Spontaneous regression of a large liver tumor with markedly elevated serum enzyme levels

The case of a liver tumor of 10 cm diameter in a 32-year-old asymptomatic woman is described with markedly elevated liver enzymes in the serum (transaminases and alkaline phosphatase). The tumor corresponded to a focal nodular hyperplasia or a hepatic adenoma. The regression of this hepatic tumor over a time period of 18 months after discontinuation of oral contraceptives was observed as well as a complete normalisation of laboratory findings. It is concluded that conservative management after withdrawal of hormonal contraception my be the preferable treatment for hepatic adenoma and focal nodular hyperplasia.     

Resolution of a contraceptive-steroid-induced hepatic adenoma with subsequent evolution into hepatocellular carcinoma

The very rare event of 3 types of liver neoplasia occurring at different times and locations in a user or oral contraceptives is reported. The woman developed benign hepatic adenoma at 36 years of age in 1977 after using pills for 14 years. She had taken a combination of norethindrone and mestranol for the last 7 years. The tumor was 13 cm in diameter and extensively involved the inferior suface of the right lobe. She discontinued pills, the tumor resolved, and she remained well. In 1984 a necrotic hemorrhagic mass with a thick fibrous capsule was then found at the same site. It was a poorly differentiated hepatocellular carcinoma. During a second laparotomy 2 months later for curative resection, another nodular mass 2 cm in diameter was found on the left lobe, apparently a focal nodular hyperplasia. 9 months later several tumor implants appeared on the serosal surface of the transverse colon, metastatic hepatocellular carcinoma. After partial colectomy the woman has been free of tumors for 2 years. The literature on the few cases of malignant transformation of adenomas associated with contraceptive steroids is discussed. Even though such adenomas usually resolve after discontinuation of the pill, patients should probably be followed with ultrasound over several years.     

Portal vein aneurysm associated with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt: A case report

A 65-year-old woman with Budd-Chiari syndrome(BCS) presented with right upper quadrant pain.A computed tomography(CT) scan showed a saccular aneurysm located at the extrahepatic portal vein main branch measuring 3.2 cm in height and 2.5 cm × 2.4 cm in diameter.The aneurysm was thought to be associatedwith BCS as there was no preceding history of trauma and it had not been present on Doppler ultrasound examination performed 3 years previously.Because of increasing pain and concern for complications due to aneurysm size, the decision was made to relieve the hepatic venous outflow obstruction.Transjugular intrahepatic portosystemic shunt(TIPS) was created without complications.She had complete resolution of her abdominal pain within 2 d and remained asymptomatic after 1 year of follow-up.CT scans obtained after TIPS showed that the aneurysm had decreased in size to 2.4 cm in height and 2.0 cm × 1.9 cm in diameter at 3 mo, and had further decreased to 1.9 cm in height and 1.6 cm × 1.5 cm in diameter at 1 year.     

Association of hepatocellular adenoma and focal nodular hyperplasia of the liver in a woman on oral contraceptives

The case of a 37-year old woman with no previous pathology who developed liver adenoma and focal nodular hyperplasia after taking various oral contraceptive (OC) combined preparations over 15 years is described. The woman was hospitalized after discovery of a mass in the right hypochondrium. Other clinical findings were normal. During laparotomy 2 hepatic tumors were found: a mass 10 cm in diameter in the right lobe found at histological examination to be a focal nodular hyperplasia, and a mass 1 cm in diameter discovered fortuitously in the left lobe and which demonstrated the histological characteristics of a hepatic adenoma. The role of OCs in the development of hepatic adenomas is supported by epidemiological evidence, but the relationship between pills and focal nodular hyperplasia is much less clear. Although they occur in men and children, their development and the appearance of occasionally serious hemorrhagic complications appear to be encouraged by OCs. The complications are probably due to the vascular modifications observed in the tumor during OC use. The association of the 2 types of tumor in 1 patient has apparently been reported only once previously. Various hypotheses may be advanced to explain the occurrence.     

