Change in inflammatory cytokine profiles after transarterial chemotherapy in patients with hepatocellular carcinoma.

BACKGROUND: Alterations in cytokine profiles after chemotherapy can affect the outcomes of cancer patients. This study evaluated the clinical implications of cytokine changes after transarterial chemo-embolization (TACE) in patients with hepatocellular carcinoma (HCC). METHODS: Cytometric bead immunoassays were used to simultaneously measure 13 cytokines (interleukin [IL]-12p70, interferon-γ, IL-17A, IL-2, IL-10, IL-9, IL-22, IL-6, IL-13, IL-4, IL-5, IL-1ß, and tumor necrosis factor-α) in the sera of 83 patients with HCC and 33 healthy controls. Cytokines were serially monitored at baseline, on days 3 and 7, and 2months after TACE in 63 evaluable patients. RESULTS: Serum levels of IL-5, IL-6, and IL-17A were higher in patients with HCC than in healthy controls, whereas IL-1ß and IL-22 levels were lower in patients with HCC. Of the cytokines measured, only the IL-6 level showed a significant positive correlation with both tumor size and Child-Pugh score. The Child-Pugh B/C group had higher IL-6 and lower IL-22 levels at baseline and exhibited relatively minor changes in cytokine levels compared with the Child-Pugh A group. We observed diverse changing patterns of individual cytokines on each date tested, with IL-6 and IL-22 increasing early after TACE. Particularly, IL-6 reached a peak on day 3 and finally decreasing on and after day 7. IL-4, IL-5, and IL-10, on the other hand, increased during the late phase, 2months after TACE. Patients with larger tumors (>5cm) showed a transient but significant early-phase increase in IL-6 levels coupled with severe post-TACE hepatitis, as well as late-phase increases in IL-4, IL-5, and IL-10 levels after TACE. CONCLUSIONS: TACE induces changes in levels of multiple cytokines. Distinct panels of cytokine changes are not uniform, and are influenced by treatment-induced inflammation, underlying liver function, and HCC stage. Early-phase increases in IL-6 after TACE reflect acute-phase responses and are partly associated with post-treatment hepatitis, while late-phase increases in Th2 cytokine profiles suggest immune suppression in patients with large tumors.

Prognostic value of C-reactive protein and neutrophil-to-lymphocyte ratio in patients with hepatocellular carcinoma.

BACKGROUND: Accumulating evidence indicates that components of the systemic inflammatory response, such as C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), have been associated with prognosis of various cancers. We aimed to elucidate whether CRP and NLR could serve as potential surrogate markers for response and survival in patients with hepatocellular carcinoma (HCC). METHODS: The study population consisted of 318 consecutive patients with HCC. CRP and NLR were measured at baseline with follow-up measurements. RESULTS: With the mean follow-up of 13.9 months, the median survival time was 13.8 months. Child-Pugh class, tumor size > 5 cm, tumor multiplicity, presence of portal vein thrombosis, α-fetoprotein > 200 ng/mL, CRP > 6.3 mg/L and NLR > 2.3 were identified as independent factors for worse survival of HCC (all p < 0.05). Patients with elevated CRP (> 6.3 mg/L) and elevated NLR (> 2.3) had a significantly shorter overall survival than those with low CRP and low NLR (all p < 0.001). The combined use of CRP and NLR provided incremental prognostic information. With significant inter-correlations, levels of CRP and NLR escalated with aggravating Child-Pugh class from A to C or progressing tumor stage from I to IV. CRP and NLR on baseline and serial measurements were well predictive of treatment response (p < 0.001). CONCLUSIONS: CRP and NLR are independent indicators for survival in HCC patients, reflecting tumor burden and hepatic reserve. Their role in predicting tumor response and survival is more enhanced when used in combination. This study suggests that CRP and NLR are important prognostic biomarkers for HCC.

Serum interleukin-6 and C-reactive protein as a prognostic indicator in hepatocellular carcinoma.

