Predicting morbidity and mortality after hepatic resection in patients with hepatocellular carcinoma: the role of Model for End-Stage Liver Disease score

BACKGROUND

The Model for End-Stage Liver Disease (MELD) score is currently used as a disease severity index of cirrhotic patients awaiting liver transplantation. This study evaluated the usefulness of the MELD score in predicting mortality and morbidity of patients with hepatocellular carcinoma (HCC) undergoing hepatic resection.

METHODS

The study cohort consisted of 1,017 patients who underwent hepatic resection for HCC between 1991 and 2005. Patient variables were examined by univariate and multivariate analyses to identify risk factors for morbidity and mortality. Accuracy in predicting mortality was assessed with the area under the receiver operator characteristic curve (AUC) analysis.

RESULTS

The morbidity and mortality rates were 30.7% and 1.9%, respectively. Age, liver cirrhosis, operation time, and MELD score were risk factors for mortality, whereas indocyanine green retention rate at 15-min value, operation time, blood loss, and Child-Turcotte-Pugh score were risk factors for morbidity. Patients with MELD score >8 had higher mortality (4.0% vs. 0.6%, p = 0.004) and higher liver-related morbidities (16.1% vs. 4.3%, p < 0.001), including massive ascites, intra-abdominal hemorrhage, and hepatic failure, compared with patients with MELD score <6. High MELD score also was related to longer postoperative hospital stay (score >8, 14.5 days vs. score <6, 12.6 days, p = 0.015). The AUC for MELD score as a predictor of mortality was 0.718, indicating high clinical usefulness.

CONCLUSIONS

The MELD score relates with mortality and liver-related morbidities in HCC patients who undergo hepatic resection. A MELD score >8 represents the trigger for intensive treatment to improve patient outcome.

Systemic amyloidosis manifesting as a rare cause of hepatic failure

In 1854, the term "amyloid" was first used in the description of a liver specimen at autopsy by Virchow. The kidneys and heart are the most commonly involved organs in amyloidosis; liver and gastrointestinal tract involvement is less common, and the symptoms are usually mild. Here, we report the case of a 57-year-old male patient who presented with oral hemorrhagic bullae, thrombocytopenia and jaundice. Disseminated intravascular coagulation profile was positive. Abdominal sonography showed ascites, and abdominal computed tomography disclosed heterogeneous enhancement of the liver, with focal low attenuation regions and splenomegaly with poor contrast enhancement. Liver decompensation was highly suspected. Diagnostic laparoscopy with liver biopsy and colonoscopic biopsy from the rectum were subsequently performed. Typical apple-green birefringence was demonstrated on polarized light microscopy by Congo red staining. Systemic amyloidosis was diagnosed and colchicine prescribed. However, liver function deteriorated and intermittent gastrointestinal bleeding was found during the patient's hospitalization. The patient died due to uncorrectable coagulopathy and massive gastrointestinal bleeding. The final diagnosis was idiopathic amyloidosis with hepatic failure. Although amyloidosis rarely presents with hepatic failure, it should be considered in patients with signs of liver decompensation. Clinicians should be aware of this rare but potentially lethal presentation and arrange appropriate treatment promptly.

An uncommon cause of abdominal pain and diarrhea-gastrinoma in an adolescent

Gastrinoma is a hormone-secreting tumor associated with the Zollinger-Ellison syndrome. It is quite rare among children, and it is also uncommon in locations other than the pancreas and the duodenum in the pediatric group. Here, we describe an adolescent male, presenting with recurrent secretory diarrhea and abdominal cramping pain, who had a solitary gastrinoma in the lesser sac, close to the stomach. The prognosis was good after complete resection.

Coexistence of large cell neuroendocrine carcinoma and adenocarcinoma of the ampulla of vater

We report a case of coexisting poorly differentiated endocrine carcinoma and conventional adenocarcinoma in the ampulla of Vater. A 70-year-old female had a recent history of symptoms and signs related to obstructive jaundice. An initial endoscopic biopsy of the ampulla of Vater showed a poorly differentiated endocrine carcinoma in the lamina propria of duodenal mucosa. The tumor could also be categorized into large cell neuroendocrine carcinoma under the WHO classification of pulmonary neuroendocrine tumors. The patient underwent Whipple's operation. After thorough microscopic examination of the ampulla of Vater, we incidentally found another conventional adenocarcinoma on the inner side of the duodenal papilla, and the tumor collided with the aforementioned carcinoma. The association of neuroendocrine tumor and adenocarcinoma has been reported in a few case reports and a small series. We also review the literature concerning large cell neuroendocrine carcinoma in this area.

Neolysogenization of Xanthomonas campestris pv. citri infected with filamentous phage Cf16

All previously described filamentous bacteriophages are capable of persistent infection while their DNA replicates as an episome in the host cell. Filamentous phage Cf16 undergoes an infectious cycle different from other filamentous phages reported heretofore. Upon initial infection with Cf16, infective centers are formed, each of which produces a large number of phage particles. As the infectious cycle progresses, the phage particles released and infective centers formed per carrier cell decrease with time. Finally, the Cf16 enters a "prophage" state, in which the carrier cell becomes lysogenic containing only one complete phage genome in an integrated form. One out of 10(3)-10(6) lysogenic cells can develop spontaneously into an infective center, which releases only one to two phage particles per cell in stationary phase culture. After infection, the Cf16 genome integrates into the host chromosome and replicates as a part of it. Free RF (replicative form) coexists with the integrated form and replicates independently from host chromosome. Upon further division, carrier cells eliminate the free RF at each succeeding generation. When Cf16 reaches the "prophage" state, only the integrated phage genome remains in the carrier cell with no detectable free RF.

A 35-year retrospective study of carcinoid tumors in Taiwan: differences in distribution with a high probability of associated second primary malignancies

BACKGROUND

A comprehensive study of carcinoid tumors from United States-based databases indicated that the small intestine, colon, rectum, and bronchopulmonary system are common locations for carcinoid tumors. In addition, certain carcinoid tumors, such as rectal carcinoids, appeared to be overrepresented in nonwhite populations in the United States. High frequencies of associated noncarcinoid malignancies were reported in some articles. The objective of the current study was to address the organ distribution, frequency of metastasis, and survival rates of carcinoid tumors and the associated noncarcinoid tumors in Taiwanese, Asian populations.

METHODS

Two hundred twenty-eight patients with carcinoid tumors were identified and evaluated from the surgical pathology files and medical records of the Veterans General Hospital, Taipei, Taiwan from January 1970 to December 2005.

RESULTS

In 228 carcinoid tumors that were analyzed, the rectum (60.5%) was the most common location followed by the lung (20.2%) and the thymus (6.6%). Metastatic lesions were demonstrated in 16.2% of patients. Disease extent was associated with survival. The 5-year survival rates for patients with localized, regional metastatic, and distant metastatic disease were 94.1%, 49.1%, and 0%, respectively (P< .001). Associated noncarcinoid malignancies were noted in 14% of patients with carcinoids, mainly in the gastrointestinal tract (52.9%), lung, and genitourinary system.

CONCLUSIONS

A different organ distribution of carcinoids was observed in Taiwanese patients, who had with significantly more carcinoids located in the rectum and thymus compared with patients in Western countries. The patients with carcinoids in the current study had a high possibility of developing associated, noncarcinoid neoplasms. Surveillance of the colon, stomach, lung, and genitourinary system for second malignant tumors is recommended.