Hepatocellular adenoma in a male with familial adenomatous polyposis coli

Hepatocellular adenoma (HA) is a benign liver tumor most frequently occurring in young women using oral contraceptives. We report a rare case of HA in a 27-year-old male patient with familial adenomatous polyposis (FAP). The patient underwent a total colectomy and ileo-rectal anastomosis for FAP in 2003. A preoperative computed tomography scan of the abdomen disclosed a tumor in the left-lobe of the liver, 5.8 cm in diameter. Pathologic examination of a needle biopsy disclosed HA, but he had never used anabolic steroids or other known inducers of HA. The size of the liver mass gradually increased to 8.5 cm during a follow-up period of 38 months, and a left hepatectomy was performed in 2006. Pathology of the resected specimen confirmed the diagnosis of HA. Although FAP is known to be complicated with neoplasia in various extracolonic organs, only five reported cases of HA have developed in patients with FAP, including this case. This is the first report of HA to develop in a male FAP patient.     

Systemic AA amyloidosis induced by oral contraceptive-associated hepatocellular adenoma: a 13-year follow up

Abstract: We report a case of a woman who showed hepatic and renal AA amyloidosis with a liver adenoma associated with the use of oral contraceptives. A nephrotic syndrome secondary to the renal amyloidosis underwent complete remission 7 years after the withdrawal of oral contraceptive therapy. Twenty-nine months after the initial presentation, the patient was admitted with acute upper abdominal pain and abdominal tenderness. The abdominal ultrasound revealed a subphrenic fluid collection, and a presumptive diagnosis of a ruptured hepatic adenoma was made. The liver adenoma diminished from 8 cm to 1 cm over a 13-year follow up after the discontinuance of oral contraceptive therapy.     

Association of focal nodular hyperplasia and hepatic hemangioma

The association between hepatic hemangioma and focal nodular hyperplasia has been occasionally reported. To evaluate the reality of this association, the prevalence of hemangioma was studied in 26 patients with focal nodular hyperplasia by comparison with 27 patients with hepatocellular adenoma. All of these patients underwent surgery, which provided the histologic confirmation of the type of tumor. The presence of hemangioma was assessed by preoperative ultrasonography, dynamic computed tomography, and pathological examination of resected liver specimens. No hemangioma was found in patients with hepatocellular adenoma, but 6 of the 26 patients with focal nodular hyperplasia (23%) had one or two associated hemangiomas that varied in size from 1.5 to 4 cm. All 6 patients having focal nodular hyperplasia and hemangioma were women who had previously used oral contraceptives. None of the patients who had not used oral contraceptives had this association. Moreover, oral contraceptives were taken for a significantly longer period by the women with focal nodular hyperplasia and hemangioma than by those without this association. It is concluded that (a) the association of hemangioma with focal nodular hyperplasia is frequent (23%) and not fortuitous, and (b) prolonged administration of oral contraceptives may facilitate the recognition of this association, possibly by affecting the growth of these tumors.     

Ultrasonography in the diagnosis and follow-up of hepatic sinusoidal dilatation

Hepatic sinusoidal dilatation is a rare complication of oral contraceptive use. A 29-year-old woman who had been taking oral contraceptive pills for eight years was found to have persistently elevated erythrocyte sedimentation rates and alkaline phosphatase levels, hepatomegaly, diffuse hepatic sinusoidal dilatation, and a large nonhomogeneous hyperechogenic lesion in the right hepatic lobe. The abdominal ultrasonogram, liver size, erythrocyte sedimentation rates, and alkaline phosphatase levels reverted to normal within 24 months after discontinuing oral contraceptives. This case should encourage the use of abdominal ultrasonography in detection and follow-up of hepatic sinusoidal dilatation.     

Locally advanced intrahepatic cholangiocarcinoma successfully resected after transcatheter arterial chemoembolization with degradable starch microspheres: report of a case

We describe a case of initially unresectable locally advanced intrahepatic cholangiocarcinoma that showed remarkable regression after transcatheter arterial chemoembolization with degradable starch microspheres, allowing for subsequent successful curative resection. A 75-year-old female was referred to our hospital with a large hepatic mass. Computerized tomography examination showed a huge mass in the right liver extended partially to the left liver. Intrahepatic cholangiocarcinoma was strongly suspected, but surgical resection was abandoned due to the local spread in the liver. Three courses of transcatheter arterial chemoembolization with degradable starch microspheres were performed. The anticancer agents, mitomycin C and epirubicin, combined with degradable starch microspheres were injected from the catheter for chemoembolization. After three courses of transcatheter arterial chemoembolization, the tumor size decreased from 10cm to 5.5cm in diameter. Then right trisegmentectomy together with extra-hepatic bile duct excision was performed. At 25 months after the first therapy and 21 months after operation, the patient remains healthy without recurrence. Transcatheter arterial chemotherapy with degradable starch microspheres may be a treatment of choice with locally advanced intrahepatic cholangiocarcinoma.     