The development of hepatocellular carcinoma (HCC) is often associated with chronic inflammation, suggesting a strong relationship between inflammation and carcinogenesis. This study evaluated the prognostic values of inflammatory and T-helper (Th) cytokines in the clinical outcome and survival of HCC. The study included 110 patients with HCC undergoing loco-regional therapy and 24 healthy controls. Five Th1/Th2 cytokines and C-reactive protein (CRP) were quantified before and after loco-regional treatment, using enzyme-linked immunosorbent assays. Levels of CRP, interleukin (IL)-4, and IL-6 were higher in patients with HCC than those in healthy subjects. Tumor characteristics, Child-Pugh class, and CRP, IL-6, and IL-10 levels were associated with HCC survival (all P<0.05). With multivariate analysis, higher IL-6 levels were identified as the independent cytokine for shorter survival (P=0.010). Higher CRP and IL-6 levels correlated well with larger tumor size, poor Child-Pugh function, and shorter survival, with a significant inter-correlation (r=0.667). On serial measurements, the association of CRP with tumor response was stronger than that of α-fetoprotein or other cytokines. IL-6 and CRP are strong inflammatory indicators predictive of outcome in patients with HCC receiving loco-regional therapy. This study suggests that inflammatory activation of the IL-6/CRP network may be a potential therapeutic target and biomarker for HCC.

Role of intrahepatic tumor control in the prognosis of patients with hepatocellular carcinoma and extrahepatic metastases.

BACKGROUND AND AIM: There has been little information about the long-term outcome and prognostic factors in patients with hepatocellular carcinoma (HCC) and extrahepatic metastases. The purpose of this study was to investigate the clinical factors affecting survival after extrahepatic metastasis and to determine the survival benefit of controlling intrahepatic HCC. METHODS: Between 2004 and 2009, a total of 240 consecutive patients with HCC and extrahepatic metastasis were recruited. Based on tumor extent, performance, and hepatic function, the patients underwent locoregional and/or systemic treatments. The treatment response of the intrahepatic tumor after extrahepatic metastasis and other prognostic parameters were analyzed retrospectively. RESULTS: During the mean follow up of 276 days, 222 patients died; the median survival time was 146 days. Multivariate analysis revealed that Child-Pugh class A, smaller hepatic tumor size, absence of portal venous invasion, single metastatic organ involvement, and objective treatment response of the intrahepatic tumor were the favorable prognostic factors for survival. Of the 183 evaluable patients, 24 achieved complete or partial response for intrahepatic tumors after treatment. The overall survival for the 24 responders was significantly improved, with a median of 521 days, as compared to 170 days for the remaining 159 patients without objective tumor response. The leading cause of death was progressive intrahepatic tumor. CONCLUSIONS: Intrahepatic tumor status and hepatic reserve are among the significant predictors of survival in patients with HCC and extrahepatic metastases. This study indicates that even in patients with metastases from advanced HCC, therapeutic approaches to control intrahepatic tumors are important in improving patient survival.

Long-term effect of stereotactic body radiation therapy for primary hepatocellular carcinoma ineligible for local ablation therapy or surgical resection. Stereotactic radiotherapy for liver cancer.

BACKGROUND: We evaluated the long-term effect of stereotactic body radiation therapy (SBRT) for primary small hepatocellular carcinoma (HCC) ineligible for local therapy or surgery. METHODS: Forty-two HCC patients with tumors ≤ 100 cc and ineligible for local ablation therapy or surgical resection were treated with SBRT: 30-39 Gy with a prescription isodose range of 70-85% (median 80%) was delivered daily in three fractions. Median tumor volume was 15.4 cc (3.0-81.8) and median follow-up duration 28.7 months (8.4-49.1). RESULTS: Complete response (CR) for the in-field lesion was initially achieved in 59.6% and partial response (PR) in 26.2% of patients. Hepatic out-of-field progression occurred in 18 patients (42.9%) and distant metastasis developed in 12 (28.6%) patients. Overall in-field CR and overall CR were achieved in 59.6% and 33.3%, respectively. Overall 1-year and 3-year survival rates were 92.9% and 58.6%, respectively. In-field progression-free survival at 1 and 3 years was 72.0% and 67.5%, respectively. Patients with smaller tumor had better in-field progression-free survival and overall survival rates (<32 cc vs. ≥32 cc, P < 0.05). No major toxicity was encountered but one patient died with extrahepatic metastasis and radiation-induced hepatic failure. CONCLUSIONS: SBRT is a promising noninvasive-treatment for small HCC that is ineligible for local treatment or surgical resection.

