Combination of dirty mass volume and APACHE II score predicts mortality in patients with colorectal perforation.

BACKGROUND: "Dirty mass" is a specific computed tomography (CT) finding that is seen frequently in colorectal perforation. The prognostic significance of this finding for mortality is unclear. METHODS: Fifty-eight consecutive patients with colorectal perforation who underwent emergency surgery were retrospectively reviewed in the study. Dirty mass identified on multi-detector row CT (MDCT) was 3D-reconstructed and its volume was calculated using Ziostation software. Dirty mass volume and other clinical characteristics were compared between survivor (n = 45) and mortality groups (n = 13) to identify predictive factors for mortality. Mann-Whitney U test and Χ2 test were used in univariate analysis and logistic regression analysis was used in multivariate analysis. RESULTS: Dirty mass was identified in 36/58 patients (62.1%) and located next to perforated colorectum in all cases. Receiver-operating characteristic (ROC) curve analysis identified the highest peak at 96.3 cm3, with sensitivity of 0.643 and specificity of 0.864. Univariate analysis revealed dirty mass volume, acute disseminated intravascular coagulation (DIC) score, acute physiology and chronic health evaluation II (APACHE II) score, and sequential organ failure assessment (SOFA) score as prognostic markers for mortality (p<0.01). Multivariate analysis revealed dirty mass volume and APACHE II score as independent prognostic indicators for mortality. Mortality was stratified by dividing patients into four groups according to dirty mass volume and APACHE II score. CONCLUSIONS: The combination of dirty mass volume and APACHE II score could stratify the postoperative mortality risk in patients with colorectal perforation. According to the risk stratification, surgeons might be able to decide the surgical procedures and intensity of postoperative management.

Primitive neuroectodermal tumor of the pancreas.

The primitive neuroectodermal tumor (PNET) of the pancreas, a member of Ewing's sarcoma family of tumors, is extremely rare. We treated a 37-year-old Japanese man who had a solitary pancreatic tumor 40 mm in diameter and multiple hepatic tumors with surgical resection. The PNET was positive for CD99 on immunohistochemical staining. Fluorescence in situ hybridization (FISH) was also performed, which revealed a Ewing sarcoma breakpoint region 1 (EWSR1) 22q12 rearrangement. According to the Japan-Ewing protocol, chemotherapy with Ifomide (ifosfamide), etoposide, vincristine, and cyclophosphamide was given after surgery. To the best of our knowledge, to date 13 PNET cases have been reported with a mean age for all patients of 19.3 years old. Surgical resection was performed in most cases and some patients received postoperative chemotherapy. The clinicopathologic characteristics and management of this extremely rare disease are also discussed.

Primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue type: case report and review of the literature.

A primary hepatic marginal zone B cell lymphoma of mucosa-associated lymphoid tissue (MALT) is very rare. We found a solitary mass 27 mm in size in the left lobe of the liver of a 58-year-old Japanese man with a history of hepatitis-C infection. Based on the results of imaging studies, the tumor was diagnosed as a hepatocellular carcinoma (HCC). The left lobe of the liver was lobectomized and microscopic findings showed that the tumor was a hepatic MALT lymphoma, while immunohistochemistry showed it to be positive for CD20 and CD79a. In a fluorodeoxyglucose-positron emission tomography examination integrated with computed tomography scanning (FDG-PET CT) before surgery, the tumor was revealed to have a high standardized uptake value (SUV) for FDG. The patient received chemotherapy after surgery. To the best of our knowledge, 45 cases had been reported with a mean age for all patients of 61.4 years. The pathogenesis remains unclear, although half of the patients had a past history of chronic inflammatory liver disease. Surgical resection was performed in most cases and some patients received postoperative chemotherapy or radiotherapy. The clinicopathologic characteristics and management of this extremely rare disease are also discussed.

Efficacy of radiofrequency ablation therapy compared to surgical resection in 164 patients in Japan with single hepatocellular carcinoma smaller than 3 cm, along with report of complications.

