Assessing the characteristics and feasibility of preventing early mortality in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: To determine strategies to prevent early death (ED) and improve the prognosis of patients with advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Patients who were diagnosed with HCC from January 2012 to June 2017 were considered for the study. Those who survived for ≤6 months from the date of diagnosis were classified into the ED group (n=21) and those who survived for ≥12 months from the date of diagnosis were classified into the non-ED group (n=88). RESULTS: There were significant differences between the ED and non-ED groups in the following conditions: when the patient age was ≥80 years (38.1% vs. 14.8% patients); maximum nodule size was >3 cm (90.5% vs. 27.3%); Child-Pugh class C liver disease was seen (66.7% vs. 26.1%); tumor-node-metastasis (TNM) Stage III-IV tumor was present (85.7% vs. 21.6%); BCLC stage C/D of liver cancer was seen (81.0% vs. 21.6%); JIS score was ≥4 (52.4% vs. 3.4%); serum creatinine level was ≥1.0 mg/dL (52.4% vs. 22.7%); and there was absence of aggressive treatments such as hepatic resection, radiofrequency ablation, transarterial chemoembolization, and chemotherapy (66.7% vs. 4.5%). Logistic regression analysis identified maximum nodule size of >3 cm (p=0.005, OR=58.7, 95% CI=3.43-1003.9), JIS score of ≥4 (p=0.021, OR=12.0, 95% CI=1.44-100.1), and absence of aggressive treatments (p=0.006, OR=24.7, 95% CI=2.47-247.2) as predictive factors for ED. The presence of aggressive treatments significantly improved the 12-month survival rate of advanced HCC patients with BCLC stage C/D (presence vs. absence: 78.3% vs. 7.4%), a maximum nodule size of >3 cm (76.7% vs. 7.7%), and a JIS score of ≥4 (60.0% vs. 0%). CONCLUSION: Although delayed detection of HCC strongly increased the onset ED, the aggressiveness of HCC treatment is not readily downgraded, and the most aggressive treatment possible should be considered to prevent ED in patients with advanced HCC.

Acute onset of autoimmune hepatitis with sinusoidal and central vein endotheliitis, and marked involvement of activated dendritic cells: A case report.

RATIONALE: Autoimmune hepatitis (AIH) is characterised by interface hepatitis. However, some acute cases exhibit atypical centrilobular necrosis with mild portal inflammation. Detailed histological and ultrastructural analyses of acute AIH are limited. PATIENT CONCERNS: A 44-year-old female was admitted to our hospital with jaundice, general fatigue and liver dysfunction. Her transaminase levels were elevated, her immunoglobulin G level was 1735 mg/dL and her anti-nuclear titres were ×80. DIAGNOSIS: AIH was diagnosed, and histochemical examination of a liver biopsy showed the presence of atypical histological features of prominent centrilobular necrosis and central vein and hepatic sinusoidal endotheliitis. Electron microscopy showed that dendritic cells (DCs) and lymphocytes were attached to disrupted liver sinusoidal endothelial cells (LSECs) in hepatic sinusoids and that DCs attached to LSECs via pseudopods in the central vein. INTERVENTIONS AND OUTCOMES: The patient was started on 40 mg/day prednisolone to control the hepatic inflammation. Her aspartate and alanine aminotransferase levels started declining after prednisolone was initiated. Three weeks later, these levels had normalised. The dosage of prednisolone was gradually decreased as liver function improved. The patient remains under observation and continues to receive 2.5 mg prednisolone. LESSONS: An important marker of acute AIH may be the presence of activated DCs in the hepatic sinusoids and central vein.

A superelderly case of TAFRO syndrome treated effectively using corticosteroid hormones.

Peripheral lymphocyte subsets may be less time-consuming and are a prognostic tool for managing thrombocytopenia, anasarca, myelofibrosis, renal dysfunction, and organomegaly (TAFRO) syndrome. Here, we report a superelderly case of plasma cell type TAFRO syndrome treated effectively using corticosteroid hormones.