Impact of serial hepatitis B virus DNA on hepatocellular carcinoma development in patients with liver cirrhosis.

OBJECTIVES: We investigated the pattern of serial HBV DNA levels in known cirrhosis patients and its impact on the development of hepatocellular carcinoma (HCC). METHODS: We analyzed a retrospective case/control study based on 352 HCC patients associated with HBV between 2005 and 2007. Prior to HCC development, 49 cirrhosis patients were tested for HBV DNA levels more than once a year (median 4 times) during the follow-up period. Ninety-eight consecutive cirrhosis patients without HCC, matched for age, sex and HBe Ag status were included as controls. Eighty-three patients in both groups had undergone antiviral therapy. RESULTS: In cirrhosis, the most common HBV DNA pattern was fluctuating (33.3%), followed by persistently high (> or =10(4) copies/ml, 23.8%). Compared to a persistently low pattern (<10(4) copies/ml), the relative risks of HCC in patients with persistently high and fluctuating patterns were 2.650 and 1.475. At multivariate analysis, a persistently high pattern was an independent risk factor for HCC (hazard ratio 3.135). Patients with sustained HBV DNA suppression during antiviral therapy were less likely to develop HCC than those with viral breakthrough/nonresponse. CONCLUSIONS: This study showed that persistent suppression of HBV DNA is also important to prevent the development of HCC in known cirrhosis patients.

Decreased S100B expression in chronic liver diseases.

BACKGROUND/AIMS: Hepatic innervation in liver diseases is not fully understood. We here evaluated S100B expression as a marker of hepatic nerves in patients with various chronic liver diseases, topographically and semi-quantitatively. METHODS: Liver specimens were obtained from 70 subjects (three controls, and 32 chronic hepatitis B, 14 chronic hepatitis C, 14 liver cirrhosis, and seven hepatocellular carcinoma patients). The hepatic nerve density was calculated based on immunohistochemical staining of S100B protein in the portal tracts and hepatic lobules. S100B mRNA levels were semi-quantitatively assessed as the S100B/glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA ratio. RESULTS: The densities of the hepatic nerves in portal tracts of chronic liver diseases were not significantly different from those of normal controls but the hepatic nerve densities in lobular areas of liver cirrhosis were significantly decreased (p = 0.025). Compared to the control, the S100B/GAPDH mRNA ratio was significantly decreased in chronic liver diseases (p = 0.006) and most decreased in chronic hepatitis C patients (p = 0.023). In chronic liver diseases, The S100B/GAPDH mRNA ratio tended to decrease as the fibrosis score > 0 (p = 0.453) but the overall correlation between the S100B/GAPDH mRNA ratio and fibrosis score was not statistically significant (r = 0.061, p = 0.657). CONCLUSIONS: Hepatic innervation is decreased in cirrhotic regenerating nodules compared to the control group and seems to decrease in early stages of fibrosis progression. Further studies are needed to clarify the association between changes of hepatic innervation and chronic liver disease progression.

[Clinical and biochemical parameters of nutrition to predict hepatic encephalopathy in cirrhotic patients].

