Hepatic resection for primary giant leiomyoma of the liver

Background

Smooth muscle tumours are common in the genito-urinary and gastro-intestinal tracts, but primary leiomyoma of the liver is extremely rare. Only a few cases have been reported to date.

Case outline

We report a case of giant leiomyoma of the liver in a 67-year-old woman that was treated by an extended right hepatectomy. There was no evidence of leiomyoma elsewhere in the abdomen (including the uterus).

Discussion

This appears to be the largest hepatic leiomyoma reported in the literature.     

Hepatic resection for benign tumours of the liver

The most frequent benign tumours of the liver include haemangioma, liver cell adenoma and focal nodular hyperplasia. Patients may undergo hepatic resection because of a preoperative diagnosis of malignancy or uncertainty in diagnosis despite an extensive work-up.     

Ultrasound liver elastography beyond liver fibrosis assessment

Several guidelines have indicated that liver stiffness(LS) assessed by means of shear wave elastography(SWE) can safely replace liver biopsy in several clinical scenarios, particularly in patients with chronic viral hepatitis. However, an increase of LS may be due to some other clinical conditions not related to fibrosis,such as liver inflammation, acute hepatitis, obstructive cholestasis, liver congestion, infiltrative liver diseases. This review analyzes the role that SWE can play in cases of liver congestion due to right-sided heart failure, congenital heart diseases or valvular diseases. In patients with heart failure LS seems directly influenced by central venous pressure and can be used as a prognostic marker to predict cardiac events. The potential role of LS in evaluating liver disease beyond the stage of liver fibrosis has been investigated also in the hepatic sinusoidal obstruction syndrome(SOS) and in the Budd-Chiari syndrome. In the hepatic SOS, an increase of LS is observed some days before the clinical manifestations;therefore, it could allow an early diagnosis to timely start an effective treatment.Moreover, it has been reported that patients that were successfully treated showed a LS decrease, that reached pre-transplantation value within two to four weeks. It has been reported that, in patients with Budd-Chiari syndrome, LS values can be used to monitor short and long-term outcome after angioplasty.     

The role of Doppler Perfusion Index as screening test in the characterization of focal liver lesions

PURPOSE: Doppler Perfusion Index (DPI) has been used in the detection of overt liver metastatic disease. In the present prospective study we evaluated the use of DPI in the differential diagnosis of liver tumours. MATERIALS AND METHODS: We have included in our study 76 patients with focal hepatic lesion and 39 subjects as control group. All patients were evaluated by Color Doppler Ultrasound, and/or Spiral Computerised Tomography, Magnetic Resonance Imaging and biopsy. The radiologist performed DPI measurements was blind from the final diagnosis of the other methods. RESULTS: DPI measurements in the control group ranged from 0.07 to 0.22 (mean value 0.14), in 42 cases with benign lesions (group A) ranged from 0.05 to 0.53 (mean 0.15) and in 34 cases with malignant lesions (group B) ranged from 0.39 to 0.75 (mean 0.53). There was a statistically significant difference in DPI measurements between the control group and group B. CONCLUSIONS: Our results suggest that the DPI may differentiate malignant from benign focal hepatic lesions and therefore can be used as a screening test in the routine clinical practice.     

Synchronous bleeding of liver adenomatosis and possible relation to acoustic trauma

BackgroundSolitary hepatic adenoma is a rare tumour but adenomatosis of the liver is even less common; it has been defined arbitrarily as more than four adenomas within otherwise normal hepatic parenchyma. Usually asymptomatic, the main clinical presentation is abdominal pain secondary to bleeding from the tumour.Case outlineA 40-year-old woman admitted for abdominal pain and operated within a few hours due to circulatory instability was found to have synchronous bleeding from three out of four liver cell adenomas. The onset of pain followed shortly after exposure to particularly loud music. The three bleeding tumours were enucleated. The fourth lesion was left in situ; during outpatient follow-up it decreased in size and eventually disappeared.DiscussionAlthough rupture with bleeding is a well-known presentation of liver cell adenomas, synchronous bleeding from more than one tumour is exceedingly uncommon and this may be the first reported case. Enucleation of the tumour is easy to perform even during active bleeding. Small asymptomatic tumours may be followed without surgical intervention.     