Endoscopic mucosal resection of a rectal malakoplakia in a healthy adult

Malakoplakia in the gastrointestinal tract is rare in healthy young people without underlying disease. Sufficient tissue is required for accurate diagnosis. We describe a malakoplakia that developed in a healthy young woman and was treated by endoscopic mucosal resection (EMR). A 40‐year‐old woman with a history of taking oral contraceptives until one year earlier was referred to our hospital with anal bleeding and constipation. A colonoscopy carried out at our another hospital 18 months earlier disclosed no abnormal findings. Colonoscopy at presentation revealed a yellowish‐white tumor, 5 mm in diameter, in the rectum. The lesion was slightly protruded and had a smooth flat surface, without erosion or ulceration. EMR was carried out for a definitive diagnosis. Histopathological examination showed that the tumor contained granular histiocytes, positive for CD68 and negative forcytokeratin (AE1/AE3). Several histiocytes contained intracytoplasmic round bodies (Michaelis–Gutmann bodies), which reacted positively with periodic acid‐Schiff and calcium (Von Kossa) stains. Intracytoplasmic Escherichia coli (von Hansemann bodies) were identified by Giemsa staining. Based on these results, the tumor in the rectum was diagnosed as a malakoplakia. Following EMR, the patient did not receive further treatment for malakoplakia because she had no symptoms associated with malakoplakia. She has been well for more than 9 months, with no symptoms of disease. Awareness of colorectal malakoplakia is important in patients taking steroids, including oral contraceptives.     

Long-term follow-up study of patients with adrenal incidentalomas

BACKGROUND: The incidence of adrenal incidentalomas has sharply increased in recent decades and concurrent subtle endocrine abnormalities, or even subclinical conditions, have been identified. Nonetheless, data concerning possible changes in adrenal size and/or hormonal pattern during follow-up are still inadequate. OBJECTIVE: To evaluate long-term morphological and functional evolution of adrenal incidentalomas after initial diagnosis and to identify possible risk factors for hormonal hyperactivity and mass enlargement. PATIENTS: Sixty-four patients (34-79 years) were followed-up for 12-120 months (median 25.5 months). Initial computerized tomography scan showed a unilateral mass in 51 patients and bilateral lesions in 13 patients. Average mass diameter at diagnosis was 2.5+/-0.1 cm (range 1.0-4.0). Twelve patients had subclinical Cushing's syndrome, 41 had mild hormonal alterations, and 11 had normal adrenal function at baseline. All patients were investigated by morphological and functional evaluation 6 and 12 months after diagnosis, and then at 1-year intervals. RESULTS: During follow-up, a mass size increase >/=1 cm was observed in 13 patients, and 18 developed further subtle endocrine alterations. Cumulative risk of developing endocrine abnormalities was 17% at 1 year, 29% at 2 years, and 47% at 5 years. The risk was higher in the first 2 years of follow-up if the initial tumor diameter was >or=3 cm. Overall, cumulative risk of mass enlargement was 6% at 1 year, 14% at 2 years, and 29% at 5 years, and it was greater in patients with normal adrenal function than in those with subtle hormonal abnormalities (P<0.05). One female subject showed a mass enlargement after 6 months of follow-up and was eventually diagnosed with non-Hodgkin's lymphoma. CONCLUSIONS: Patients with an adrenal incidentaloma are at risk for tumor growth and development of hormonal alterations. The risk of adrenal malignancy, although not elevated, also indicates the need for long-term follow-up.     

