography

OBJECTIVE

The aim of this study was to evaluate the void frequency (V(F)) and void volume (V(V)) in different flowable composites using swept-source optical coherence tomography (SS-OCT).

METHODS

Standard class I cavities were prepared and filled with six different flowable composites: Clearfil Majesty LV (MJ; Kuraray), MI Flow (MW; GC), MI Fil (ML; GC), Beautifil flow plus (BF; Shofu), Palfique Estelite low flow (EL; Tokuyama) and Surefil SDR flow (SF; Dentsply). The restorations were scanned under OCT. The OCT tomograms were analyzed and average V(F) and V(V) per restoration for each composite were calculated. Scanning electron microscope (SEM) was used to observe the structure of each composite. In addition, the flowability of the materials was evaluated measuring the displacement of each material placed up-right on a glass slide. V(F) and V(V) obtained by OCT were also compared to those calculated using micro-computed tomography (micro-CT).

RESULTS

Kruskal-Wallis ANOVA and Mann-Whitney U tests revealed significantly different V(F) and V(V) values (p<0.05) among the composites. Voids ranging from 35 to 785 μm in diameter were detected in OCT tomograms. MJ showed highest V(F) and V(V) values followed by MW, but ML, BF, EL and SF showed no significant difference. Filler volume in composites showed a positive correlation with void formation, but flowability did not show a specific trend. Micro-CT evaluation validated the V(F) and V(V) calculation by OCT, with a significant correlation in void size (p<0.001, r=0.94).

CONCLUSION

The results of this study indicate the reliability of SS-OCT for real-time void characterization of composite materials and restorations. Void formation in flowable composites is material dependent.

Enamel Lesion Parameter Correlations between Polychromatic Micro-CT and TMR

Transverse microradiography (TMR) is considered as the gold standard technique for the evaluation of enamel lesions. Micro-computed tomography (µCT) has the advantage of non-destructive measurements, but the beam-hardening effect with polychromatic x-rays is a major drawback. To date, no study has validated µCT against TMR. The objective of this study was to validate µCT measurements of enamel lesions under various x-ray conditions and software beam-hardening correction (BHC) against TMR. Human molars with natural white-spot lesions were scanned for 5 min by µCT at 100 kV in different conditions: 50 µA (0.5-mm Al filter), 165 µA (0.5-mm Al/0.3-mm Cu), and 200 µA (0.5-mm Al/0.4-mm Cu), with or without BHC. Grayscale values were converted into mineral density values using phantoms. Thin sections at the same positions were then prepared for TMR. Lesion depth (LD; µm) and mineral loss (ΔZ; vol%µm) were compared between µCT and TMR by Pearson’s correlations. µCT measurements correlated well with TMR under all conditions (p < 0.001, r > 0.86 for LD and ΔZ), except for 0.5-mm Al without BHC (p > 0.05). Even without BHC, combined Al/Cu filters successfully reduced the beam-hardening effect. µCT can be used as a non-destructive alternative to TMR with comparable parameters for the study of enamel lesions.

Gum Containing Calcium Fluoride Reinforces Enamel Subsurface Lesions in situ

The aim of this study was to assess the effect of chewing gum containing phosphoryl oligosaccharides of calcium (POs-Ca) and a low concentration of fluoride (F) on the hardness of enamel subsurface lesions, utilizing a double-blind, randomized, and controlled in situ model. Fifteen individuals wore removable lingual appliances with 3 bovine-enamel insets containing subsurface demineralized lesions. Three times a day for 14 days, they chewed one of the 3 chewing gums (placebo, POs-Ca, POs-Ca+F). After the treatment period, cross-sectional mineral content, nanoindentation hardness, and fluoride ion mapping by time-of-flight secondary ion mass spectrometry (TOF-SIMS) were evaluated. Although there were no statistical differences in overall mineral content and hardness recovery rates between POs-Ca and POs-Ca+F subsurface lesions (p > 0.05), nanoindentation at 1-μm distance increments from the surface showed statistical differences in hardness recovery rate between POs-Ca and POs-Ca+F in the superficial 20-μm region (p < 0.05). Fluoride mapping revealed distribution of the ion up to 20 μm from the surface in the POs-Ca+F group. Nanoindentation and TOF-SIMS results highlighted the benefits of bioavailability of fluoride ion on reinforcement of the superficial zone of subsurface lesions in situ (NCT01377493).