Successful radiofrequency ablation therapy for hepatocellular carcinoma in a male patient with early stage primary biliary cirrhosis and positive serum hepatitis B core antibody

Hepatocellular carcinoma (HCC) occurring in a 66-year-old male patient with early stage primary biliary cirrhosis (PBC) was successfully treated by radiofrequency ablation (RFA) therapy. He was diagnosed with PBC based on the findings of pruritus, elevated serum alkaline phosphate level and positive serum antimitochondrial antibody in 2005. The serologic tests for hepatitis B surface antigen, hepatitis B surface antibody and hepatitis C virus antibody were all negative. But antibody against hepatitis B core antigen was positive. Abdominal ultrasonography and dynamic computed tomography revealed 1 hypervascular tumor, 2.6 cm in diameter, in segment V of the liver in 2007. Liver biopsy showed a moderately differentiated HCC. Non-tumorous liver was compatible with Scheuer's classification of stage II PBC. The tumor was successfully treated by RFA. This case report demonstrates that HCC can arise from precirrhotic PBC and can be successfully treated by RFA. Regular surveillance for HCC is warranted for all patients with PBC, irrespective of stage.

Lacrimal gland extranodal marginal zone B-cell lymphoma of MALT-type

PURPOSE

To evaluate the clinical features and outcome of extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma) in the lacrimal gland.

DESIGN

Retrospective, noncomparative, observational case series in an academic referral setting.

METHODS

A consecutive series of 13 histologically verified MALT lymphoma in the lacrimal gland at presentation was studied. Clinical characteristics, treatment, and prognosis were analyzed.

RESULTS

Eight males and five females with a median age of 64 years and a median follow-up time of 48 months were included. All patients had no prior lymphoma and initially presented as MALT lymphoma in the lacrimal gland. Extraorbital involvement at diagnosis was noted in six patients (46.2%). Two patients had autoimmune disease, and both had Stage IV disease at presentation. Treatment consisted of surgical resection in one patient, radiotherapy in four, chemotherapy in four, and combined radiotherapy and chemotherapy in four. Complete remissions were obtained in eight patients (61.5%). Patients with bilateral disease (61.5%) had a higher rate of advanced-stage disease and a poor outcome. Recurrence was noted in two patients. At the last follow-up, eight patients were free of disease, three were alive with disease, one died of sepsis as a complication of chemotherapy, and one died of lymphoma.

CONCLUSIONS

MALT lymphoma in the lacrimal gland has a high rate of extraorbital involvement and synchronous bilateral lacrimal gland involvement at presentation. The prognosis is relatively poor, especially in patients with advanced disease and bilateral involvement. Extensive staging and long-term follow-up are warranted for these patients.

Clinical significance of p16INK4a and p53 overexpression in endocrine tumors of the gastrointestinal tract

This study was designed to determine the expression of p16, p53, and CD117 in gastrointestinal tract endocrine tumors. Immunohistochemical studies of p16, p53, and CD117 were performed in 57 gastrointestinal tract endocrine tumors, including 22 poorly differentiated endocrine carcinomas (PDECs) and 35 well-differentiated endocrine tumors (WDETs). Overexpression of p16 and p53 was observed in 16 (73%) and 10 (45%) of the PDECs, respectively, whereas only 1 WDET showed overexpression of p53 and none showed overexpression of p16. A total of 18 (82%) of the PDECs showed overexpression of p16 or p53 proteins. This is closely associated with PDEC (P < .0001). By using overexpression of p16 or p53 as the criteria for PDEC, the sensitivity and specificity are 81.8% and 97.1%, respectively, with positive and negative predictive values of 94.7% and 89.5%, respectively. CD117 was not detected in any of the 57 gastrointestinal endocrine tumors by immunohistochemical analysis.

Prognostic value and clinical relevance of the 6th Edition 2002 American Joint Committee on Cancer staging system in patients with resectable hepatocellular carcinoma

BACKGROUND

A simplified American Joint Committee on Cancer (AJCC) TNM staging system for hepatocellular carcinoma (HCC) (the 6th edition) was proposed in 2002. In this study, we validated the prognostic value of the staging system in a patient cohort undergoing hepatic resection with longterm followup.

STUDY DESIGN

From a prospective database, the study cohort consisted of 440 patients who underwent curative hepatic resection for HCC between July 1991 and January 1999. Median followup time was 66 months. Multivariate analysis was performed to identify the independent prognostic factors related to postoperative survival. Patients were staged according to both the 5th edition (TNM-5) and 6th edition (TNM-6) AJCC TNM staging criteria.

RESULTS

The independent prognostic factors included major vascular invasion, microvascular invasion, surgical margin < 1 cm, indocyanine green retention rate at 15 minutes > 10%, multiple tumors, tumor rupture, male, and serum aspartate aminotransferase > 90 U/L. The breakdown by TNM-5 staging: I, 27 (6.1%); II, 108 (24.5%); III, 218 (49.5%); and IVA, 87 (19.8%) and by TNM-6 staging: I, 120 (27.3%); II, 170 (38.6%); and III, 150 (34.1%). When stratified according to the TNM-5 system, difference in survival was notable between stages II and IIIA (p < 0.001), between stages IIIA and IVA (p < 0.001), but not between stages I and II (p > 0.05). When stratified according to the TNM-6 system, difference in survival was considerable between stages I and II (p < 0.01), stages II and III (p < 0.001), and stages I and III (p < 0.001).

CONCLUSIONS

Overall, the TNM-6 staging system appears to provide a reliable prognostic classification of HCC patients and is simpler to use than the TNM-5 staging system.

Postresectional adjuvant intraportal chemotherapy in patients with hepatocellular carcinoma: a case-control study

BACKGROUND

The postresectional tumor recurrence rate is high in patients with hepatocellular carcinoma (HCC). Tumor portal venous invasion is the most important factor related to recurrence. Adjuvant intraportal infusion chemotherapy (IPIC) was used in HCC patients to improve the outcomes.

METHODS

Between June 1998 and May 1999, 28 HCC patients (IPIC group) underwent postresectional IPIC daily for 2 days with 5-fluorouracil (650 mg/m(2)), leucovorin (45 mg/m(2)), doxorubicin (10 mg/m(2)), and cisplatin (20 mg/m(2)). Treatment was repeated every 3 weeks for six cycles. Patient outcomes were compared with those of 66 matched HCC patients (control group) who underwent hepatectomy without adjuvant therapy.

RESULTS

The IPIC group received an average of 5.2 cycles of chemotherapy, starting 5 to 24 days after surgery. The most frequent IPIC-related adverse events were upper abdominal pain, vomiting, and myelosuppression. Five-year disease-free and overall survival rates for the IPIC group were 44.6% and 60.7%, respectively. Subgroup analysis of patients with tumor-node-metastasis stage I and II disease identified significantly lower recurrence rates for the IPIC group (33.3%) than the control group (65.0%; P = .025). For patients with stage I and II disease, 5-year disease-free and overall survival rates for the IPIC group (70.6% and 83.3%, respectively) were significantly higher than those of the control group (33.4% and 46.9%, respectively; P < .05). Patients with stage III disease do not benefit from IPIC.