Resection of the liver for colorectal carcinoma metastases

In this review of a collected series of patients undergoing hepatic resection for colorectal metastases, 100 patients were found to have survived greater than five years from the time of resection. Of these 100 long-term survivors, 71 remain disease-free through the last follow-up, 19 recurred prior to five years, and ten recurred after five years. Patient characteristics that may have contributed to survival were examined. Procedures performed included five trisegmentectomies, 32 lobectomies, 16 left lateral segmentectomies, and 45 wedge resections. The margin of resection was recorded in 27 patients, one of whom had a positive margin, nine of whom had a less than or equal to 1-cm margin, and 17 of whom had a greater than 1-cm margin. Eighty-one patients had a solitary metastasis to the liver, 11 patients had two metastases, one patient had three metastases, and four patients had four metastases. Thirty patients had Stage C primary carcinoma, 40 had Stage B primary carcinoma, and one had Stage A primarycarcinoma. The disease-free interval from the time of colon resection to the time of liver resection was less than one year in 65 patients, and greater than one year in 34 patients. Three patients had bilobar metastases. Four of the patients had extrahepatic disease resected simultaneously with the liver resection. Though several contraindications to hepatic resection have been proposed in the past, five-year survival has been found in patients with extrahepatic disease resected simultaneously, patients with bilobar metastases, patients with multiple metastases, and patients with positive margins. Five-year disease-free survivors are also present in each of these subsets. It is concluded that five-year survival is possible in the presence of reported contraindications to resection, and therefore that the decision to resect the liver must be individualized. John Radcliffe Infirmary, Oxford, England Read at the meeting of the American Society of Colon and Rectal Surgeons, Washington, D.C., April 5 to 10, 1987. Supported in part by Cooper Laser Sonics, Inc.     

Surgical treatment of malignant liver tumours

Surgical resection is the mainstay of treatment for malignant liver tumours and offers the only chance of cure. Advances in radiological imaging, surgical technique and peri-operative management have enabled liver resection to be performed safely. Partial hepatectomy is indicated for the treatment of hepatocellular carcinoma and hepatic metastases from colorectal cancer. In addition, it may be utilized for selected patients with liver metastases from other primary tumours. Total hepatectomy with transplantation may be of benefit in some patients with unresectable neuroendocrine metastases or small hepatocellular carcinomas. The role of cryosurgery has not been precisely defined, and it needs to be compared with other palliative therapies such as ethanol injection and hepatic artery embolization.     

Two-stage liver transplant for ruptured hepatic adenoma:A case report

BACKGROUND Only one case of liver transplantation for hepatic adenoma has previously been reported for patients with rupture and uncontrolled hemorrhage.We present the case of a massive ruptured hepatic adenoma with persistent hemorrhagic shock and toxic liver syndrome which resulted in a two-stage liver transplantation.This is the first case of a two-stage liver transplantation performed for a ruptured hepatic adenoma.CASE SUMMARY A 23 years old African American female with a history of pre-diabetes and oral contraceptive presented to an outside facility complaining of right-sided chest pain and emesis for one day.She was found to be in hemorrhagic shock due to a massive ruptured hepatic hepatic adenoma.She underwent repeated embolizations with interventional radiology with ongoing hemorrhage and the development of renal failure,hepatic failure,and hemodynamic instability,known as toxic liver syndrome.In the setting of uncontrolled hemorrhage and toxic liver syndrome,a hepatectomy with porto-caval anastomosis was performed with liver transplantation 15 h later.She tolerated the anhepatic stage well,and has done well over one year later.CONCLUSION When toxic liver syndrome is recognized,liver transplantation with or withouthepatectomy should be considered before the patient becomes unstable.     

原发性肝癌合并肝囊型棘球蚴病1例

本文报道1例原发性肝癌合并肝囊型棘球蚴病病例的诊治经过。患者因“间断性上腹部不适半月余”收治入院,行辅助检查提示原发性肝癌合并肝囊性棘球蚴病,行肝动脉灌注化疗栓塞术,囊型棘球蚴病病灶未处理,术后患者肝功能明显好转。     

肝衰竭/重型肝炎的研究进展

本文对肝衰竭／重型肝炎的新进进行综述。在定义上倾向于将急性肝衰竭与慢性肝衰竭及脑病型与非脑病型分开；对新近提出的终末期肝病模型（MELD）预后判断公式进行评价；应用拉米夫定（LAM）治疗伴乙型肝炎病毒（HBV）复制的肝衰竭有效，但肝炎肝硬化患者因不当停药所致肝功能不全患者有所增多；LAM加乙型肝炎病毒免疫球蛋白（HBIg)预防肝移植后HBV感染有效，但其逸逸株有增多趋势；当前国际上将肝性脑病（HE）分为三种类型，A型为急性肝衰竭相关HE（ALFA－HE），B型为不伴有内在肝病的门体分离，C型指在慢性肝病／肝硬化基础上发生的HE。     