Histologic factors affecting prognosis following hepatectomy for intrahepatic cholangiocarcinoma

Long-term survival following hepatectomy for intrahepatic cholangiocarcinoma has been poor, and specific factors influencing survival are unclear. In a retrospective study we sought to determine prognostic factors related to survival in these patients. In 28 patients who underwent hepatic resection for intrahepatic cholangiocarcinoma, we investigated the relations of several histologic factors to patient survival by univariate and multivariate analyses. No deaths occurred during the first 30 days. Median and mean survival times following hepatectomy were 409 and 935 days, respectively. The respective survival rates at 1, 3, and 5 years were 57%, 27%, and 27%. Resection margin status, intrahepatic metastasis, lymph node involvement, and lymphatic invasion were significant predictors of outcome. In a multivariate analysis using the Cox proportional hazards model, only lymphatic invasion independently predicted survival. Curative resection with clear margins was found to prolong survival after surgery. Hepatectomy for intrahepatic cholangiocarcinoma without lymphatic invasion offers hope for long-term survival.

Reactivation of viral replication after liver resection in patients infected with hepatitis B virus

OBJECTIVE

To investigate the mechanisms and risk factors underlying postoperative reactivation of hepatitis after liver resection for hepatitis B virus-related hepatocellular carcinoma.

SUMMARY BACKGROUND DATA

Although risk factors for acute hepatic failure after liver resection have been reported in patients with chronic liver disease, the issue of reactivation of hepatitis B virus replication after liver resection is unresolved.

METHODS

Fifty-five patients with hepatocellular carcinoma and hepatitis B surface antigen underwent liver resection. In 25 of these 55 patients, serum levels of hepatitis B virus DNA and the type of hepatitis B virus were determined before and after surgery.

RESULTS

Postoperative hepatitis occurred in 13 of the 55 patients (24%). Reactivation of viral replication occurred after liver resection in 7 of the 25 patients tested, and alanine aminotransferase activity increased in 6 of these 7 patients. High preoperative alanine aminotransferase activity, high levels of hepatitis B virus DNA, presence of wild-type DNA, and detection of hepatitis B core antigen in hepatocytes, all features of the immune clearance phase in the natural course of hepatitis B virus infection with no surgery, were more likely to be found in patients with reactivation than in patients without reactivation.

CONCLUSIONS

During the immune clearance phase of hepatitis B virus infection, especially the period of acute exacerbation, changes in serum hepatitis B virus DNA level should be monitored for early warnings of reactivation of viral replication, likely to cause severe postoperative hepatitis and acute hepatic failure.

Malignant lymphoma presenting as a large mass in the anterior chest wall

In general, the preferred treatment for malignant lymphoma is the cytotoxic chemotherapy. However, the surgical intervention is often required for diagnosis and treatment in cases where the diagnosis is not obvious. In well-chosen cases the surgical treatment can contribute importantly to a good outcome and quality of life even in malignant lymphoma. We report a rare case of non-Hodgkin's lymphoma presenting as a large, rapidly growing mass in the anterior chest wall; resection was the key initial treatment.

Resection of a non-functioning islet cell carcinoma occupying the entire pancreas

A 46-year-old woman with jaundice was found to have enlargement of the entire pancreas on computed tomography. Endoscopy revealed a tumor at the papilla of Vater, although examination of biopsy specimens did not demonstrate a malignancy. The jaundice resolved spontaneously, but reappeared at 7 months. Also noted was increased swelling of the papilla. The serum pancreatic endocrine and exocrine hormone concentrations were within the reference ranges. At surgery, a hard mass was found occupying the entire pancreas. Examination of incisional biopsy specimens from the pancreatic mass and papilla of Vater revealed an islet cell tumor. A total pancreatectomy was performed. The tumor extended from the pancreatic tail to the papilla of Vater. Histopathologic and immunopathologic examination revealed a non-functional islet cell carcinoma. There was no evidence of recurrence at 3 years. A good outcome can be achieved with resection of non-functioning islet cell carcinomas, even if they are advanced.