CONCLUSIONS

Postoperative IPIC benefits HCC patients with tumor-node-metastasis stage I and II disease. The survival advantages demonstrated justify a selection of patients for future trials.

Nonalcoholic fatty liver disease manifesting esophageal variceal bleeding

Nonalcoholic fatty liver disease (NAFLD) is a fatty liver disease occurring in patients without alcohol consumption. It includes a broad spectrum of liver disease, from fatty infiltration, inflammation and fibrosis, to cirrhosis, usually having obesity, hyperlipidemia, and diabetes mellitus as its etiology. NAFLD-related cirrhosis has rarely been reported in Taiwan. We herein report a 41-year-old male patient with nonalcoholic fatty liver cirrhosis (NAFLC), with the first clinical manifestation being bleeding esophageal varices (EV). The patient was obese with diabetes mellitus, but without hyperlipidemia or any history of drinking alcohol. The laboratory tests, abdominal sonography, and computed tomography revealed a typical case of liver cirrhosis. The pan-endoscopy disclosed EV with red-color sign. EV ligation was performed successfully to stop the bleeding. When the patient was in a stabilized clinical condition, a liver biopsy showed a typical histologic finding of NAFLD. Most of the cases of NAFLC reported in the literature have silent signs and symptoms. Sudden onset of the EV as the first clinical manifestation, as in this case, is rare. This case reminds us that NAFLD may indeed induce severe liver impairment, such as liver cirrhosis. Liver biochemical tests and abdominal sonography should be considered in patients with overt obesity and diabetes.

Effects of gabexate mesilate on serum inflammatory cytokines in rats with acute necrotizing pancreatitis

Gabexate mesilate is a synthetic protease inhibitor. The effectiveness of gabexate mesilate in patients with acute pancreatitis is controversial. Proinflammatory cytokines are associated with systemic inflammatory response syndrome (SIRS) in acute pancreatitis. A compensatory anti-inflammatory response occurs in parallel with SIRS. We investigated the effects of gabexate mesilate on acute necrotizing pancreatitis in rats, emphasizing the changes in serum levels of proinflammatory and anti-inflammatory cytokines. Acute necrotizing pancreatitis was induced by retrograde infusion of sodium taurodeoxycholate into the pancreatobiliary duct in rats. The rats were divided into three groups. Group I was given gabexate mesilate 2 mg/kg/h i.v. continuously 1 h before the induction of acute pancreatitis. Group II was given gabexate mesilate the same dose immediately after the induction of acute pancreatitis. Group III was given normal saline as the controls. Serum levels of amylase, lipase, tumor necrosis factor alpha, interleukin-6, and interleukin-10, pancreatic histopathology and hemodynamics were examined at 5h after the induction of acute pancreatitis. Gabexate mesilate significantly reduced serum levels of amylase, lipase, tumor necrosis factor alpha and interleukin-6 at 5 h. Serum levels of interleukin-10 significantly increased in Group I, as compared with Groups II and III. The severity of pancreatic histopathology, the reduction of mean arterial pressure, the volume of ascites and pancreatic wet weight/body weight ratios were also significantly improved by the administration of gabexate mesilate. The beneficial effects of gabexate mesilate on acute pancreatitis may be, in part, due to the modulation of inflammatory cytokine responses.

Urothelial carcinoma with rhabdoid features: report of 6 cases

Extrarenal rhabdoid tumors have been described in a variety of primary sites with only rare case reports of urothelial carcinomas with rhabdoid features in the literature. In this report, we describe the clinicopathologic characteristics, including clinical follow-up on 6 cases of urothelial carcinoma with prominent rhabdoid features. Four cases were retrieved from the consultation files of one of the authors and 2 were retrieved from the surgical pathology files at our institution. The patients were all men, with ages ranging from 53 to 86 years (mean, 66.5 years). Patients initially presented with hematuria or obstructive symptoms. The sites included bladder (n = 4) and renal pelvis (n = 2). All cases had a prominent rhabdoid component (mean, 60%), ranging from 40% to 80%. In addition to the rhabdoid component, multiple coexistent histological components were seen, including in situ urothelial carcinoma (carcinoma in situ) and high-grade papillary urothelial carcinoma (n = 2), poorly differentiated carcinoma with small-cell features (n = 1), sarcomatoid (n = 2), and a myxoid component (n = 2). All cases in this series had focal or diffuse positive staining with one or more cytokeratin markers (epithelial membrane antigen, CAM 5.2, AE1/AE3). Of the 6 patients, 4 were treated initially with surgery (radical cystoprostatectomy, n = 2; radical nephrectomy, n = 2). Of 6 patients, 2 died within 1 month, whereas a third patient died within 4 months. The remaining 3 patients were alive at 3, 3, and 9 months after diagnosis. The histological and immunohistochemical findings in this study serve to broaden the morphological spectrum of urothelial carcinomas with prominent rhabdoid features and add further evidence as to their poor prognosis.

Acute hepatitis induced by Chinese hepatoprotective herb, xiao-chai-hu-tang

Xiao-chai-hu-tang (syo-saiko-to in Japanese) is a herbal remedy that has been widely used in China for treatment of respiratory, hepatobiliary, and gastrointestinal diseases, particularly among patients with chronic liver disease. However, its safety has recently been challenged. We, herein, report a Chinese patient with acute hepatitis induced by this herb. A 52-year-old woman presented with weakness, fatigue, and tea-colored urine after continual consumption of the decoction of xiao-chai-hu-tang for 1.5 months. Laboratory studies disclosed acute hepatitis even though all of the viral hepatitis markers were negative. Liver biopsy also revealed a picture of acute hepatocellular hepatitis. The symptoms improved after discontinuing the drug, and liver biochemical tests normalized 2 months later. The case report reminds us of the probable adverse drug reaction of herbs, even in some that are claimed to have hepatoprotective effects.

Differential immunoprofiles of hepatocellular carcinoma, renal cell carcinoma, and adrenocortical carcinoma: a systemic immunohistochemical survey using tissue array technique

The differential diagnoses of hepatocellular carcinoma (HCC), renal cell carcinoma (RCC), and adrenocortical carcinoma (ACC) are sometimes difficult due to their overlapping histologic features. Immunohistochemistry is a helpful adjunct in supporting the histologic diagnosis. In this study, the authors used the tissue array technique to systemically analyze the efficacy of different immunohistochemical panels in discerning these neoplasms. Immunohistochemical stains were performed on a total of 895 tumors (including 170 HCCs, 176 RCCs, and 40 ACCs) using monoclonal antibodies against hepatocyte antigen (HPA), CD10, RCC marker, vimentin, alpha-inhibin, keratins (KL-1, CAM 5.2, 7, and 20), epithelial membrane antigen, and polyclonal antibodies against carcinoembryonic antigen (pCEA) and alpha-fetoprotein, and antibodies Melan-A (A103), MOC31, and BG8. HPA immunostain alone detected 85.9% of HCCs, and the addition of canalicular pattern of pCEA and CD10 immunostains raised the sensitivity to 94.7%. RCC marker was positive in 54.5% of RCCs but was negative in all non-RCC tumors. Using positive CD10 and negative HPA and pCEA together with RCC marker increased the sensitivity to 74.4%. Immunoreactivity for alpha-inhibin and A103 could be detected in 67.5% and 55% of ACCs, respectively. When the two antibodies were combined, 82.5% of ACCs were labeled. Proper selection of immunohistochemical stains aid in the differential diagnosis of the three neoplasms. Using the tissue array technique, the authors also showed an effective model for comprehensive antibody testing.