Regular hospital visits improve the prognosis of hepatocellular carcinoma after initial diagnosis: A single regional community hospital study.

BACKGROUND/AIMS: The aims of this study were to investigate the relationship between regular hospital visits and prognosis of hepatocellular carcinoma (HCC) and to suggest methods to avoid poor prognoses in HCC. MATERIALS AND METHODS: In total, 103 patients with initial HCC were classified into 3 groups based on hospital visits occurring 1 year before diagnosis: group A was patients with regular hepatologist visits (n=41), group B was those with regular visits to other hospital divisions (n=50), and group C was those with no hospital visits (n=12). The relationships between the 3 groups and survival rates, backgrounds, hepatic reserve, and stages of HCC were analyzed. RESULTS: Survival rates of groups A, B, and C after diagnosis at 36 months were 77.9%, 66.3%, 31.3%, respectively. These were significantly higher in group A than in B and in group B than in C (p=0.042 and p=0.003, respectively; generalized Wilcoxon test). Child-Pugh classification, Japan integrated staging (JIS) score, and Barcelona clinic liver cancer (BCLC) staging were poor in group C compared with group A (p<0.01) and group B (p<0.01 or p<0.05). Males with viral infection (15 of 16 males in group B, p<0.01) and non-virally infected patients (34 patients in group B, p<0.01) had fewer regular hepatologist visits. CONCLUSION: Hepatologist visits appeared to improve the prognosis of initial HCC. Males and non-virally infected patients should be screened to avoid delays in diagnosis. Since cases of non-viral HCC are likely to increase in Japan, surveillance methods for all clinicians should be established.

Primary hepatic angiomyolipoma: immunohistochemistry and electron microscopic observations: a case report.

BACKGROUND: Hepatic angiomyolipomas are a rare, benign group of mesenchymal tumors in the liver. Hepatic angiomyolipoma is sometimes misdiagnosed as hepatocellular carcinoma, and there is the possibility of a malignant transformation. Hence, the accurate diagnosis of this disorder is necessary. CASE PRESENTATION: A 64-year-old Japanese man was observed to have a space-occupying lesion of 15-mm diameter in the liver during a follow-up examination for a previously resected cecal carcinoma. He underwent lateral segmentectomy of the liver with a provisional diagnosis of hepatic metastatic recurrence of the carcinoma based on gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging and diffusion-weighted imaging. CONCLUSIONS: We have explored the combination of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging and histological examination to confirm our diagnosis of hepatic angiomyolipoma comprising an intimate mixture of numerous abnormal blood vessels, adipocytes, and epithelioid spindle cells of various sizes. Immunohistochemical examination revealed characteristic pathological findings associated with positive qualitative immunoreactions for human melanoma black 45 and desmin. Electron microscopic findings revealed the presence of melanosomes in the epithelioid cells. Diffusion-weighted imaging provides a more accurate diagnostic image with the characteristic macroscopic appearance of hepatic angiomyolipoma. Through immunohistochemistry and electron microscopy, we also show that this benign tumor comprises tissue elements.

Over-the-counter Drug Induced Autoimmune Hepatitis.

A 64-year-old man seeking treatment for a common cold was admitted to our hospital due to symptoms of general fatigue and liver dysfunction. A thorough history review revealed that the patient had recently started taking an over-the-counter (OTC) drug. Drug-induced lymphocyte stimulation tests were positive. Serum markers for autoimmune hepatitis (AIH) were particularly elevated. Liver biopsy revealed spotty necrosis and ceroid-pigmented Kupffer cells and piecemeal necrosis with multiple plasma cells. He responded to corticosteroids, thus suggesting the presence of an immune-mediated component associated with the liver injury. Liver injury after using OTCs should be included in the differential diagnosis for chronic hepatitis with features of AIH.

Relevance of frozen sections and serum markers in invasive squamous cell carcinoma arising from ovarian mature cystic teratoma: two case reports.