Doppler sonography in hepatolithiasis: a case report

In the treatment of hepatolithiasis, it is important to not only remove all stones and eliminate bile stasis in the biliary tract, but also to remove atrophic hepatic tissue, as such tissue may cause recurrent cholangitis as well as latent cholangiocarcinoma. A 75-year-old woman was diagnosed as having hepatolithiasis with stenosis at the branching of the bile ducts in segment II and segment III by sonography, computed tomography, endoscopic retrograde cholangiography, and magnetic resonance cholangiography. Portograms did not reveal portal branches in segment III but did demonstrate the portal branches in segment II. During the operation, Doppler sonography was done. Doppler sonography did not reveal the portal blood flow in segment III, but did demonstrate a "to-and-fro" pattern in the portal branches in segment II, indicating atrophic hepatic tissue with disrupted portal blood flow. Lateral segmentectomy (resection of segments II and III and lithotomy with choledo-chotomy were done. The patient is in good health 2 years 6 months after the operation. Doppler sonography is useful in the detection of disrupted portal blood flow and the diagnosis of hepatic atrophy. This is clearly advantageous in the decision-making about whether to perform a liver resection with hepatolithiasis.

A pancreatic anaplastic carcinoma of spindle-cell form

A 56-yr-old man with complaint of abdominal pain and body weight loss was admitted to our hospital. Contrast-enhanced computed tomography on admission revealed a pancreatic tumor. Contrast-enhanced computed tomography 1 m.o. after admission revealed rapid growth of this tumor. We performed exploratory laparotomy with only a needle biopsy of the unresectable tumor because of extensive spread, including liver metastases. Further histological and immunohistochemical examination revealed that both the pancreatic tumor and the hepatic metastases featured malignant spindle-shaped cells. Despite radiotherapy, the patient died 40 d after laparotomy.

Patterns of and risk factors for recurrence after liver resection for well-differentiated hepatocellular carcinoma: a special reference to multicentric carcinogenesis after operation

BACKGROUND/AIMS

We studied the patterns of, and risk factors for, recurrence after resection of well-differentiated hepatocellular carcinoma to make a strategy for such carcinoma.

METHODOLOGY

The subjects were 36 patients who underwent liver resection for well-differentiated hepatocellular carcinoma. Multicentric carcinogenesis after the operation (multicentric recurrence) was diagnosed when a recurrent tumor included a component of well-differentiated hepatocellular carcinoma. Tumor-free survival rates of patients with various risk factors were calculated and differences between groups were evaluated. For multivariate analysis, Cox's proportional hazard model was used.

RESULTS

All recurrent tumors after operation were of multicentric origin. Univariate analysis showed a history of blood transfusion, high alpha-fetoprotein concentration (> 20 ng/ml), and low platelet count (< 10(5)/mm3) to be significant factors. By multivariate analysis, a history of blood transfusion and a low platelet count were independent risk factors. Nonanatomic resection was not a risk factor.

CONCLUSIONS

In patients with well-differentiated hepatocellular carcinoma, especially with risk factor(s) for multicentric recurrence, not only anatomic but also nonanatomic resection (partial resection) are indicated for a primary tumor, because almost all recurrent tumors are of multicentric origin. After resection of well-differentiated hepatocellular carcinoma, careful monitoring for multicentric recurrence is important in patients with risk factors.

Clinical significance of prior hepatitis B virus infection in patients with hepatitis C virus-related hepatocellular carcinoma

BACKGROUND

The effect of prior hepatitis B virus (HBV) infection on the clinicopathologic findings for patients with hepatitis C virus (HCV) RNA and hepatocellular carcinoma (HCC) is still unclear.

METHODS

Of 59 patients who underwent liver resection for HCV-related HCC (</=2.0 cm in greatest dimension) without metastases between 1990 and 1997, 38 patients had anti-HB core antibody (anti-HBc) and did not have HB surface antigen in their sera (Group 1). Their clinicopathologic findings and outcomes after surgery were compared with those of the remaining 22 patients without anti-HBc (Group 2).

RESULTS

The proportion of well-differentiated HCC was significantly lower in Group 1 than in Group 2 (P = 0.0214). The percentage of patients with cirrhosis was significantly lower in Group 1 than in Group 2 (P = 0.0228). The cumulative survival rate was significantly lower in Group 1 than in Group 2 (P = 0.0224). The risk ratio of anti-HBc for shorter survival time was 3.817.