Risk factors associated with bile leakage after hepatic resection for hepatocellular carcinoma

BACKGROUND/AIMS

Bile leakage after hepatic resection can cause septic complications and mortality. This study evaluated the risk factors associated with postoperative bile leakage in hepatocellular carcinoma patients.

METHODOLOGY

Between July 1991 and December 2000, 605 consecutive hepatocellular carcinoma patients who underwent hepatic resection were enrolled. Risk factors associated with postoperative bile leakage were examined, with 38 clinicopathological variables being analyzed. Data were collected prospectively and analyzed retrospectively.

RESULTS

Bile leakage developed in 35 (5.8%) of 605 patients. When compared with patients without bile leakage, those with bile leakage had higher risk for concomitant morbidities (54.3% vs. 29.2%, P=0.002), postoperative mortality (8.6% vs. 2.6%, P=0.045), and a prolonged postoperative hospital stay (29 days vs. 14 days, P<0.001). The bile leakage rate of centrally located tumors (9.4%) was significantly higher than that of peripherally located tumors (3.5%; P=0.002). The bile leakage rate of patients with preoperative chemoembolization (13.8%) was significantly higher than those without chemoembolization (4.9%; P=0.004). Stepwise logistic regression analysis identified preoperative chemoembolization (OR=3.274, P=0.005) and tumor(s) being centrally located (OR=2.927, P=0.003) as the independent predictors of development of bile leakage.

CONCLUSIONS

For HCC patients, preoperative chemoembolization and tumor(s) with central location are risk factors for post-hepatectomy bile leakage. As bile leakage can cause septic complications and liver failure, careful surgical procedures and use of preventive measures are necessary, especially in patients with high risk factors.

Hepatocellular carcinoma confined to Couinaud segment VIII: experience with extensive or limited resection

BACKGROUND/AIMS

Surgical treatment of hepatocellular carcinoma (HCC) confined to Couinaud segment VIII has been regarded as difficult. This study evaluates surgical and oncological results after extensive or limited resection of the tumor(s).

METHODOLOGY

Of the 399 HCC patients that underwent hepatic resection, 36 patients had the tumor(s) confined to segment VIII. These 36 patients were divided into group 1 (extensive resection) (n=15) (three right hepatectomies, 12 anterior segmentectomies) and group 2 (limited resection) (n=21) (11 subsegmentectomies, 10 wedge resections). Data were collected prospectively and analyzed retrospectively.

RESULTS

Hospital mortality and morbidity were 0% and 20% in group 1, 9.5%, and 38% in group 2 (P>0.05). Group 1 patients had larger tumor (4.0cm vs. 2.8cm; P=0.01), heavier resected specimen (380g vs. 118g; P<0.01), and a higher incidence of wide surgical margin (> or =1cm) (67% vs. 29%; P=0.041) than those in group 2. The percentage of patients in whom the a-fetoprotein levels returned to the normal range after resection was higher in group 1 (75.0%, 6 of 8 patients) than in group 2 (26.7%, 4 of 15 patients) (P=0.037). The 1-, 3-, and 5-year disease-free survival in group 1 (93%, 79% and 52%) were significantly better than those of group 2 (67%, 38% and 22%) (P=0.021).

CONCLUSIONS

In selected patients, extensive resection of HCC located in segment VIII correlates with better survival.

Epithelioid hemangioendothelioma of the nasal cavity

Epithelioid hemangioendothelioma (EH) is an unusual vascular neoplasm characterized by proliferation of endothelial cells with epithelioid morphology. It has an indolent course, with the potential for recurrence, but rarely metastasizes. The common locations include soft tissue, skin, viscera and bone. We present an unusual case of EH in the nasal cavity and describe the clinical characteristics, histopathologic findings, differential diagnosis and management. The 25-year-old male patient initially presented with an 8-month history of intermittent epistaxis. Nasal endoscopy revealed a vascular tumor involving the nasal cavity. The tumor was excised and the final histopathologic diagnosis was consistent with EH. EH in the head and neck is extremely rare. Wide excision is the treatment of choice, and regular follow-up is suggested due to the potential for recurrence. Definitive diagnosis depends on histopathologic and immunohistochemical features.

Splenic hamartoma: presentation on contrast-enhanced sonography

Splenic hamartoma is a rare benign tumor of the spleen. It is usually found incidentally at autopsy or splenectomy. We report a case of splenic hamartoma that was discovered during medical workup for vague upper abdominal pain. Abdominal sonography demonstrated a well-demarcated, slightly hypoechoic splenic solid mass; the mass was markedly enhanced on color Doppler sonography after injection of microbubble contrast agent. This finding may help to distinguish splenic hamartomas from other relatively common splenic tumors, such as hemangiomas or metastases.

Donor lymphocyte infusion induced acute hepatitis

Hepatic graft-versus-host disease (GVHD) post allogeneic hematopoietic stem cell transplantation generally presents as cholestatic jaundice and increased serum alkaline phosphatase (ALK-P). Currently accepted standards for evaluating the clinical severity of hepatic GVHD are not based on serum aminotransferase levels but on the serum bilirubin levels. We describe a 25-year-old female who initially had no liver damage at all after an allogeneic peripheral blood stem cell transplantation (allo-PBSCT) from her HLA-indentical sister. Markedly elevated aminotransferases, without hyperbilirubinemia, however, developed 7 and 9 weeks after the first and second donor lymphocyte infusion (DLI), respectively. Liver biopsies performed in both events revealed lymphocytic infiltration of the portal tracts and pericentral necrosis of the lobuli. There was also a picture of periductal lymphocytic infiltration and vacuolization of the biliary epithelial cells, which was compatible with the diagnosis of GVHD of cholangiohepatitic type. These findings indicate that hepatic GVHD may present as acute hepatitis and should be included in the differential diagnosis for patients with increased aminotransferases after DLI.

Acinar cell carcinoma of the pancreas: clinical and computed tomography manifestations

PURPOSE

Acinar cell carcinoma (ACC) is a subtype of pancreatic neoplasm sufficiently rare that its imaging has not been fully analyzed. The purpose of this article is to present the computed tomography (CT) appearance of ACC of the pancreas.

METHODS

Clinical data and CT studies of 10 patients (7 male and 3 female) with pathologically proven ACC of the pancreas were reviewed. Among the CT features emphasized were the presence of a well-defined enhancing capsule, foci of internal calcification, intratumoral hemorrhage, presence of a central hypodense area, and degree of contrast enhancement.

RESULTS

The presenting symptoms of ACC of the pancreas were nonspecific. An elevated serum level of alpha-fetoprotein, carcinoembryonic acid, and CA 19-9 was noted in 2 (20%), 1 (10%), and 3 (30%) patients, respectively. The tumor locations were in the uncinate process in 4 (40%), in the head and neck in 2 (20%), in the body in 1 (10%), and in the tail in 3 (30%) patients. The average tumor size was 7.2 cm (range: 3.3-18 cm). A well-defined enhancing capsule, internal foci of calcification, and intratumoral hemorrhage appeared in 6 (60%), 5 (50%), and 0 tumors, respectively. Eight (80%) tumors had a central hypodense area; of these, 4 (40%) tumors exhibited a hypodense area greater than 50% of the tumor. During dynamic CT in 8 patients, 6 tumors showed early arterial (EA) enhancement and persisted into the portal venous (PV) phase, whereas the other 2 tumors revealed enhancement in the EA phase and washout in PV phase.