BACKGROUND/AIMS: Protein-calorie malnutrition is a common complication in cirrhosis. Protein restriction for the treatment of hepatic encephalopathy (HE) may cause disease progression and poor prognosis. Therefore, we evaluated important clinical parameters for nutritional state in cirrhotic patients with or without HE to predict the development of HE. METHODS: Twenty-two cirrhotic patients were divided into two groups; group A-13 patients without HE and group B-9 patients with HE. Clinical and biochemical parameters, serum proteins {serum albumin, insulin-like growth factor-1 (IGF-1), transferrin, leptin, etc}, immunologic parameters and anthropometry were measured. RESULTS: Child-Pugh score and Model for End-stage Liver Disease (MELD) scale were higher in group B (p<0.01). After correction of various factors affecting nutritional assessment, especially of Child-Pugh score and MELD scale, leptin was higher in group B (p<0.05). There was no difference in anthropometric measurements. Transferrin correlated inversely with MELD scale in group A (p<0.01). IGF-1 correlated inversely with total lymphocyte count in group B (p<0.05). Leptin correlated with Child-Pugh scores, total lymphocyte count and mid-arm muscle circumference in group A (p<0.05, p<0.05 and p<0.05, respectively), and correlated inversely with CD8 in group B (p<0.05). CONCLUSIONS: Leptin level is higher in patients with HE, and further studies for parameters of nutrition to predict HE in many cirrhotic patients will be needed.

The human cervical cancer oncogene protein is a biomarker for human hepatocellular carcinoma.

Human cervical cancer oncogene (HCCR) was identified and appeared to function as a negative regulator of p53 gene. The objective of this study was to validate HCCR expression as a candidate marker for human hepatocellular carcinoma. HCCR epitope was identified as Y(355)LGTRR(360). According to immunofluorescence study, HCCR was predominantly localized in the plasma membrane and cytoplasm of hepatocellular carcinoma. HCCR proteins were overexpressed in the tumorous compared with the nontumorous cirrhosis tissues. However, HCCR was not detected in normal liver tissue. Concentration of HCCR protein in the serum was measured in a total of 570 subjects, and comparisons were made to alpha-fetoprotein. Serological studies revealed 78.2% sensitivity of HCCR (cutoff value, 15 microg/ml), which was significantly higher than 64.6% of alpha-fetoprotein (P = 0.0098) and 95.7% specificity for hepatocellular carcinoma. Forty of 52 (76.9%) patients with carcinoma negative for alpha-fetoprotein showed positive values for HCCR. A positive rate of 69.2% in carcinoma patients with tumor sizes <2 cm was found to be a higher rate than measurement of alpha-fetoprotein. Furthermore, HCCR expression was also detected in liver cirrhosis at an intermediate level between carcinoma and normal groups, which gave 88.1% sensitivity and 79.0% specificity using 8 microg/ml as a cutoff value. In summary, the HCCR assay may have an advantage over the alpha-fetoprotein assay in that it is elevated according to disease progression from liver cirrhosis to carcinoma, and it is more frequently positive in patients with early, small hepatocellular carcinoma.

A case of acute cholestatic hepatitis associated with the seeds of Psoralea corylifolia (Boh-Gol-Zhee).

The potential hepatotoxicity of herbal remedies is usually ignored in daily life. One such compound, Boh-Gol-Zhee (in Chinese, Bu Ku Zi), appeared to be associated with the occurrence of acute cholestatic hepatic injury in the following case. Some alternative medicine therapists claim that Psoralea corylifolia is effective for the treatment of osteoporosis. We observed a case of acute cholestatic hepatitis associated with the use of the seeds of Psoralea corylifolia in amounts over 10 times the usual dose in a postmenopausal woman. Liver biopsy showed zone three necroses, degenerating cells, cholestasis, and infiltrations with inflammatory cells. This case stresses the need to warn of the potential hepatotoxicity of the seed of Psoralea corylifolia, especially in a large dose.

[Small bowel metastasis from breast cancer: a case report].