CONCLUSIONS

HCC more often developed before cirrhosis in patients with HCV RNA and anti-HBc than in patients positive for HCV RNA alone. Prior HBV infection was a risk factor for poor outcome after liver resection for patients infected with HCV.

Post-operative blood tests and multicentric recurrence of hepatocellular carcinoma

Second hepatic resections (SHR) were performed in 2 patients with recurrent hepatocellular carcinoma (HCC) with hepatitis C virus (HCV) more than 10 years after initial curative resections. Appearance on imaging studies of the late recurrences thought to be multicentric primary tumors, was preceded by fluctuating laboratory abnormalities such as increased alanine aminotransferase activity (ALT), increased serum alpha-fetoprotein (AFP), and decreased platelet counts by as long as 2 years. Therefore, serial changes of blood tests after resection of HCC with HCV might be useful predictors of late multicentric recurrence.

Adenomyoma of the common bile duct

An unusual case of adenomyoma of the common bile duct is reported. A 31 year-old woman with intermittent epigastralgia was found to have cholestasis and stenosis of the common bile duct. A malignant tumor could not be excluded. Resection of the common bile duct with the tumor was performed with choledochojejunostomy reconstruction. The tumor consisted of glandular hyperplasia and proliferation of smooth muscle fibers and fibrous connective tissue. The patient was well at the 30-month follow-up. Although the benign tumors of the extrahepatic bile ducts are rare, the clinical importance lies in the recognition that they can cause biliary tract obstruction. Intra-operative frozen section for histologic examination is required to make the diagnosis and plan the surgical procedure. Complete extirpation of the lesion is recommended. A radical operation is not necessary.

Perforated duodenal diverticulum: report of two cases

Duodenal diverticula may be complicated by diverticulitis, perforation, hemorrhage, pancreatitis, or biliary obstruction. Two cases of perforated duodenal diverticulum are reported. Both patients were elderly females. Computed tomography of the abdomen showed retroperitoneal air around the duodenum in the first case, and an enterolith in a duodenal diverticulum and a retroperitoneal abscess in the second case. Laparotomy and diverticulectomy with two-layer closure of the duodenum was performed in the first case. The second patient was treated conservatively with antibiotics, percutaneous abscess drainage, and endoscopic lithotomy. Both recovered well. Computed tomography is useful in the diagnosis of a perforated duodenal diverticulum. Although surgical intervention is the standard treatment, conservative therapy is also an option. Duodenal enteroliths are rare but may cause perforation of a diverticulum or biliary obstruction. The duodenal blind loop created by a Billroth II gastrectomy provides a static environment for the formation of enteroliths in duodenal diverticula.

Influence of histological inflammatory activity on regenerative capacity of liver after percutaneous transhepatic portal vein embolization

Percutaneous transhepatic portal vein embolization (PTPE) produces regenerative hypertrophy in the nonembolized part of the liver, but the regenerative capacity after PTPE in patients with chronic hepatitis is unknown. We studied 34 patients with hepatocellular carcinoma and chronic hepatitis who underwent PTPE at the right portal vein. Hepatic lobular volumes were calculated by computed tomography before and 2 weeks after PTPE. The increase in left lobular volume was analyzed using a stepwise multiple regression method incorporating 11 factors: age; portal venous pressure; proportional volume of the right lobe; indocyanine green retention test; platelet count; serum levels of aspartate transaminase, alanine transaminase, total bilirubin, and albumin; and histological inflammatory grade and stage of fibrosis, according to the criteria of the International Association for the Study of the Liver recommended at their 1994 meeting. The median volume of the left lobe had increased from 405 to 554 cm3 (P < 0.0001) by 2 weeks after PTPE. Inflammatory grade was the only independent factor predicting regenerative hypertrophy (regeneration ratio (%) = 80.3 - 20.1 x grade; standard correlation coefficient = -0.566; P = 0.0014). Histological inflammatory activity was the essential factor regulating liver regeneration after PTPE in patients with chronic hepatitis.

