Extrahepatic biliary obstruction caused by metastatic breast carcinoma.

We describe our experience with seven patients who had extrahepatic biliary obstruction caused by metastatic breast cancer. The interval from the original diagnosis of breast cancer to the development of jaundice averaged 40 months, with a range of 9 months to 8 years. All patients were treated with surgical decompression, radiation, transhepatic catheter drainage, chemotherapy, or a combination of these modalities. Resolution of jaundice was achieved in six patients. Prolonged survival was realized in three; one patient lived for more than 6 years after surgical bypass, and two are alive and well at present (greater than 11 months after relief of biliary obstruction). Extrahepatic biliary obstruction by metastatic breast carcinoma should be distinguished from jaundice due to hepatic parenchymal destruction by this tumor; while the latter implies end-stage cancer, the former has the potential for significant palliation and prolonged survival.     

Self-expandable metallic stents for malignant duodenal obstruction caused by biliary tract cancer

BACKGROUND: Malignant duodenal obstruction is a common event in patients with advanced biliary tract cancer. Because bypass surgery is accompanied by significant morbidity, self-expandable metallic stents have emerged as a possible alternative for palliation. METHODS: Twenty patients with biliary tract cancer (7 gallbladder, 13 Klatskin tumors) and duodenal obstruction were treated with metallic stents at a single institution between 1999 and 2001. Survival, morbidity, and stent function were studied prospectively. The ability to eat was assessed by using a scoring system. RESULTS: Stent placement was technically successful in all patients. An additional stent was required in 6 cases (4 occlusions, 2 dislocations). Median survival was 20.5 weeks; there was no treatment-related death. Twenty-eight biliary stent exchanges were performed in 13 (65%) patients. Erosive reflux esophagitis improved in 11 of 12 (92%) cases. After 4 weeks, all 17 surviving patients tolerated soft or solid food, whereas 13 of 17 (77%) tolerated a more solid diet (p < 0.001, gastric outlet obstruction scoring system). Twelve of 17 (71%) patients gained a median of 1.5 kg of body weight (p = 0.001). The median Karnofsky scale increased from 50% to 60% in 13 of 17 (77%) patients. CONCLUSIONS: Self-expandable metallic stents are a safe, efficacious, and minimally invasive treatment option for palliation of patients with duodenal obstruction from biliary tract cancer. Technical complications can be managed endoscopically and the bile duct remains accessible for endoluminal treatment.     

Pathology of small-cell lung cancer

The morphological differentiation between small-cell and non-small-cell lung cancer has great prognostic and therapeutic significance for the patient. Malignant lung tumors are now classified according to the new 1999 WHO/IASLC classification of lung and pleural tumors. The variant of heterogeneously differentiated “combined small-cell carcinoma” can be distinguished from classical small-cell carcinoma, whereas the subtype of “intermediate cell carcinoma” is no longer used. Together with “large-cell neuroendocrine carcinomas” and typical or atypical carcinoid tumors, small-cell lung cancers are currently histogenetically categorized as neuroendocrine lung tumors. In contrast to large-cell neuroendocrine carcinoma, the immunohistochemical demonstration of neuroendocrine differentiation is not a prerequisite for the diagnosis of small-cell lung cancer. Although electron-microscopical, immunohistochemical, and molecular-biological findings have considerably increased our understanding of the pathogenesis and progression of malignant lung tumors, routine pathological-anatomical diagnostics are still decisively based on light-microscopical evaluation of tissue samples. Received: 15 February 2000 / Accepted: 17 February 2000     

Treatment of small-cell lung cancer

Treatment of small cell lung cancer (SCLC) is based on the stage of disease. While combination of chemo- and radiotherapy preferably as concomitant chemoradiotherapy represents standard treatment in patients with locally advanced tumors (UICC stage I-III), patients with metastatic disease (stage?IV) should be treated with an established platinum based chemotherapy regimen. After chemotherapy and in case of an achieved tumor response treatment should be completed by an adjuvant radiation of the brain in patients with adequate performance status. In patients with a very early stage of disease without involvement of lymph node metastasis a surgical approach in combination with an adjuvant chemotherapy can be discussed. In patients with relapsed tumors second line therapies like the topoisomerase I inhibitor Topotecan have proven efficacy. Up to now neither molecular targeted therapies nor cytotoxic or immunological maintenance strategies have provided any benefit to patients with SCLC.     

An unusual case of biliary obstruction caused by Dicrocoelium dentriticum

Dicrocoelium dentriticum (D. dentriticum) is a liver fluke induced biliary obstruction. Infection usually occurs in herbivores such as sheep, goats and deer; human infection is very rarely encountered in clinical practice. We report on a 65-y-old female presenting with biliary obstruction caused by D. dentriticum. Following treatment with triclobendazole, her symptoms disappeared, and laboratory values returned to normal range within 6 months. Parasitosis is an important cause of biliary obstruction. We suggest that for patients presenting with biliary obstruction, D. dentriticum should be included in the differential diagnosis.     