CONCLUSION

Acinar cell carcinoma typically presents as a sizable pancreatic mass with a well-defined enhancing capsule and internal calcifications. Significant central hypodensity is frequently present. Recognition of these features can provide clues to the CT diagnosis of ACC.

Fenofibrate-induced acute cholestatic hepatitis

Fenofibrate-induced acute or chronic hepatitis is rare, and only 11 reports from French, Italian or Spanish literature have been published up to date. We report a case of fenofibrate-induced acute cholestatic hepatitis. To the best of our knowledge, this is the first one reported in Taiwan. A 61-year-old man developed acute cholestatic hepatitis after taking fenofibrate 100 mg tid for 10 days. Laboratory profile on admission showed serum total bilirubin 9.3 mg/dL, direct bilirubin 2.7 mg/dL, alanine aminotransferase 249 IU/L, aspartate aminotransferase 259 IU/L, alkaline phosphatase 259 IU/L, and gamma-glutamyl transpeptidase 1014 IU/L. Pathology proved hepatocanalicular cholestasis in liver. Fenofibrate was discontinued immediately. His clinical manifestations and liver function tests improved gradually and returned to nearly normal in 2 months. We suggest that liver function tests, including total bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and gamma-glutamyl transpeptidase, be checked at least 2 weeks after taking the drug and that serum aminotransferase be monitored every 3 months during the first 12 months of therapy. Treatment should be discontinued if alanine aminotransferase values increase by more than 100 IU/L.

Long-term results of hepatic resection for hepatocellular carcinoma originating from the noncirrhotic liver

HYPOTHESIS

In patients with hepatocellular carcinoma who do not have cirrhosis, the clinicopathologic characteristics and long-term postresectional outcomes must be clarified and liver transplantation may also have a role in future treatment strategy.

DESIGN

Case series. The mean (SD) follow-up time was 52.4 (33.8) months.

SETTING

A tertiary care medical center.

PATIENTS

From a prospective database, 445 patients with hepatocellular carcinoma who underwent hepatectomy were classified into 2 groups-those without cirrhosis (n = 223) and those with cirrhosis (n = 222). Clinicopathologic factors and postresectional outcomes were compared between these groups based on the new American Joint Committee on Cancer/Union Internationale Contre le Cancer TNM (sixth edition) staging system and the patient selection criteria for undergoing transplantation.

MAIN OUTCOME MEASURES

Postresectional disease-free and overall survival rates.

RESULTS

Compared with patients with cirrhosis, patients without cirrhosis were younger, had a lower rate of viral hepatitis type C infection, and had more advanced TNM stage III disease. Also more of the patients who did not have cirrhosis had undergone major resection. The tumor recurrence rate was significantly lower in the noncirrhotic group than in the cirrhotic group (59.5% vs 69.5%, P =.03). The 5- and 10-year disease-free and overall survival rates of the noncirrhotic group were 36.8% and 25.7%, and 53.0% and 36.9%, respectively. The survival of the members of the noncirrhotic group was better than the survival of the members of the cirrhotic group for patients with early stage (TNM stage I or transplantable) diseases. The 5-year disease-free and overall survival rates in patients without cirrhosis with transplantable diseases were 54.8% and 70.0%, respectively.

CONCLUSIONS

In early stage diseases, patients without cirrhosis had significantly better survival rates than patients with cirrhosis. For a small hepatocellular carcinoma originating in a noncirrhotic liver, hepatic resection is a reasonable first-line treatment. Liver transplantation can be reserved as salvage treatment for patients with recurrent disease after hepatic resection.

Cytoplasmic immunoreactivity for thyroid transcription factor-1 in hepatocellular carcinoma: a comparative immunohistochemical analysis of four commercial antibodies using a tissue array technique

To evaluate the consistency of cytoplasmic immunoreactivity in hepatocellular carcinoma (HCC), we performed immunohistochemical stains for 4 commercial anti-thyroid transcription factor (TTF)-1 antibodies (DAKO, Zymed, Novocastra, Santa Cruz Biotechnology [see text]) on 77 HCCs and 334 nonhepatic epithelial tumors. The HCC cases were submitted for hepatocvte antigen immunohistochemical stain. Heat-induced epitope retrieval (HIER) methods were used: with DAKO Target Retrieval Solution, the positive rates of cytoplasmic TTF-1 in HCC for DAKO, Zymed, Santa Cruz, and Novocastra antibodies were 58% (45), 14% (11), 6% (5), and 0% (0), respectively; with EDTA buffer, the positive rates increased to 70% (54), 40% (31), 69% (53), and 0% (0), respectively. Immunoreactivity for the DAKO anti-TTF-1 antibody generally correlated with that for hepatocyte antigen. Among nonhepatic tumors, 2 of 6 ovarian mucinous carcinomas and 2 of 11 pancreatic adenocarcinomas showed cytoplasmic reactivity for the DAKO antibody; 28 cases showed nonspecific cytoplasmic staining for the Santa Cruz antibody with EDTA HIER. Zymed and Novocastra antibodies did not produce cytoplasmic staining in nonhepatic tumors. Owing to the staining variation, we do not consider TTF-1 a reliable marker to distinguish HCC. In general, the Novocastra antibody with EDTA HIER is superior for its consistent nuclear positivity and absence of erratic cytoplasmic staining.

Malignant fibrous histiocytoma of the maxillary sinus presenting as toothache

Malignant fibrous histiocytoma (MFH) is a high-grade and aggressive sarcoma. It is relatively rare in the head and neck region. Its diagnosis is based on immunohistochemical stains. Wide excision followed by postoperative radiotherapy is believed to be the treatment of choice for MFH. In October 2001, a case of MFH in the maxillary sinus, which presented as a toothache at the beginning, was successfully diagnosed and treated. Using the external approach, the tumor mass was completely removed, and postoperative radiotherapy was subsequently performed. Seventeen months after the surgery, the patient was clinically well without any evidence of local recurrence or distant metastasis.

Effects of nitric oxide synthase inhibitors on retrograde bile salt-induced pancreatitis rats

BACKGROUND

The serum levels of proinflammatory cytokines have been reported to be significantly higher in severe acute pancreatitis compared with mild pancreatitis. Nitric oxide (NO) produced by cytokine-inducible NO synthase might be involved as the mechanisms for the progression of pancreatitis and the occurrence of systemic complications. The aim of the study was to evaluate the effects of a non-selective NO synthase inhibitor, nitro-L-arginine methyl ester (L-NAME), and an inducible NO synthase inhibitor, L-canavanine, on sodium taurodeoxycholate-induced acute necrotizing pancreatitis in rats.