High prevalence of infection with hepatitis B and C viruses in patients with hepatocellular carcinoma in Japan

BACKGROUND/AIMS

Hepatitis B and C viruses are closely associated with hepatocellular carcinoma. We studied the prevalence of infection with either virus in patients with this cancer by examination of sera and tumor tissue.

METHODOLOGY

Serum samples obtained before treatment from 330 patients with hepatocellular carcinoma were assayed for antibodies against hepatitis C virus and against hepatitis B surface and core antigen. Tumor tissues from 65 patients were examined for hepatitis B virus RNA.

RESULTS

Of the 330 patients, 87 had anti-hepatitis C alone; 161 had anti-hepatitis C and anti-hepatitis B (core); 13 had anti-hepatitis C and anti-hepatitis B (surface); 39 had anti-hepatitis B (surface) alone; and, 19 had anti-hepatitis B (core) alone. Eleven patients had none of these. Hepatitis B virus genes were detected in tumor tissue in all 13 patients with anti-surface antibody, in 21 of 30 patients with anti-core antibody, and in 9 of 22 patients without hepatitis B antibodies. Viral genes were detected in tumor tissue in 5 of 11 patients with neither B nor C virus markers in their sera; viral markers were found in either serum or tumor tissue in 324 of 330 patients (98.2%).

CONCLUSIONS

The prevalence of hepatitis B or C virus infection in patients with hepatocellular carcinoma in Japan is extremely high. The prevalence of co-infection with both viruses is also high.

Hepatocellular carcinoma with chondrosarcomatous variation: case report with immunohistochemical findings, and review of the literature

Hepatocellular carcinoma with chondrosarcomatous variation is very rare. We report a case with the results of pathology examination, and review the literature. The patient, a 72-year-old may had a very large tumor in the liver revealed during follow-up for diabetes mellitus. The liver mass, which was 14 cm in diameter, was diagnosed as hepatocellular carcinoma by abdominal ultrasonography. Anterior segmentectomy and partial liver resection were performed. Histopathology examination revealed that the tumor consisted of two different components: the major one was hepatocellular carcinoma (HCC), which occupied most of the tumor; and a sarcomatous component, which occupied a smaller area, and included spindle-shaped cells with chondroscarcomatous variation. Intrahepatic metastases and tumor thrombi of HCC were also found in portal and hepatic veins. Investigations of the immunohistochemical localization of keratin (KRT), vimentin (VMT), and S-100 protein (S 100) were performed by the avidin-biotin complex method. Some of the spindle cells were immunohistochemically positive for both KRT and VMT, and the chondrosarcomatous cells were positive for S 100. These results strongly suggested that the sarcomatous lesion resulted from a sarcomatous change of HCC.

Delayed hepatic resection for ruptured hepatocellular carcinoma

BACKGROUND

Although transcatheter arterial embolization is advocated as initial therapy for ruptured hepatocellular carcinoma (HCC), hepatic resection is necessary for cure. The effectiveness of delayed hepatic resection for ruptured HCC was determined.

METHODS

The records of 10 patients who underwent delayed hepatic resection for ruptured HCC were reviewed.

RESULTS

All patients were men, and the mean age was 63 years. For hemostasis, transcatheter arterial embolization was performed in three patients, whereas in the other patients bleeding stopped without special procedures. Mean interval from rupture to hepatic resection was 74 days. Liver function test results before hepatic resection were almost normal. Trisegmentectomy in one and bisegmentectomy in four patients were performed, whereas minor hepatic resection was performed for four extrahepatic HCCs. There were no operative or hospital deaths. Four patients had cirrhosis. The mean tumor diameter was 7.5 cm. Of seven patients with recurrence, two with dissemination had tumors that ruptured on the inferior aspect of the liver. The 1- and 3-year survival rates were 77% and 48%, respectively.

CONCLUSIONS

Because delayed hepatic resection for ruptured HCC was safe and compared similarly with that for other patients who underwent resection for HCC, it should be used. However, when HCC ruptures in an inferior location, recurrence of tumor as dissemination is likely.