Extrahepatic biliary obstruction versus intrahepatic disorder. Differentiation with hepatobiliary scintigraphy and ultrasonography

In 43 patients with various hepatobiliary disorders, we compared retrospectively the sensitivity and specificity of hepatobiliary scintigraphy and ultrasonography in diagnosing extrahepatic biliary obstruction. Hepatic uptake of radioactivity from the circulation was assessed by early scintiscan at 2 min, and the clearance ratio was combined with transit time in the interpretation of hepatobiliary scintiscans. The transit time was defined as the time taken by detectable radioactivity to appear in the extrahepatic biliary tree or small intestine, whichever occurred sooner. The sensitivity and specificity were 92% and 97%, respectively. However, the specificity dropped to 74% when biliary-bowel transit time, i.e., time taken for detectable radioactivity to appear in small intestine only, was used instead of transit time in the interpretation of the scintiscans. The sensitivity and specificity of ultrasonography were 55% and 94%, respectively. We conclude that hepatobiliary scintiscan is more sensitive than ultrasonography and is reliable for diagnosing extrahepatic biliary obstruction when it is done and interpreted by the method described here.     

Extrahepatic portal vein obstruction

Extrahepatic portal vein obstruction (EHPVO) is an important cause of noncirrhotic portal hypertension, especially in Third World countries. The etiology and clinical presentation are different in children and adults. The portal vein is transformed into a cavernoma, resulting in portal hypertension and oesophagogastic varices. In addition, extensive collateral circulation develops, involving paracholecystic, paracholedochal and pancreaticoduodenal veins resulting in formation of ectopic varices, and portal biliopathy. Besides variceal bleeding, which is the commonest presentation, patients may have symptomatic portal biliopathy, hypersplenism, and growth retardation. Although the liver may appear normal, functional compromise develops in the long term. Variceal bleeding in EHPVO can be successfully managed by endoscopic obliteration of varices, which has low morbidity but requires repeated visits, or by portosystemic shunt surgery, which provides good control of bleeding, possibly helps growth retardation, hypersplenism, and protects against future development of portal biliopathy but is associated with surgical mortality and is sometimes not feasible due to nonavailability of a satisfactory vessel.     

Uterine metastasis of a small-cell lung cancer

Despite a very poor prognosis of small cell lung cancer, recent advances in chemotherapy produced long-term survivors requiring a high level of surveillance. Indeed, it is becoming more important to identify earlier unusual sites of tumoral recurrence. We report the first case of uterine metastasis of a small cell lung carcinoma.     

Pyogenic liver abscess after choledochoduodenostomy for biliary obstruction caused by autoimmune pancreatitis

INTRODUCTION The differentiation of autoimmune pancreatitis (AIP) from pancreatic cancer is sometimes difficult because these diseases share many clinical features[1]. When pancreatic cancer cannot be ruled out, laparotomy or pancreatic resection may be p…     

Spontaneous hemothorax caused by lung cancer

Spontaneous hemothorax is an extremely rare complication of malignant disease. We describe the case of a 26-year-old man with spontaneous hemothorax secondary to large-cell carcinoma of the lung, with liver and bone metastases. The patient died in the fifth week after hospitalization.     

Taste thresholds in patients with small-cell lung cancer

Summary Recognition thresholds for the four basic tastes (salt, sour, sweet and bitter) were tested by the forced-choice technique in 27 patients with small-cell lung cancer, and 22 weight-matched control patients with non-malignant diseases. No significant differences in threshold concentrations could be demonstrated. When patients who were losing weight were compared with weight-stable patients, significantly lower taste thresholds for bitter substances were found in weight losing groups in both cancer and control patients. Small-cell lung cancer patients who responded to therapy had obtained an increased threshold for bitter taste at the time of reevaluation than at the time of diagnosis, an effect that may be explained by the chemotherapeutic regimen. The results suggest that in patients with small-cell lung cancer it is not the cancer disease per se but the weight loss that often accompanies it that causes an increased taste sensitivity for bitter substances.Abbreviations SCLC small-cell lung cancer     

Reversible Kupffer cell suppression in biliary obstruction is caused by hydrophobic bile acids

BACKGROUND/AIM: Biliary obstruction is associated with suppressed Kupffer cell clearance of bacteria and intracellular bactericidal activity of the phagocytes. We studied the superoxide generation of Kupffer cell in biliary obstruction and after incubation with bile acids to elucidate the mechanism of impaired intracellular killing of these phagocytes. METHODS: Kupffer cells were extracted from rats with common bile duct ligation or sham-operation. The extracted cells were tested for superoxide production immediately after extraction, 2 h and 24 h post-extraction. Superoxide generation from Kupffer cells after incubation with five bile acids (cholic acid, taurocholic acid, deoxycholic acid, chenodeoxycholic acid and ursodeoxycholic acid) at two different concentrations (0.1 mM and 1.0 mM) were also studied. Cell viability was monitored by trypan blue exclusion. RESULTS: Kupffer cells extracted from common duct-ligated animals had significantly lower superoxide production (-1.37+/-0.24 nmol O2(-)/10(6) cells) compared to that from sham-operated rats (2.54+/-0.58 nmol O2(-)/10(6) cells) and non-operated rats (2.15+/-0.76 nmol O2(-)/10(6) cells) (p<0.05). After 2 h of resting in culture medium, these cells recovered significantly in superoxide production to 2.72+/-0.63 nmol O2(-)/10(6) cells (p<0.01). A dose-related reduction in superoxide production was demonstrated when Kupffer cells were incubated with bile acids. Hydrophobic bile acids (deoxycholic acid and chenodeoxycholic acid) caused more significant suppression than with hydrophilic bile acids (cholic acid, taurocholic acid, ursodeoxycholic acid). The drop in superoxide production after bile acid treatment was not due to cell death. Washing in Hank's balanced salt solution resulted in partial recovery of Kupffer cell superoxide production. CONCLUSION: High blood levels of hydrophobic bile acids are likely to be the cause of impaired intracellular bactericidal activity of Kupffer cells in biliary obstruction.