Breast cancer is a common malignancy in women and frequently metastasizes to various organs such as liver, lung, brain, bone and so on. But metastasis to gastrointestinal tract is rare. We describe a 73-year-old woman with small intestinal metastasis of breast cancer. She was diagnosed as right breast cancer in stage I, received modified radical mastectomy 6 years ago and had been followed up without any evidence of residual disease. During investigation for lower abdominal pain and weight loss of 9 kg, we found a small bowel mass. The histology of the tissue taken from small bowel mass was adenocarcinoma, poorly differentiated. The immunohistochemical stain of this specimen showed 75% positivity of estrogen receptor and 90% positivity of progesterone receptor. This is a case of small bowel metastasis from breast cancer and we report this case with a review of literatures.

[A case of portal vein thrombosis associated with acute pancreatitis and cholangitis].

Portal vein thrombosis is a rare complication accompanied with acute pancreatitis or cholangitis/cholecystitis. The main pathogenesis of portal vein thrombosis in pancreatitis or cholangitis/cholecystitis are suggested to be venous compression by pseudocyst and an imbalance between the blood coagulation and fibrinolysis. In this case report, we experienced a 63 year old male who developed portal vein thrombosis later in the course of the treatment of acute gallstone pancreatitis with cholangitis/cholecystitis without any symptom or sign. The diagnosis of portal vein thrombosis was given on follow up CT scan and serum protein S activity was decreased to 27% in laboratory study. Immediate anticoagulation therapy with heparin and thrombolytic therapy with urokinase and balloon dilatation were performed. Despite the aggressive treatment, complete reperfusion could not be obtained. With oral warfarin anticoagulation, the patient showed no disease progression and was discharged. We report a case of portal vein thrombosis as a complication of acute pancreatitis and cholangitis/cholecystitis with a review of literatures.

A case of the hepatocellular carcinoma during the pregnancy and metastasis to the left atrium.

A 28-year-old female with a pregnant state of 29th gestational week was admitted because of nausea and vomiting. MRI showed a huge hepatocellular carcinoma. At the 36th gestational week, a normal delivery was done. Surgery of hepatocellular carcinoma was done at 20 days after delivery. After 22 months from the operation, pulmonary metastasis was found and resection of lung mass was done. About 3 years after resection, a low attenuating nodule was detected in the left atrial chamber of heart. We report a case of hepatocellular carcinoma with metastatic lesions to lung and heart in a pregnant woman.

Short Term Virologic Efficacies of Telbivudine versus Entecavir against Hepatitis B-Related Hepatocellular Carcinoma.

Telbivudine has been reported to be more effective than lamivudine. However, because of the resistance rate to telbivudine (TLV), the current guidelines recommend entecavir (ETV) or tenofovir (TNV) as the first-line therapy for chronic hepatitis B. We investigated the short term virologic efficacy of TLV in comparison with ETV as the first-line agent of HBV suppression in HBV-related advanced HCC patients. A total of 86 consecutive patients with HBV-related HCC for whom antiviral treatment was initiated in Incheon St. Mary's Hospital between 2010 and 2013 were analyzed. Virologic responses were investigated on the 4th, 12th, and 24th weeks of the antiviral therapies. In patients with advanced TNM stage cancer (stage 3 or 4) and poor liver function (Child-Pugh class B or C), the virologic response rates at weeks 12 and 24 were 25% (1/4) and 42.8% (3/7) in the TLV group and 33.3% (1/3) and 33.3% (1/3) in the ETV group, respectively (P = 0.424, P = 0.800). The short term efficacy of TLV was similar to that of ETV. Since TLV is highly cost-effective, it should be considered as a first-line antiviral agent in patients with advanced HCC, poor liver function, and short life expectancies.

Reactivation of hepatitis B virus in HBsAg-negative patients with hepatocellular carcinoma.