BACKGROUND: Ovarian mature cystic teratoma (MCT) is a common neoplasm in women. While malignant transformation of MCT is relatively rare, squamous cell carcinoma is the most frequent malignant neoplasm arising from MCT. Some tumor markers have been reported to be useful for prediction of MCT malignant transformation prior to operation. However, widely accepted use of these markers remains to be established. In the present study, we report the usefulness of frozen section assessment during operation, as well as preoperative measurement of tumor marker levels. CASE PRESENTATION: We present two cases of squamous cell carcinoma arising from ovarian MCT. The first case was a 45-year-old Asian woman referred to our hospital after her periodical company medical checkup, due to possible ovarian tumor. Image analysis suggested a dermoid cyst, and left salpingo-oophorectomy was performed. Because the cyst was histologically diagnosed as an invasive squamous cell carcinoma arising from an MCT, our patient underwent an additional preventative operation. The TNM classification and FIGO stage were T1aNXM0 and Ia, respectively. The second case was a 53 -year-old Asian woman who visited our hospital due to complaints of abdominal pain and urinary retention. Image analysis and laboratory data showing high serum levels of SCC antigen (normal range: < 1.5 ng/mL) and CA19-9 (normal range: < 37 U/mL), which strongly suggested malignant transformation of MCT. Frozen sections obtained during the operation were histologically analyzed to confirm malignancy, and our patient underwent an additional operation. The TNM classification and FIGO stage were T1aNXM0 and Ia, respectively. CONCLUSIONS: We report the usefulness of frozen section assessment during operation, as well as preoperative measurement of tumor marker levels.

Co-registered positron emission tomography/computed tomography and gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid magnetic resonance imaging features of multiple angiosarcoma of the liver.

Hepatic angiosarcoma is a very rare disease, accounting for only 2% of primary liver malignancy. An 82-year-old man was admitted to our hospital because of jaundice and weight loss. Computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse and multiple space-occupying lesions. On gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced MRI, the tumor was not enhanced intensely in the arterial phase following contrast injection, and was then gradually enhanced homogeneously. In the delayed phase and hepatobiliary phase, the tumor was completely washed out. Whole-body (18) F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT fusion scanning confirmed metabolic activity with maximum uptake value of 3.64 in the lesions. A liver biopsy showed spindle-shaped tumor cells proliferating along sinusoids, with elongated and hyperchromatic nuclei. Immunohistochemical studies showed tumor cells positive for von Willebrand factor and CD34. These findings were consistent with angiosarcoma of the liver. This case report is the first description of co-registered FDG-PET/CT images and Gd-EOB-DTPA-enhanced MRI of primary hepatic angiosarcoma.

Prediction of postoperative pulmonary function: preliminary comparison of single-breath dual-energy xenon CT with three conventional methods.

PURPOSE: To assess the use of xenon ventilation maps (Xe-images) for predicting postoperative pulmonary function. MATERIALS AND METHODS: After study approval by the institutional review board, written informed consent was obtained from 30 patients with lung tumors who underwent pre- and postoperative spirometry, pulmonary perfusion SPECT and dual-energy CT (80 kV and 140 kV/Sn) after single-breath inspiration of 35 % xenon. Xe-images were calculated by three-material decomposition. Sum of pixel values of the part to be resected (A) and of the whole lung (B) on Xe-images or lung perfusion SPECT, and volumes or the number of segments of the part to be resected (A) and of the whole lung (B) on Xe-images were enumerated, respectively. We multiplied (1 - A/B) by each preoperative value from spirometry for prediction. Predictions by each of the four methods were compared with postoperative values. RESULTS: Predicted values for vital capacity (VC), forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) by the four methods regressed significantly with measured values (R (2) = 0.56-0.77, p < 0.001 for all). CONCLUSION: Analysis of Xe-images can predict postoperative VC, FVC and FEV1 with accuracy comparable to that of CT volumetry.

Multidetector CT appearance of adhesion-induced small bowel obstructions: matted adhesions versus single adhesive bands.