Surgery of liver tumours

The liver is a segmental organ that allows resection through anatomically defined planes. The surgical management of an intrahepatic lesion, discovered either during investigation of hepatological symptoms or coincidentally, must involve an approach to investigation that carries a minimum risk and does not compromise subsequent excision of the lesion. Biopsy of an intrahepatic lesion found at laparotomy is essential, but attempts at early tissue diagnosis by percutaneous biopsy of operable tumours may lead to unnecessary morbidity and tumour spread. Preoperative studies often allow a firm pathological diagnosis to be made and ultrasonography, CT scanning and arteriography can be used to fully assess operability. Hepatocellular carcinoma (HCC) is the commonest primary liver cancer and is often found in association with cirrhosis and in patients with inadequate functional hepatic reserve. Surgical excision represents the only hope of cure for these patients and a 35% 5-year survival can be achieved by resection in the non-cirrhotic patient. Fibrolamellar HCC is less often associated with cirrhosis and is more often resectable with a better prognosis. Secondary tumours are often diffuse but about 5% of colorectal metastases are either solitary or confined to a resectable area of the liver. These tumours and secondary deposits from gastrointestinal endocrine tumours represent a small group of patients with potentially curable metastatic disease. Morbidity and mortality of operation depends on the extent of resection and the functional reserve of the liver. Local resections and resection for benign disease should carry no operative mortality. Major hepatic resection has a mortality of 3-5% and resection involving the structures at the hilus of the liver has an operative mortality of 10-12%. Liver transplantation in the management of neoplastic disease in the liver has yet to show any benefit over resectional surgery except where tumours have been discovered incidentally in the removed liver after transplantation for cirrhosis.     

Role of cannabinoids in chronic liver diseases

Cannabinoids are a group of compounds acting primarily via CB1 and CB2 receptors. The expression of cannabinoid receptors in normal liver is low or absent. However, many reports have proven up-regulation of the expression of CB1 and CB2 receptors in hepatic myofibroblasts and vascular endothelial cells, as well as increased concentration of endocannabinoids in liver in the course of chronic progressive liver diseases. It has been shown that CB1 receptor signalling exerts profibrogenic and proinflammatory effects in liver tissue, primarily due to the stimulation of hepatic stellate cells, whereas the activation of CB2 receptors inhibits or even reverses liver fibrogenesis. Similarly, CB1 receptor stimulation contributes to progression of liver steatosis. In end-stage liver disease, the endocannabinoid system has been shown to contribute to hepatic encephalopathy and vascular effects, such as portal hypertension, splanchnic vasodilatation, relative peripheral hypotension and probably cirrhotic cardiomyopathy. So far, available evidence is based on cellular cultures or animal models. Clinical data on the effects of cannabinoids in chronic liver diseases are limited. However, recent studies have shown the contribution of cannabis smoking to the progression of liver fibrosis and steatosis. Moreover, controlling CB1 or CB2 signalling appears to be an attractive target in managing liver diseases.     

Primary hepatic neuroendocrine tumour requiring live donor liver transplantation: case report and concise review

Primary hepatic neuroendocrine tumours are rare tumours effecting relatively young patients. As metasta- tic neuroendocrine tumours to the liver are much more common, extensive investigations are crucial to exclude a primary tumour elsewhere. We report a case of a 27 year old woman who presented with fati- gue, increased abdominal girth and feeling of early satiety and bloating. Extensive work up failed to show tumour at another primary site. Hepatic artery embolization showed no effect, so the patient underwent total hepatectomy and live-donor liver transplant. Grossly the tumour measured 27 cm. Microscopic exami- nation showed bland, monomorphic cells growing in tubuloglandular and trabecular growth patterns. Cells were positive for neuroendocrine (synaptophysin, chromogranin, CD56) and epithelial markers (MOC31, CK7, CK19). Cytoplasmic dense neurosecretory vesicles were seen on ultrastructural examination. Based on the Ki-67 rate, mitotic count, lack of marked nuclear atypia and absence of necrosis, a diagnosis of primary neuroendocrine grade 2 was conferred.     

Parvovirus B19 induced hepatic failure in an adult requiring liver transplantation

Parvovirus B19 induced acute hepatitis and hepatic failure have been previously reported, mainly in children. Very few cases of parvovirus induced hepatic failure have been reported in adults and fewer still have required liver transplantation. We report the case of a 55-year-old immunocompetent woman who developed fulminant hepatic failure after acute infection with Parvovirus B19 who subsequently underwent orthotopic liver transplantation. This is believed to be the first reported case in the literature in which an adult patient with fulminant hepatic failure associated with acute parvovirus B19 infection and without hematologic abnormalities has been identified prior to undergoing liver transplantation. This case suggests that Parvovirus B19 induced liver disease can affect adults, can occur in the absence of hematologic abnormalities and can be severe enough to require liver transplantation.     

Application of radionics on primary and metastatic tumours of the liver

The aim of our study is to present our initial experience on the use of radiofrequency ablation (RFA) on hepatic tumours. Four patients with tumours of the liver were submitted to RFA. The first patient underwent an emergency left lobectomy due to rupture of a tumour of the left hepatic lobe. A synchronous tumour was detected on the right lobe. He has been submitted to four sessions of RFA. The second patient was submitted to transverse colon resection (adenocarcinoma) and a year later three metastatic tumours were detected. Two sessions of RFA have been applied in this case. The third patient, with adenocarcinoma of the sigmoid and one metastatic lesion on the right hepatic lobe, and the fourth patient with breast cancer and metastatic lesion of the liver, underwent one session of RFA each. The use of RFA on metastatic or primary tumours of the liver enriches the possibilities of therapeutic treatment.     