[Percutaneous transhepatic portal vein embolization for hepatocellular carcinoma]

We report on the significance of percutaneous transhepatic portal vein embolization (PTPE) for hepatocellular carcinoma based on the results in 111 patients who underwent PTPE in our hospital. All patients tolerated the procedure without major complications, although transient elevations in serum transaminase levels were noted. Immediately after PTPE, the portal pressure increased. Portal venous flow at the main portal trunk decreased, but the flow in the nonembolized part of the liver increased. PTPE produced regenerative hypertrophy in the nonembolized part of the liver, which was mainly predicted by the volume of the embolized area and the morphological score of the hepatitis or cirrhosis. PTPE increased the safety of subsequent hepatectomy and expanded the indications for hepatectomy. PTPE is also useful as a type of multiplicative therapy for hepatocellular carcinoma.

Mirizzi syndrome caused by xanthogranulomatous cholecystitis: report of a case

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory disease of the gallbladder. In severe cases, inflammation extends to adjacent structures, and XGC is sometimes confused with a malignant neoplasm. We recently diagnosed XGC as the preoperative cause of Mirizzi syndrome in a patient based on the clinical course. The patient was admitted because of obstructive jaundice, with gallbladder carcinoma as the suspected cause. The gallbladder was swollen with gallstones and the serum level of carbohydrate antigen 19-9 (CA19-9) was 3070 U/ml at admission. A percutaneous transhepatic cholangiodrainage (PTCD) was done, and the common hepatic duct as well as the right and left hepatic ducts were found to be obstructed. Later, the CA19-9 level and swelling of the gallbladder decreased and the obstruction of the bile ducts disappeared. A cholecystectomy was performed and the intraoperative pathohistological diagnosis of chronic cholecystitis was made from frozen sections. The pathohistological diagnosis of XGC was made from paraffin-embedded sections. Mirizzi syndrome such as that seen in our patient is a rare complication of XGC. XGC occasionally causes extensive inflammation; thus, performing a conventional cholecystectomy can be unsafe. However, in our opinion, a total, not subtotal, cholecystectomy should be done whenever possible because the incidence of gallbladder carcinoma accompanied with XGC is higher than that with ordinary cholecystitis or gallstones.

Concentrations of bile and serum endotoxin and serum cytokines after biliary drainage for acute cholangitis

Endotoxin contributes to cholangitis. We measured concentrations of bile and serum endotoxin and serum cytokines after biliary drainage for obstructive jaundice with or without acute cholangitis. Patients who underwent percutaneous transhepatic cholangiodrainage (PTCD) in 1995 were classified as having acute cholangitis (group A; n = 11), having a history of acute cholangitis (group B; n = 5), or not having a history of acute cholangitis (group C; n = 13). Bile endotoxin was positive (above the cut-off value) in all patients in groups A and B, and in five patients in group C. The mean concentration of bile endotoxin was significantly higher in groups A and B than in group C. After PTCD, the bile endotoxin level decreased more slowly in group A than in the other groups. Before PTCD, the mean serum levels of IL-1 receptor antagonist (IL-1ra), IL-6, and IL-8 were higher in group A than the other groups. The serum levels of IL-1ra and IL-6 before PTCD were significantly higher when the acute cholangitis was more severe. The mean serum levels of cytokines increased just after PTCD and then decreased. In group A, the serum level of IL-6 at 5 h after PTCD was significantly correlated to the endotoxin level in bile at this time. Increases in cytokines may participate in the pathophysiological changes of acute cholangitis. Biliary drainage for acute cholangitis causes improvement by decreasing the bile endotoxin level addition to decreasing bile-duct pressure, thereby preventing excess production of inflammatory cytokines.

Magnetic resonance cholangiography in hepatolithiasis

OBJECTIVES

Our objective was to examine the usefulness of magnetic resonance cholangiography in hepatolithiasis.

METHODS

Ten patients with hepatolithiasis were studied by ultrasonography, computed tomography, direct cholangiography, and magnetic resonance cholangiography to detect stones and to determine the morphological features of the bile ducts. In nine patients who underwent surgery, dilation and stenosis of the bile ducts were confirmed by intraoperative cholangioscopy, pathology, or both.