METHODS

Twenty-eight rats were randomized into 3 groups to receive L-NAME 5 mg/kg/h, L-canavanine 20 mg/kg/h, and equivalent volume of saline, respectively, i.v. infusion after the induction of pancreatitis for 5 hours. The serum levels of amylase and lipase and mean arterial pressure and heart rate at baseline and 5 hours, and cardiac output, systemic vascular resistance, the amount of ascites and pancreatic histopathology at 5 hours were examined.

RESULTS

Five hours after induction of pancreatitis, all rats treated with L-canavanine and all but 1 treated with saline survived; however, all rats treated with L-NAME died. As compared with the control group, L-canavanine significantly reduced serum levels of amylase and lipase, the severity of pancreatic edema and necrosis, and the volume of ascites in 5 hours. In addition, L-canavanine significantly improved the reduction of mean arterial pressure and systemic vascular resistance at 5 hours.

CONCLUSIONS

L-NAME results in the mortality of acute necrotizing pancreatitis. L-canavanine reduces serum pancreatic enzymes and improves the changes of pancreatic histopathology and systemic hemodynamics at the early stage of acute pancreatitis. Inducible NO synthase inhibitor is beneficial for severe acute pancreatitis.

Reliability of contemporary radiology to measure tumour size of hepatocellular carcinoma in patients undergoing resection: limitations and clinical implications

BACKGROUND

Preoperative radiology has been widely used to detect and measure hepatocellular carcinoma (HCC). However, its accuracy and reliability are unclear. This study aimed to assess the ability of current radiology to measure tumour size in patients undergoing resection.

METHODS

We evaluated 212 HCC patients undergoing curative resection. Tumour size measured in the pathological examination was correlated with that obtained in preoperative ultrasound (US) and contrast-enhanced dynamic computed tomography (CT). Accuracy and association with tumour recurrence were investigated.

RESULTS

The mean size of the tumour was 4.5 +/- 2.6 cm and was accurate in both US and CT in only 6 (3%) patients. Cirrhosis (P = 0.015), absence of tumour stain (P = 0.002) and small (< or = 4 cm) tumour (P < 0.001) were the significant factors associated with size deviation using both US and CT. Ninety-four (44%) patients developed tumour recurrence within 17 +/- 11 months of resection. Recurrence rate was 52%, 52% and 67% in patients with underestimation in US (relative risk [RR]: 2.0, 95% confidence interval [CI]: 1.2-3.4, P = 0.01), CT (RR: 2.1, 95% CI: 1.1-4, P = 0.022) and both modalities (RR: 2.5, 95% CI: 1.4-4.2, P = 0.001), respectively, compared to 30% recurrence in patients with accurate estimation of tumour size.

CONCLUSION

The accuracy of radiology in measuring tumour size was poor, and may lead to inappropriate treatment. The finding that underestimation of tumour size was associated with a higher tumour recurrence rate is consistent with the hypothesis that HCC may recur from pre-existing tumour foci which could not be identified from the current imaging modalities.

Surgical resection of duodenal lymphangiectasia: A case report

Intestinal lymphangiectasia, characterized by dilatation of intestinal lacteals, is rare. The major treatment for primary intestinal lymphangiectasia is dietary modification. Surgery to relieve symptoms and to clarify the etiology should be considered when medical treatment failed. This article reports a 49-year-old woman of solitary duodenal lymphangiectasia, who presented with epigastralgia and anemia. Her symptoms persisted with medical treatment. Surgery was finally performed to relieve the symptoms and to exclude the existence of underlying etiologies, with satisfactory effect. In conclusion, duodenal lymphangiectasia can present clinically as epigastralgia and chronic blood loss. Surgical resection may be resorted to relieve pain, control bleeding, and exclude underlying diseases in some patients.

Risk factors associated with intra-operative major blood loss in patients with hepatocellular carcinoma who underwent hepatic resection

BACKGROUND

Minimizing intraoperative blood loss during hepatectomy for hepatocellular carcinoma (HCC) decreases the need for blood transfusion. The purpose of this study was to investigate the risk factors associated with major blood loss in performing liver resection for HCC.

METHODS

A total of 643 consecutive patients who underwent hepatic resection for HCC were included in this retrospective study. Patients were divided into groups according to the intraoperative blood loss. Blood loss more than 1,000 mL was defined as major blood loss. Twenty-eight variables were analyzed.

RESULTS

As compared with patients with blood loss < 1,000 mL, patients with major blood loss had worse disease-free and overall survival rates (p < 0.001). Patients with major blood loss had higher surgical morbidity, mortality and prolonged hospital stay (p < 0.001). Multivariate analysis shows that independent risk factors associated with major blood loss include: male gender, alanine aminotrasferase > 55U/dL, prothrombin time < 95%, resection more than 3 Couinaud segments, en bloc resection, surgeon with low case volume (< 65 cases) and tumor with central location.

CONCLUSIONS

Hemorrhage control is the main problem in liver resection for HCC. In patients with risk factors of major bleeding, it is essential to take effective measure in order to minimize intraoperative blood loss in hepatectomy for patients with HCC.

Diabetes mellitus is a recurrence-independent risk factor in patients with hepatitis B virus-related hepatocellular carcinoma undergoing resection

OBJECTIVES

The prognostic impact of diabetes mellitus and its association with virological factors on patients with hepatocellular carcinoma (HCC) are unclear. This study aimed to investigate the outcome in HCC patients undergoing resection with and without diabetes mellitus and the interaction with hepatitis B virus (HBV) and hepatitis C virus (HCV).

METHODS

A total of 239 HCC patients were included. Survival and tumour recurrence were analysed according to the status of diabetes mellitus and viral hepatitis.

RESULTS

Diabetic patients tended to have an overall decreased survival compared with non-diabetic patients in 32 +/- 19 months of follow-up. A total of 113 (47%) patients developed tumour recurrence during the follow-up period. No significant difference of tumour recurrence between diabetic and non-diabetic patients, or between patients seropositive and seronegative for HBV surface antigen (HBsAg), was noted. Stratified analysis showed that diabetic patients with HBV but not with HCV infection had a poor long-term outcome. In the HBV group, the one-, three- and five-year survival rates were 83%, 51% and 41% versus 90%, 78% and 73% in diabetic and non-diabetic patients, respectively, compared with 90%, 83% and 42% versus 91%, 73% and 73% in the HCV group with and without diabetes mellitus, respectively. Cox multivariate analysis disclosed that diabetic patients seropositive for HBsAg had a significantly poor survival.

CONCLUSIONS

Diabetes mellitus does not affect the long-term survival in HCV-related HCC but is a recurrence-independent poor prognostic factor for HBV-related HCC.

Clinicopathologic features and factors related to survival of patients with small hepatocellular carcinoma after hepatic resection

Hepatic resection for small hepatocellular carcinomas (HCCs) offers patients a chance of cure but is associated with a significant tumor recurrence rate. We characterized 145 resected small HCCs and defined patients who would most benefit from hepatic resection. A retrospective study was conducted of 485 HCC patients who had undergone curative resection. The clinical features and survival rates of patients with HCCs </= 3 cm (group 1, n = 145) were compared with those of patients with HCCs > 3 cm (group 2, n = 340). Compared with group 2 patients, group 1 had worse liver function, a higher frequency of hepatitis C infection, and a lower alpha-fetoprotein level. The 1-, 3-, and 5-year disease-free survival rates of group 1 were better than those of group 2 (82%, 59%, and 42% vs. 56%, 39%, and 31%, respectively) ( p < 0.001). From the sixth postoperative year onward, the proportions of disease-free survivors were not significantly different between the two groups (32% vs. 31%). By multivariate analysis, factors influencing small-HCC patients' outcomes were tumor centrally located ( p = 0.003), indocyanine green retention rate > 10% ( p = 0.017), and albumin level < 3.7 g/dl ( p = 0.004). A clinical risk scoring system incorporating these factors correlated closely with the patients' outcomes and it may be used to select patients who would most benefit from hepatic resection.