Laparoscopic management of benign liver diseases: where are we?

BACKGROUND: The role of laparoscopic surgery in the management of benign cystic and solid liver tumours appears to differ according to each tumour type. As regards congenital liver cysts, laparoscopic treatment is now the gold standard for treating selected, huge, accessible, highly symptomatic or complicated cysts. In contrast, the laparoscopic approach is not useful for patients suffering from adult polycystic liver disease (PLD), except for type I PLD with large multiple hepatic cysts. For benign hepatocellular tumours, the surgical management has recently benefited from a better knowledge of the natural history of each type of tumour and from the improvement of imaging techniques in assuring a precise diagnosis of tumour nature. Thus the general tendency has led to a progressive restriction and tailoring of indications for resection in benign liver tumours, selecting only patients with huge, specifically symptomatic or compressive benign tumours or patients suffering from liver cell adenoma. Despite the enthusiastic use of the laparoscopic approach, selective indications for resection of benign liver tumours should indeed remain unchanged. For all types of benign liver tumours, the best indication remains small, superficial lesions, located in the anterior or the lateral segments of the liver. Deep, centrally located lesions or tumours in contact with major vascular or biliary trunks are not ideal candidates for laparoscopic liver resections. When performed by expert liver and laparoscopic surgeons using an adequate surgical technique, the laparoscopic approach is safe for performing minor liver resections and is accompanied by the usual postoperative benefits of laparoscopic surgery. When applied in selected patients and tumours, laparoscopic management of benign liver diseases appears to be a promising technique for hepatobiliary surgeons.     

Primary hepatic carcinoid tumours

BACKGROUND: Carcinoid tumours of the liver are predominantly metastases from the gastrointestinal tract. Primary hepatic carcinoids are extremely rare. DISCUSSION: In contrast to metastases, primary hepatic carcinoids are usually solitary and resectable. It is important that these tumours are differentiated from metastases. Complete surgical resection should be contemplated and is generally curative.     

Hepatic lymph node involvement in resected cases of liver metastases from colorectal cancer

PURPOSE: Lymph node metastasis in the hepatoduodenal ligament is known as one of the most significant prognostic factors after liver resection for colorectal metastasis. However, there have been very few articles on the clinical features of node-positive patients and on detailed distribution of positive nodes. Further, there has been no established strategy on how to handle hepatic lymph nodes during liver resection. To address these subjects, a retrospective study was conducted. METHODS: During the period of 1980 through April 1998, 182 hepatic resections were performed for metastatic colorectal carcinoma. Of these, 78 cases had hepatic lymph node sampling during the operation. Distribution of positive nodes, location of liver metastasis, stage of the primary lesion, and outcome after liver resection were analyzed. RESULTS: Nine cases (12 percent) had secondary lymph node metastases in the hepatoduodenal ligament. The incidence was slightly higher (13.5 percent) in the most recent 44 consecutive cases. There was a tendency for liver metastases in the right lobe to metastasize to No. 12b (or node of the foramen of Winslow, lymph nodes along the common bile duct) and liver metastases in the left lobe to metastasize to No. 8a (anterosuperior group of the lymph nodes along the common hepatic artery). Outcome of node-positive patients (n=9) was extremely poor (P<0.001) compared with that of node-negative patients (n=66), and the most common site of recurrence in the node-positive patients was remnant liver and hepatic lymph nodes. Preoperatively, there were no significant predicting factors for positive hepatic lymph nodes. CONCLUSIONS: No. 8a and No. 12b nodes are principal nodes that should be palpated and sampled during liver resection to check the secondary lymphatic spread from liver metastases. Hepatic nodal involvement indicates the progression of disease beyond simple liver metastases and may not be the indication for simple surgical removal. Further study, including hepatoduodenal dissection and systemic adjuvant chemotherapy, may elucidate the survival benefit, if any, of liver resection in node-positive patients.     

Hypoxia,angiogenesis and liver fibrogenesis in the progression of chronic liver diseases

Angiogenesis is a dynamic,hypoxia-stimulated and growth factor-dependent process,and is currently referred to as the formation of new vessels from preexisting blood vessels.Experimental and clinical studies have unequivocally reported that hepatic angiogenesis,irrespective of aetiology,occurs in conditions of chronic liver diseases(CLDs) characterized by perpetuation of cell injury and death,inflammatory response and progressive fibrogenesis.Angiogenesis and related changes in liver vascular architecture,th...