RESULTS

Stones were demonstrated in seven patients by ultrasonography, in eight by computed tomography, in seven by direct cholangiography, and in all by magnetic resonance cholangiography. The locations of stones were identified in four patients by ultrasonography, in seven by computed tomography, in six by direct cholangiography, and in nine by magnetic resonance cholangiography. Among nine patients with dilation of the bile ducts, the dilation was shown by ultrasonography in seven, by computed tomography in eight, by direct cholangiography in six, and by magnetic resonance cholangiography in eight. Among seven patients with stenosis of the bile ducts, this stenosis was shown by direct cholangiography in four and by magnetic resonance cholangiography in six. Ultrasonography and computed tomography did not show the stenosis. Sensitivity for detection of biliary stenosis was significantly higher in magnetic resonance cholangiography.

CONCLUSIONS

This study shows that magnetic resonance cholangiography not only detects stones, but can also delineate detailed information on the bile ducts, which is useful in the planning of treatment for hepatolithiasis.

Analysis of 69 patients with amebic liver abscess

All 69 patients with amebic liver abscess that we treated in 1981-1992 were studied retrospectively. Men predominated by a 10:1 ratio. Of our 227 patients with amebiasis, some 30% yearly had liver involvement. The incidence peaked in 1988, decreasing later but increasing again in 1992. Most patients were 30-50 years old, the overall mean age being 45 years (range, 22-79), and decreasing with time. Patients with the related factors of travel abroad, positive results of a test for Treponema pallidum hemagglutination, and homosexuality have increased in number in recent years. Fever, abdominal pain, and hepatomegaly were the most frequent findings, and 39 patients had neither bloody stools nor diarrhea. Only 8 patients had had amebiasis previously. A solitary abscess in the right lobe of the liver was found in 40 patients. Entamoeba histolytica was found in the stool of 31 patients and in the pus of 39 patients. Sixty-one patients had positive results for an amebic serological test(s). The abscesses ruptured into the peritoneal cavity in 4 patients. All patients received metronidazole. Percutaneous or surgical drainage (or both) was done in 62 patients. The outcome was good, with 1 exception, and only 2 patients had recurrences.

Hepatolithiasis associated with cholangiocarcinoma

Hepatolithiasis is a risk factor for cholangiocarcinoma. It is difficult to make an accurate diagnosis before treatment. In a retrospective study, we identified characteristic clinical features of 103 patients with hepatolithiasis (group H) and 10 patients with hepatolithiasis associated with cholangiocarcinoma (group HC), and examined the methods for diagnosis and treatment. The main symptoms were abdominal pain, fever, and jaundice, although few patients in group HC had jaundice. The incidence of abnormal serum levels of carcinoembryonic antigen (CEA) in group HC was higher than in group H. The incidence of cholangiocarcinoma in cases in which most of the stones were present in the intrahepatic ducts of the left lobe (type I-L) was higher than the incidence in the other patients. Of the patients who underwent portography in group HC, portal veins in the portion of the liver containing the cholangiocarcinoma were not seen, and this region was atrophic in the operative specimens. The incidence of portal obstruction in portograms in group HC was higher than that in group H. The possibility of carcinoma should be kept in mind if there are high levels of CEA, if the location of the stones is classified as type I-L, or if portal veins cannot be seen on portograms. In such patients, liver resection should be considered because there may be undiagnosed cholangiocarcinoma.

Portography in decision-making about indications for liver resection in hepatolithiasis

We studied the findings of portograms of patients with hepatolithiasis and the role of portography in decision-making about indications for hepatic resection. The subjects were 20 patients in whom hepatic arteriography including the portal phase or percutaneous transhepatic portography was done. We studied the relationships between the findings of the portograms and cholangiograms and hepatic atrophy or associated cholangiocarcinoma. The portal vein in the involved segment of the liver was obstructed in nine patients, and these patients had hepatic atrophy with or without cholangiocarcinoma. There were 16 patients with hepatic atrophy. Four of five other patients in whom protal shrinking was seen had hepatic atrophy. Bile ducts in the involved segment were obstructed in six patients with hepatic atrophy. In all five patients with cholangiocarcinoma, there was portal obstruction at the branching point in the hepatic hilum, with obstruction of the bile ducts at the same point in two of these patients. Hepatic atrophy and cholangiocarcinoma was more closely associated to changes of the portal vein than obstruction of the bile ducts. Portography is useful to diagnose hepatic atrophy and cholangiocarcinoma and for decision-making about indications for hepatic resection in hepatolithiasis.