Characteristics of autoimmune hepatitis in Taiwan: the 11 years' experiences of a medical center

BACKGROUND

Unlike in Western countries, autoimmune hepatitis (AIH) is an infrequent diagnosis in Taiwan. The clinical characteristics of AIH in this area are unclear. The aim of this study was to elucidate the clinical features of AIH in Taiwan.

METHODS

All the medical records of in-patients with the diagnosis of chronic hepatitis in our hospital from 1990 to 2001 were reviewed for the possibility of AIH. The clinical features, biochemical data, immunological presentations, treatments and survival of the patients were evaluated.

RESULTS

Twenty-two patients (15 females and 7 males) were diagnosed as having AIH within 11 years. The median age at onset was 64 years (range: 17-77 years). Compared with female patients, male patients had older age (p = 0.001), shorter duration from initial presentation of symptoms to diagnosis (p = 0.015), lower serum levels of alkaline phosphatase (ALK-P, p = 0.022) and albumin (p = 0.043). Five (23%) patients presented with cirrhosis upon diagnosis. Compared with non-cirrhotic patients, cirrhotic patients had lower serum levels of alanine aminotransferase (p = 0.002), aspartate aminotransferase (p = 0.015), gamma-glutamyl transferase (G-GT, p = 0.002), albumin (p = 0.14), white cell counts (p = 0.009) and platelet counts (p = 0.002). Thirteen (59%) patients had concomitant clinico-pathological features of cholestatic liver disease (ALK-P > or = 2 times of upper normal limit or pathologic evidence of cholangiopathy). They had higher serum levels of ALK-P (p < 0.001) and G-GT (p = 0.004) than 9 non-cholestatic patients. There were no significant differences in survival between these groups. The prescribed initial and maintained prednisolone dosages for our patients to control disease activity were 19 +/- 15 mg and 8 +/- 1 mg, respectively, which were lower than those recommended in Western countries. The remission rate to steroid treatment and relapse rate after discontinuing corticosteroids were 87.5% and 50%, respectively.

CONCLUSIONS

Compared with Western AIH patients, the AIH patients in Taiwan are older and more likely to develop cholestasis, and need a relatively lower dose of steroid for treatment. Owing to one quarter of the patients already having liver cirrhosis on diagnosis, AIH should be suspected in any Taiwanese patient with cryptogenic hepatitis or cirrhosis.

Solitary metastasis from renal cell carcinoma presenting as diffuse pancreatic enlargement

Late metastasis of renal cell carcinoma (RCC) to the pancreas is uncommon. Diffuse pancreatic metastasis of any carcinoma rarely causes global enlargement of the pancreas. We present the case of a 73-year-old man diagnosed with metastatic RCC of the pancreas 9 years after radical nephrectomy had been performed and describe our radiologic findings. The disease involved the entire pancreas, which was hypoechoic on sonography, hypodense on CT without contrast enhancement, and markedly hyperdense after intravenous administration of a contrast agent. Color Doppler sonography showed that the involved areas of the pancreas had increased color flow signals, indicating that the metastatic tumor was characteristically hypervascular. In patients with a history of RCC, color or power Doppler sonographic demonstration of diffuse enlargement of the pancreas with evidence of hypervascularity may indicate metastasis of RCC to the pancreas.

Simple blood tests can predict compensated liver cirrhosis in patients with chronic hepatitis C

BACKGROUND/AIMS

Twenty to fifty percent of patients with chronic hepatitis C virus infection will insidiously progress to cirrhosis after 10-20 years' follow-up. The aim of this study is to retrospectively evaluate the role of simple non-invasive blood tests in detecting the presence of compensated liver cirrhosis in Chinese patients with chronic hepatitis C.

METHODOLOGY

One hundred and eleven biopsy-proven chronic hepatitis C patients were enrolled, 23 (20.7%) patients showed cirrhosis with class A in Child-Pugh's classification and were all asymptomatic. Liver biochemistry, complete blood count, and serum N-terminal propeptide of type III procollagen were determined and then compared between chronic hepatitis C patients with compensated cirrhosis and without cirrhosis. Multivariate logistic regression analysis was used to predict factors associated with compensated cirrhosis.

RESULTS

Multivariate logistic regression analysis showed platelet count < or = 140,000/mm3 (odds ratio: 23.44, P < 0.001), globulin/albumin ratio > or = 1 (odds ratio: 31.47, P = 0.008), and AST/ALT ratio > or = (odds ratio: 6.58, P = 0.035) were significant predictors associated with hepatitis C virus-related compensated cirrhosis. Platelet count < or = 140,000/mm3 had 83% sensitivity and 85% specificity in detecting liver cirrhosis. Globulin/albumin ratio > or = 1 had 43% sensitivity, 98% specificity and AST/ALT ratio > or = 1 had 39% sensitivity, 92% specificity in detecting liver cirrhosis. Combined tests with AST/ALT > or = 1 and globulin/albumin > or = 1, platelet count < or = 140,000/mm3 and globulin/albumin > or = 1 had 100% specificity, 100% positive predictive value but lower sensitivity (22% and 39% respectively), lower negative predictive value (83% and 86%, respectively) in detecting hepatitis C virus-related compensated liver cirrhosis.

CONCLUSIONS

Simple blood tests with platelet count < or = 140,000/mm3, globulin/albumin ratio > or = 1, and AST/ALT ratio > or = 1 can indicate liver cirrhosis in follow-up patients with chronic hepatitis C.

Cholestatic hepatitis caused by acute gold potassium cyanide poisoning

INTRODUCTION

Poisoning after oral ingestion of gold potassium cyanide is rarely reported. A case of suicidal ingestion of gold potassium cyanide (potassium dicyanoaurate; CAS# 13967-50-5) is described.

CASE REPORT

A 27-year-old man attempted suicide by ingesting 5 mL gold potassium cyanide solution. He developed vomiting, hyperamylasemia, and hepatic dysfunction. Cyanide poisoning was not detected but acute gold toxicity was noted. Pathologic findings of the liver showed centrilobular cholestasis with eosinophilic degeneration. The whole blood and serum gold were 4361 and 6011 microg/L, respectively, and the 24-hour urine gold was 429 microg/d in samples obtained on day 4.

CONCLUSION

Gold-induced hepatotoxicity has been seen infrequently in patients receiving gold therapy. Reported agents include sodium aurothiomalate, sodium aurothiopropranol sulfonate, aurothioglucose, aurothiopolypeptide (Auro-detoxin), auric sulfide, and gold thiosulfate, our report adds gold potassium cyanide.