BACKGROUND & AIMS: Despite increasing attention to hepatitis B virus (HBV) reactivation in hematologic settings, information on reactivation in hepatitis B surface (HBsAg)-negative patients with hepatocellular carcinoma (HCC) remains unknown. This study aimed to determine the incidence and risk factors of HBV reactivation in HBsAg-negative patients undergoing transarterial chemoembolization (TACE). METHODS: A total of 109 HBsAg-negative patients with HCC were consecutively recruited for this study and treated with either mono- (n = 75), combination-drug TACE (n = 20), or combination-drug TACE plus radiotherapy (n = 14). With serial monitoring of virological markers every 2-3 months, patients were observed for HBV reactivation (defined as the reappearance of HBV DNA or sero-reversion of HBsAg) in comparison with control subjects with HBsAg-negative cirrhosis (n = 16) or HBsAg loss (n = 46). RESULTS: During the study period, HBV reactivation occurred in 12 (11.0%) and 1 (1.6%) patients in the TACE and control groups, respectively. The median level of HBV DNA at reactivation was 5,174 copies/ml (range: 216-116,058). Of the 12 patients with HBV reactivation, four (33.3%) developed clinical hepatitis, including one patient who suffered from decompensation. All antiviral-treated patients achieved undetectable HBV DNA or HBsAg loss after commencement of antiviral drugs. TACE was significantly correlated with a high incidence of HBV reactivation, with increasing risk of reactivation with intensive treatment. On multivariate analysis, treatment intensity and a prior history of chronic hepatitis B remained independently predictive of reactivation. CONCLUSIONS: TACE can reactivate HBV replication in HBsAg-negative patients, with a dose-risk relationship between treatment intensity and reactivation. Patients with prior chronic HBV infection who are to undergo intensive TACE should be closely monitored, with an alternative approach of antiviral prophylaxis against HBV reactivation.

Obstruction of right ventricular outflow tract by extended cardiac metastasis from esophageal cancer.

We report a patient in whom there was right ventricular outflow tract obstruction by extended metastasis from esophageal cancer. A 65-year-old man was admitted to the hospital for evaluation of recent onset of weight loss and heart murmur. Esophagogram and endoscopy showed a 10-cm, ulcerative, infiltrative esophageal cancer. This esophageal cancer was histologically proven to be a squamous cell carcinoma. To assess the cardiac metastasis, echocardiography, magnetic resonance imaging, coronary angiography, and endomyocardial biopsy were performed. The magnetic resonance imaging, echocardiography, and right ventriculography revealed a 7-cm lobulated mass extending to the right ventricular outflow tract, right ventricle, septum, and anterior wall of the left ventricle. Interestingly, the feeding vessels of the tumor were identified by echocardiography and coronary angiography. Histologically, the cardiac tumor was proven to be have the same pathologic findings as esophageal cancer, compatible with carcinomatous metastasis.

[Usefulness of plasma tumor M2-pyruvate kinase in the diagnosis of gastrointestinal cancer].

BACKGROUND/AIMS: Pyruvate kinase (PK) is a key enzyme of glycolysis. Different isoforms of this enzyme are tissue-specifically expressed (M2-PK, M1-PK, R-PK, L-PK). The concentration of the dimeric M2-PK is increased in a metabolic state of tumor cells. In this case, the dimeric M2-PK is termed Tumor M2-PK. We investigated EDTA-plasma of 73 patients with gastrointestinal (GI) cancer and 61 healthy controls to evaluate its significance in diagnosing GI cancer. METHODS: Plasma Tumor M2-PK was measured using an ELISA assay based on two monoclonal antibodies which specifically react with the dimeric Tumor M2-PK. RESULTS: The sensitivity of Tumor M2-PK was 67.1% for all GI cancers, that of CA 19-9 was 38.4% and that of CEA was 34.3%. The specificity of Tumor M2-PK was 91.8% (cutoff=20 U/mL). Tumor M2-PK showed a high sensitivity in gastric cancer (62.2%), colorectal cancer (66.7%) and bile duct cancer (75.0%). In colorectal cancer, the combination of Tumor M2-PK with CEA resulted in a remarkable increase in the sensitivity (86.2%). The average Tumor M2-PK levels were generally elevated in the metastatic GI cancer patients compared to nonmetastatic patients, especially in stomach cancer with statistical significance (p=0.005). CONCLUSIONS: Tumor M2-PK in EDTA-plasma seems to be a new valuable tumor marker in GI cancer.