BACKGROUND/AIMS: Radiofrequency ablation therapy (RFA) has become widely used against hepatocellular carcinoma (HCC), mainly because of its ease of use, lower level of invasiveness, and high level of effectiveness. To compare the efficacy and safety of RFA with surgery, we retrospectively investigated relevant patient clinical data. METHODOLOGY: The patients with a single HCC (3 cm > or =, Child-Pugh A or B) who were treated with RFA (RFA-group: n=105) or surgery (Surgery-group: n=59) from January 2000 to June 2007 were enrolled. RESULTS: The ratio of patients classified as Child-Pugh B was greater in RFA-group (24.8% vs. 8.5%, P=0.011), though the sizes of the tumors were not significantly different. There were no significant differences for survival rates or disease free survival rates after 3- and 5-years (RFA-group vs. Surgery-group; survival: 87.8 and 59.3% vs. 91.4 and 59.4%, disease free survival: 58.7 and 24.6% vs. 64.3 and 22.4%, respectively). As for complications, in RFA-group there was no severe complication while there was 1 case of postoperative hepatic failure death and 2 with a postoperative abscess in Surgery-group. CONCLUSIONS: In the present study, patients with a single HCC smaller than 3cm who underwent RFA had a lower frequency of severe complications, thus the efficacy of RFA was thought to be equal to a surgical procedure.

Balloon occluded retrograde transvenous obliteration and percutaneous transhepatic obliteration for ruptured duodenal varices after operation for rectal cancer with multiple liver metastasis: report of a case.

We report a patient with duodenal varices oozing blood who had undergone low anterior resection of the rectum and resection of the liver tumor because of multiple liver metastasis from rectal cancer 80 months previously. Although endoscopic variceal ligation (EVL) was carried out for the ruptured duodenal varices, their bleeding persisted and hepatic encephalopathy also appeared. Finally, balloon occluded retrograde transvenous obliteration (BRTO) with percutaneous transhepatic obliteration (PTO) was carried out for the duodenal varices. Percutaneous transhepatic portography revealed detailed hemodynamics. Following PTO, the duodenal varices were stagnated by BRTO, and no complications were recognized. No re-bleeding episode has been observed since the treatment. In addition, the hepatic encephalopathy was also improved.

Multiple hepatic angiomyolipomas with a solitary omental angiomyolipoma.

Angiomyolipoma (AML) is a rare benign tumor that occurs most commonly in the kidney. Lesions in the liver are usually solitary and multiple AMLs of the liver are extremelyrare. Furthermore, extra renal or hepatic AML are rarely found. We report an unusual case of a 34-year-old man with a solitary omental AML and multiple hepatic AMLs. At the age of 23, the patient underwent right nephrectomy and enucleation of a left renal tumor because of bilateral AMLs. At the age of 34, more than 6 lesions in the liver and an enlarged solitary omental AML were discovered. The omental tumor, 50 x 40mm, 49g, was extirpated; it was well-defined and encapsulated a soft elastic mass. Histologically it was an epithelioid AML and positive for the melanogenesis-related marker HMB-45, the same as the earlier right renal tumor. We describe the first case of a solitary omental AML, which had metastasized, and with more than 6 hepatic AMLs.

Activin and activin receptor expression changes in liver regeneration in rat.

BACKGROUND: This study aimed to investigate regulatory mechanisms of hepatocyte proliferation by comparing liver regeneration of the remnant lobe after 70% partial hepatectomy (PH) and portal vein branch ligation (PBL) in rat. METHODS: Expressions of activins betaA, betaC, and betaE and their receptors were investigated after PH and PBL. The proliferating cell nuclear antigen (PCNA) labeling index was used to monitor hepatocyte proliferation. RESULTS: The PCNA labeling index in the regenerative lobe of PBL rats reached a peak at 48 h, a delay of 24 h compared with the remnant lobe in PH rats. In the postoperative early stage, the expression of activin betaA, betaC, and betaE mRNAs was stronger in PBL than PH. At 72 h the expression of activin receptor type IIA mRNA reached a peak in PH but was significantly lower in PBL. CONCLUSIONS: Hepatocyte proliferation, and the regulated expression of activins and their receptors, differs during liver regeneration after PH and PBL in the rat. Thus, regulation of activin signaling through receptors is one of the factors determining liver regeneration after PH and PBL.

Possible endocrine control by follistatin 315 during liver regeneration based on changes in the activin receptor after a partial hepatectomy in rats.

BACKGROUND/AIMS: Activin A is an autocrine inhibitor of cell growth in the liver. The biological activity of activin A is mediated by a heteromeric receptor complex. Follistatin (FS) binds to activin and inhibits its biological effects, and acts as a negative regulator of muscle cells. The role of activin receptors during liver regeneration following a hepatectomy has not been fully assessed. This study investigates the mechanism underlying how activin receptors regulate hepatocyte growth, and the effects of intravenous administration of FS during liver regeneration. METHODOLOGY: The expression of both activins and activin receptors in the liver after a 70% partial hepatectomy (HT) was assessed by RT-PCR and immunohistochemistry. FS 315 or 288 was infused for different periods of time based on changes in hepatocyte activin receptor expression after HT. RESULTS: Activin receptor expression peaked between 48 and 72 hours after HT. 72 hours after HT, an injection of FS 315 resulted in a more potent stimulation of DNA synthesis and produced a greater increase in body weight compared with the control rats. CONCLUSIONS: The expression of activin receptors after peak DNA synthesis might be a key component in the downregulation of DNA synthesis. Intravenous administration of FS 315 might promote liver regeneration and have anabolic actions.