A progressive growing inflammatory pseudotumor of the liver

Inflammatory pseudotumors of the liver are very rare, and their etiology and pathogenesis remain unclear. The diagnosis is often difficult to make because these masses often mimic other lesions such as primary neoplasms, metastases or liver abscesses. Herein, we report a rare case of progressive growing hepatic pseudotumor in a 47-year-old man. The patient presented with body weight loss and general malaise. A series of radiological examinations showed the progressive growth of the hepatic tumor from 3.5 cm to 10.0 cm in diameter within 8 months. He underwent a right lobectomy of the liver, and the final diagnosis was proven by pathology. There were no complications in the post-operative course.

Long-term evaluation of recombinant interferon alpha2b in the treatment of patients with hepatitis B e antigen-negative chronic hepatitis B in Taiwan

The effect of interferon (IFN) on hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB) has not been fully investigated in Chinese patients. We enrolled 58 HBeAg-negative CHB Chinese patients with hepatitis B viremia in Taiwan to evaluate the response to IFN. 30 patients received recombinant IFN 5 million units 3 times weekly for 6-10 months, and 28 patients who refused IFN treatment served as controls. Rates of virological response and biochemical response were higher in the treated group at the end of treatment (57% vs 18%, P = 0.006, and 73% vs 29%, P = 0.002, respectively). Both effects were superior in the treated group at 6 months after IFN withdrawal (virological: 30% vs 7%, P = 0.06; biochemical: 47% vs 7%, P = 0.002). Improvement of liver histological activities with persistently biochemical response was found in 65% of the treated patients. After a mean of 32 months' follow-up, virological response was rarely maintained (17% vs 4%, P = 0.228) but biochemical response was better in the treated group (27% vs 4%, P = 0.039). None of the treated patients but five controls developed severe complications of CHB during the follow-up period. A larger total IFN dosage or a younger age (< or = 40 years) were associated with 'sustained' virological response. Younger age and higher baseline alanine transaminase values (> or = 120 Ul(-1)) were related to 'sustained' biochemical response.

Resection of triple synchronous tumors--gastric adenocarcinoma, gallbladder adenocarcinoma and stromal tumor of the stomach

We herein report a rare case of triple synchronous tumors: gastric adenocarcinoma, gallbladder adenocarcinoma and stromal cell tumor of stomach, which were resected in the same operation. A 72-year-old male patient suffered from poor appetite and epigastric pain that radiated to his back for one month. Upper gastrointestinal endoscopy showed a gastric ulcer measuring 1.5 cm at the prepyloric area, which was proven to be adenocarcinoma by biopsy. A second tumor was found in the gallbladder, measuring 3 cm, by ultrasonography. On computed tomography, a third tumor about 2.5 cm in size was recognized posterior to the gastric high body and anterior to the pancreas. Given the presence of three tumors, he underwent a radical subtotal gastrectomy with Billroth-II gastrojejunostomy and simultaneous cholecystectomy. Pathological findings revealed gastric adenocarcinoma, gallbladder adenocarcinoma and stromal cell tumor of the stomach. The postoperative course was smooth.

Malignant melanoma of the eustachian tube

The case report describes the diagnosis and the management of malignant melanoma of the eustachian tube. This is an exceedingly rare condition that was treated with endoscopic surgery and post-operative radiotherapy. During a 15-month follow-up, there was no evidence of recurrence.

Clinicopathologic and prognostic differences between patients with hepatitis B- and C-related resectable hepatocellular carcinoma

BACKGROUND AND PURPOSE

Hepatitis B and C viral infections are important factors in the development of hepatocellular carcinoma (HCC). This study examined the clinicopathologic and prognostic differences in patients with hepatitis B- and C-related resectable HCC.

METHODS

A total of 270 HCC patients who underwent hepatic resection were enrolled. Among these patients, 211 were positive for hepatitis B surface antigen (HBsAg) and 59 were positive for anti-hepatitis C virus antibody (anti-HCV). The clinical manifestations, pathologic features, and treatment outcomes were compared between the HBsAg-positive and anti-HCV-positive groups.

RESULTS

Compared to anti-HCV-positive patients, HBsAg-positive patients were significantly younger, had a higher familial incidence of HCC, larger tumor size, and a higher incidence of multiple tumors. HCC patients who were anti-HCV positive had worse liver function and a higher incidence of history of blood transfusion. DNA flow cytometric analysis revealed significantly more proliferative activity in the non-tumor part of the liver in HBsAg-positive HCC patients. The 1-, 3-, and 5-year overall survival rates of HBsAg-positive patients were 79%, 57%, and 48%, respectively, and for anti-HCV-positive patients were 91%, 75%, and 62%, respectively. HBsAg-positive patients had a significantly lower overall survival rate than anti-HCV-positive patients (p = 0.018).

CONCLUSIONS

HBsAg-positive patients with resectable HCC had a less favorable survival rate after tumor resection than anti-HCV-positive HCC patients. This survival difference might have been related to the relatively advanced stage of disease and the higher proliferative activity of the non-tumor part of the liver in HBsAg-positive HCC patients.

Clinical, virological, and pathological significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C

PURPOSE

Hepatic bile duct injuries are characteristic histological findings in patients with chronic hepatitis C virus (HCV) infection. However, the pathogenesis and clinical significance of this phenomenon remain unclear. The aims of this study were to evaluate the prevalence and clinical significance of hepatic bile duct injuries in Chinese patients with chronic hepatitis C.

METHODS

One hundred and seventeen Chinese patients with chronic hepatitis C were enrolled. Clinical, biochemical, immunological (serum autoantibodies and cryoglobulinemia), histological, and virological data (serum HCV RNA titer and HCV genotype) were compared between patients with and without hepatic bile duct injuries.

RESULTS

Eighty-three (71%) of the 117 patients with chronic hepatitis C had hepatic bile duct injuries. Patients with hepatic bile duct injuries had a significantly higher frequency of HCV genotype 1b; a higher mean serum globulin level; significantly higher mean scores for histological periportal necro-inflammation, portal inflammation, and fibrosis; and more severe portal lymphoid aggregation/follicles when compared with patients without hepatic bile duct injuries (P < 0.05, all). No significant differences in the presence of serum autoantibodies, cryoglobulinemia, mean serum HCV RNA titer, or response to interferon treatment were noted between the two groups. Multivariate logistic regression analysis showed that HCV genotype 1b infection, portal inflammation, and lymphoid aggregation/follicles were significant independent predictors associated with hepatic bile duct injuries.

CONCLUSIONS

The presence of hepatic bile duct injuries in Chinese patients with chronic hepatitis C was significantly correlated with HCV genotype 1b infection, and the patients with these injuries had more severe portal inflammation and formation of lymphoid aggregates/follicles.

An unusual cutaneous metastasis from hepatocellular carcinoma

Cutaneous metastases from hepatocellular carcinoma are rare. In this report we detail a case of hepatocellular carcinoma with the unusual manifestations of multiple skin metastases. A 49-year-old male, who had received surgical resection of hepatocellular carcinoma one year prior, presented with multiple reddish-blue, firm, painless and nonulcerative cutaneous papules and nodules over the fingers, palms, toes, soles and back. Pathology of the cutaneous nodules showed characteristic hepatocellular carcinoma with trabecular gland formation. These lesions grew very rapidly and developed to cauliflower appearances which had not been described previously in the literature. The patient died of respiratory failure secondary to lung metastasis two months after the first appearance of the skin lesions.