[Prediction of hepatic fibrosis using serum hyaluronic acid in patients with chronic liver disease].

BACKGROUND/AIMS: The extent of hepatic fibrosis is important in chronic liver disease. Liver biopsy is essential for diagnosis of fibrosis. However, biopsy is invasive and may not represent the whole liver state. Serum hyaluronic acid (HA), a major component of connective tissues, was introduced as a useful non-invasive index of hepatic fibrosis. The aim of this study was to evaluate the relationship among HA, the degree of fibrosis, several hematologic and biochemical parameters in patients with chronic liver diseases or post state liver transplantation (PSLT). METHODS: Total 102 cases were divided into 4 groups: 57 chronic hepatitis (CH), 12 cirrhosis, 21 hepatocellular carcinoma (HCC), 12 PSLT. HA was measured by enzyme-linked binding protein assay and evaluated in relation the degree of fibrosis, several hematologic and biochemical parameters. RESULTS: Among four groups, HCC showed the highest HA and HA of HCC significantly higher than that of CH. The degree of fibrosis were correlated with HA. HA was correlated with age, platelet count and albumin but, not with ALT and PT. There is no significant relation between HA and the presence of acute rejection in liver transplantation. CONCLUSIONS: In chronic liver diseases, HA is a useful non-invasive index of hepatic fibrosis and disease severity.

[A case of pheochromocytoma with hyperamylasemia].

Pheochromocytoma, a catecholamine-producing tumor of the chromaffin tissue, may present with various features. Herein, we report case of 66-year-old woman with pheochromocytoma accompanying hyperamylasemia and acute abdomen. She was admitted to another hospital due to myocardial infarction 5 months ago. At that time, pheochromocytoma was suggested on the basis of hormonal studies, but she refused surgical resection. When she came to our hospital, serum amylase level was 703 U/L. Subsequent studies revealed pancreatic type isoenzyme, and elevated lipase level. After normalization of serum amylase level, she undertook laparoscopic adrenalectomy. On pathologic examination, pheochromocytoma was confirmed. There are several cases of pheochromocytoma with hyperamylasemia. In general, the source of hyperamylasemia was thought to be pulmonary endothelial cells under ischemic damage caused by potent vasoconstrictive action of circulating catecholamines. In our case, analysis of isoenzymes and serum lipase level suggest that hyperamylasemia can originate from the pancreas. Thus, pancreatitis also should be considered when serum amylase level is elevated in pheochromocytoma.

[A study for clinical correlation of neuropsychological test and brain magnetic resonance spectroscopy in patients with minimal hepatic encephalopathy].

BACKGROUND/AIMS: The aim of the study was to correlate neuropsychological test results with regional cerebral biochemistry determined by magnetic resonance spectroscopy (MRS) in patients with minimal hepatic encephalopathy (MHE). METHODS: The patients with liver disease were divided into 4 groups; group 1 chronic hepatitis; group 2, liver cirrhosis (LC) without a history of HE; group 3, LC with a history of HE of no manifestation, and group 4, LC with overt HE. All patients were examined using neuropsychological tests and brain MRS. RESULTS: Trail making, Digit span, Digit symbol, and Peg board test in groups 2 and 3 were significantly different compared with control. These neuropsychological tests were regarded more available test for diagnosis of MHE. In the LC patients, compared with control, MRS results showed a typical pattern with decrease of myoinositol/Cr (0.24+/-0.24 vs. 0.68+/-0.10, p<0.05) and increased glutamine-glutamate/Cr (2.97+/-0.80 vs. 1.94+/-0.47, p<0.05). The difference of myoinositol/Cr and glutamine-glutamate/Cr between patients with MHE and control was statistically significant (0.16+/-0.15 vs. 0.68+/-0.10, 3.11+/-0.72 vs. 1.94+/-0.47, p<0.05). CONCLUSIONS: Neuropsychological tests and MRS maybe useful for diagnosing MHE.