Adhesive small bowel obstruction (SBO) is a common cause of abdominal pain after surgery or peritonitis. The role of computed tomography (CT) in the evaluation of SBO has expanded. Diagnosis of adhesive SBO, however, remains challenging. Adhesions causing SBO are classified as either matted adhesions or single adhesive bands, and both types have different mechanisms that lead to SBO. In patients with matted adhesions, SBO results from angulation and kinking or from torsion of the intestines. In patients with adhesive bands, SBO results from compression of the intestine caused by the band itself. Recent advances in spatial resolution using multidetector CT (MDCT) have enabled detailed assessment of the configuration of the SBO site. Presented in this pictorial essay are characteristic MDCT findings regarding the mechanism of the obstruction process of adhesive SBO.

Cystic artery bleeding due to blunt gallbladder injury: computed tomography findings and treatment with transcatheter arterial embolization.

Blunt gallbladder injury is rare, and bleeding from the cystic artery due to blunt trauma is even rarer. We report herein a case of extraluminal bleeding of the gallbladder in a patient following blunt abdominal trauma. Contrast-enhanced computed tomography revealed pericholecystic fluid and extravasation of contrast material in the subcapsular liver space adjacent to the gallbladder. Abdominal digital subtraction angiography revealed pseudoaneurysm originating from a branch of the cystic artery. Successful treatment was achieved using selective transcatheter embolization, and cholecystectomy was not required.

Relation between pulmonary embolus volume quantified by multidetector computed tomography and clinical status and outcome for patients with acute pulmonary embolism.

PURPOSE: The aim of this study was to determine whether pulmonary embolus volume (PEV) obtained with multi-detector row computed tomography is related to clinical status and outcomes. MATERIALS AND METHODS: Subjects comprised 48 patients with acute pulmonary embolism (PTE). PEV was measured by tracing the contours manually and compared between sets of two groups divided by clinical status. Correlations of PEV to blood gases and D-dimer levels were investigated. PEV was tested as a predictor of clinical probability of acute PTE using Wells' criteria and as a predictor of survival after PTE by logistic regression analysis. RESULTS: The PEV was greater in groups with respiratory symptoms (P < 0.001), PTE as pretest clinical diagnosis (P = 0.027), and heart rate >100 beats/min (P < 0.001). It was smaller in subjects with concurrent malignancy (P = 0.02). It was correlated with PaCO(2) (P = 0.04, rho = -0.37) and the D-dimer level (P = 0.002, rho = 0.46); it was not a predictor of clinical probability of acute PTE or survival after PTE. The survival rate did not differ between groups with PEV > 10 ml (8/9) or

Arteriovenous malformation of the gallbladder: CT and angiographic findings.

We encountered a case of arteriovenous malformation (AVM) of the gallbladder in a patient with hepatocellular carcinoma (HCC). Contrast-enhanced computed tomography (CT) showed serpentine vessels around and within the gallbladder wall. Angiography showed dilated and tortuous cystic arteries, a racemose vascular network, and early-filling cystic veins. Transcatheter arterial embolization of two cystic arteries feeding the AVM was performed with platinum microcoils prior to transcatheter arterial chemoembolization for HCC to prevent embolic particles from flowing into these arteries. Follow-up contrast-enhanced CT showed blood flow in the gallbladder AVM, which appeared to be fed by the arterial collaterals.

Scintigraphic findings of MALT lymphoma of the thyroid.

Mucosa-associated lymphoid tissue (MALT) lymphoma has been established as a distinct entity among non-Hodgkin's lymphomas, and the most common primary site is the stomach. We describe scintigraphic findings in a patient with MALT lymphoma of the thyroid. A 71-year-old woman with Hashimoto's thyroiditis suffered from rapid cervical swelling, and ultrasonography and CT revealed a thyroid nodule. The nodule showed accumulation of 99mTc pertechnetate comparable to the surrounding thyroid tissue, mimicking a benign nodule. Both 67Ga and 201Tl imaging visualized the lesion as an increased uptake area. After radiotherapy, abnormally increased uptake disappeared on 67Ga images, which predicted a favorable outcome. MALT lymphoma of the thyroid may be visualized as a warm nodule on 99mTc pertechnetate scintigraphy.