[Management of spontaneous ruptured hepatocellular carcinoma].

Spontaneous rupture is a major life-threatening complication of hepatocellular carcinoma(HCC). Ruptured HCC often causes hypovolemic shock and hepatic hypoperfusion. Patients with impaired liver function tend to lapse into liver failure, which is the main cause of death. To prevent liver failure, accurate diagnosis and adequate treatment for the restoration of the efficient liver perfusion are required. Emergent transarterial embolization (TAE) is the most effective and less-invasive treatment for hemostasis. On the other hand, emergent hepatic resection should be avoided because of the increased risk of postoperative liver failure and incomplete resection of the tumor. After achieving hemostasis, a second-stage therapeutic approach for HCC is required. Patients with acceptable liver function should undergo surgery. The prognosis of ruptured HCC treated with second-stage hepatectomy is considered to be comparable with that of nonruptured HCC. In conclusion, spontaneous rupture of HCC is considered to be a combination of acute and severe peritoneal hemorrhage with malignant disease. To improve the prognosis, adequate early treatment for the control of hemorrhage while preserving liver function is an important factor. TAE followed by elective hepatectomy is considered the most effective treatment.

Arterial infusion chemotherapy for the patient of unresectable pancreatic carcinoma with multiple liver metastases: a case report.

INTRODUCTION: Despite various treatment trials for unresectable pancreatic carcinoma with liver metastases, the outcome has not been satisfactory. This paper reports a case of pancreatic carcinoma with multiple liver metastases that responded well to arterial infusion chemotherapy. CASE REPORT: A 65-year-old male was diagnosed with multiple liver tumors, and needle biopsy revealed adenocarcinoma. With endoscopic ultrasonography, a tumor in the pancreatic head was detected, and pancreatic carcinoma with multiple liver metastases was diagnosed. He received arterial infusion chemotherapy: cisplatin at a dose of 10 mg/body/day and 500 mg/body/day of 5-fluorouracil After 14 days administration, liver metastases had decreased in number and size, but thereafter, because of hepatic arterial occlusion, the same dose of drugs was administered intravenously. The patient was discharged from the hospital and was given chemotherapy 3 days a week on an outpatient basis. Although the chemotherapy was effective, it was stopped because of severe general fatigue 5 months after discharge. His general status continued to gradually worsen, and he died 12 months after diagnosis. CONCLUSIONS: Prognosis of pancreatic carcinoma with liver metastases is poor; however, transarterial infusion chemotherapy may be effective to improve the prognosis and quality of life of the patients.

Imprint cytology of epithelioid angiomyolipoma in a patient with tuberous sclerosis. A case report.

BACKGROUND: Angiomyolipoma composed predominantly of epithelioid cells has been referred to as epithelioid angiomyolipoma. As this subtype shows considerable cellular atypia, it may be erroneously diagnosed as malignant epithelioid tumor, such as renal cell carcinoma and hepatocellular carcinoma. So far, only one report describing the cytologic findings of epithelioid angiomyolipoma has been documented, and epithelioid angiomyolipoma occurring in the peritoneal cavity has not been reported. CASE: Eleven years after resection of a renal epithelioid angiomyolipoma in a 34-year-old male with tuberous sclerosis, a tumor appeared in the peritoneal cavity and three masses in the liver. The intraoperative smears imprinted from part of the peritoneal mass revealed many large, atypical cells. The well-preserved atypical cells showed abundant, round to polyhedral, granular cytoplasm. Bizarre, giant nuclei with hyperchromasia and huge nucleoli were occasionally seen. Intranuclear cytoplasmic inclusions and mitotic figures were occasionally observed. As the epithelioid cells were markedly pleomorphic, we could not rule out hepatocellular carcinoma, cytologically and histologically, in the intraoperative consultation. In permanent sections the tumor was composed predominantly of epithelioid cells showing an alveolar pattern or sheetlike arrangement. Mitotic counts were zero to one per 10 high-power fields. Immunohistochemically, the epithelioid tumor cells were positive for vimentin, alpha-smooth muscle actin and HMB-45, consistent with epithelioid angiomyolipoma. MIB-1-labeling index was 1.6%. CONCLUSION: When one sees atypical epithelioid tumor cells in a tuberous sclerosis patient during an intraoperative consultation, one must consider epithelioid angiomyolipoma.