Oral contraceptives raise the cholesterol saturation of bile by increasing biliary cholesterol secretion

To discover the mechanism by which oral contraceptives increase the level of cholesterol saturation of human bile, we measured biliary lipid secretion rates, gallbladder and hepatic bile lipid composition, bile acid pool size, bile acid composition, and plasma lipoprotein levels in five healthy women during routine oral contraceptive treatment and again during normal menstrual cycles on no medication. The molar percent cholesterol in both gallbladder and hepatic bile was higher in every subject while taking oral contraceptives (p < .02). Oral contraceptive usage was accompanied by a significant enhancement of biliary cholesterol secretion (65 versus 46 mg/hr, p < .01), but there was no significant change in bile acid or phospholipid secretion, total bile acid pool size, or bile acid composition. These findings indicate that oral contraceptive usage increases biliary cholesterol secretion, thereby raising the level of cholesterol saturation of bile and predisposing to cholesterol precipitation and gallstone formation.     

Gastric polyps

Summary When roentgen examination shows a sharply defined polyp less than 2 cm. in diameter, the polyp is of a benign adenomatous type, and conservative treatment is recommended. If the polyp is smooth and larger than 2 cm. in diameter it is usually benign. However, since there may be such findings with a polypoid carcinoma, surgery is indicated. Of 138 cases studied the polyps resembled a villous adenoma on roentgen and pathologic examination in 8. These lesions have a high malignant potential and should be removed. Irregular contour defects should be considered as carcinomas no matter what the size.Thirty-one patients with the roentgen diagnosis of a benign polyp, observed for 9 months to 12 years, revealed no essential change in appearance during the period of observation. Some of the differences in the statistics relative to the malignant potential of gastric polyps may be due to the inclusion of villous adenomas or papillomas, polypoid carcinomas, and small flat ulcerating carcinomas.     

Liver cell adenoma with malignant transformation： A case report

A 57-year-old woman was referred to our hospital because of a liver mass detected by computed tomography. She had taken oral contraceptives for only one month at the age of thirty. Physical examination revealed no abnormalities, and laboratory data, including hepatic function tests, were within the normal range, with the exception of elevated levels of those serum proteins induced by the absence of vitamin K or by raised levels of the antagonist (PIVKA)-II (3,502 AU/ml). Abdominal ultrasonography revealed a hyperechoic mass measuring 10 X 10 cm in the left posterior segment of the liver. Because hepatocellular carcinoma could not be completely excluded, this mass was resected. The tumor consisted of sheets of uniform cells with clear cytoplasm, perinuclear eosinophilic granules and round nuclei. These histological findings were consistent with liver cell adenoma. Background hepatic tissue appeared normal. After resection of the tumor, serum PIVKA-II fell to within the normal range. An area of hepatocellular carcinoma (HCC) with a mid-trabecular pattern was immunohistochemically found, which was positive for PIVKA-II. Sinusoidal endothelial cells were CD34-positive, containing scattered PIVKA-II positive cells. This tumor was therefore finally diagnosed as liver cell adenoma with focal malignant transformation to HCC.     

Squamous cell carcinoma of the liver originating from non-parasitic cysts after a 15 year follow-up

Squamous cell carcinoma is an extremely rare primary liver tumour. A 42-year-old man presented at our hospital on 19 February 1986, with pain in the right upper quadrant of the abdomen and general fatigue, and reported an 8 year history of this complaint. Ultrasonography showed four cystic masses in the liver with a maximum diameter of 15 cm, one of which contained a solid component. A computed tomography (CT) scan confirmed a huge, predominantly cystic, mass in the liver with a small solid component and irregular wall. Calcifications were seen in the solid components. On 22 April 1986, a laparotomy was performed but the masses were too large to be removed. During 15 years of follow-up after the laparotomy, there had been no change seen in his abdominal CT scan. He subsequently arrived at our hospital again on 10 July 2001 with loss of appetite and of body weight. A CT scan showed a cyst in the liver of 25 cm in diameter with calcification that had a large solid part invading the liver. A post-mortem pathological dissection showed multiple cysts, the largest of which was 25 cm in diameter. They had large solid parts with calcification invading the liver. There were widespread metastatic lesions. Microscopic examination showed the tumour to be a well differentiated squamous cell carcinoma. To the best of our knowledge, this is the first report of a squamous cell carcinoma arising from 15 multiple non-parasitic hepatic cysts after a 15 year follow-up. Furthermore, 23 years had passed since the patient's symptoms appeared for the first time.     

肺球孢子菌感染一例并文献复习

目的 提高对肺球孢子菌病的认识.方法 结合1例肺球孢子菌病患者的临床资料及诊治经过并复习相关文献,对球孢子菌病的临床表现、病理结果及治疗进行分析.结果 患者男,74岁,因"体检发现双肺占位性病变9个月,咳嗽2周"于2009年2月10日收入南京医科大学第一附属医院呼吸内科.患者9个月前体格检查发现双肺多发占位性病变,于2008年6月17日在外院行肺穿刺活检,病理结果提示隐球菌感染,给予氟康唑治疗6个月后,复查胸部CT病灶无明显改变.入院后13 d行胸腔镜下双肺楔形切除术,术后病理结果提示球孢子菌病、孢子菌瘤形成.术后先后给予伏立康唑和氟康唑治疗共6个月,复查胸部CT未见复发.结论 原发性肺球孢子菌病少见,临床表现不典型,其病理所见易与隐球菌混淆.随着免疫抑制剂的广泛使用,本病可能会逐渐增多,临床医生应提高对该病的认识.     

Primary adenosquamous carcinoma of the liver: case report

We describe a case of adenosquamous carcinoma of the liver, including treatment for the recurrence. A 67‐year‐old man with prolonged high fever was diagnosed with a mass lesion in the left lobe of the liver seen by imaging studies. That mass lesion was histologically diagnosed as cholangiocarcinoma by needle biopsy. Left hepatic lobectomy was performed, and a tumor was found that measured 8.0 × 7.0 × 6.0 cm. It was a yellowish white solid mass without macroscopic invasion of the intrahepatic bile duct. Histological examination of the resected specimen revealed both adenocarcinoma and squamous cell carcinoma. The postoperative course was uneventful, but abdominal computed tomography 3 months after operation revealed seven masses in the remnant liver. We diagnosed recurrence of the tumor, and intrahepatic arterial infusion of cisplatin and 5‐fluorouracil was begun. A partial remission resulted. Progression‐free survival after chemotherapy lasted 2 months. However, the tumor markers and remnant tumor size increased gradually 9 months after the operation, and he died 14 months after surgery. We also review 41 cases of adenosquamous carcinoma of the liver reported in the Japanese and English language literature, including the present case.     

Treatment of hepatic cysts by B-ultrasound-guided radiofrequency ablation

BACKGROUND:The traditional therapy for hepatic cysts has limited success because of recrudescence. Radiofrequency ablation(RFA)has become popular because of its advantages including little damage,therapeutic effect and reduced suffering.This report describes the effects and reliability of RFA in the treatment of 29 patients with hepatic cysts. METHODS:B-ultrasound-guided RFA was used to treat hepatic mono-cyst or multi-cysts of 29 patients(63 tumors). Ablative efficiency and complications were assessed by imaging and clinical symptoms. RESULTS:The tumors were abated completely in 34 cysts with a diameter<5 cm and no recurrence was seen after 3 months.In 21 cysts with a diameter of 5-10 cm,tumor volume was decreased by over 70%,then reduction and fiberosis were found.In 8 cysts with a diameter greater than 10 cm,tumor volume was decreased by more than 60%,and in 2 cysts it was increased more slightly than that at 1 month after RFA.In subsequent follow-up(6 and 12 months after RFA),tumors<10 cm in diameter were fully ablated.No significant discomfort and complications were found in any patient. CONCLUSION:RFA for the treatment of hepatic cysts is safe,and free from complications.     

Hemorrhagic hemangioma in the liver: A case report

Hemangioma is the most common type of benign tumor that arises in the liver. Although rupture and hemorrhage of hepatic hemangioma are rare complications, they can be the cause of mortality. The authors report a case of hemorrhagic hepatic hemangioma: in a 54-year-old woman who was admitted with epigastric pain. She had taken oral contraceptives several weeks prior. The results of a blood examination were normal. An abdominal computed tomography scan revealed a tumor in hepatic segment 4, and a hemorrhage inside the cystic mass was suspected. The mass was removed laparoscopically to confirm the tumor properties and control the hemorrhage. The pathologic findings of the resected mass were consistent with hepatic hemangioma with intratumoral hemorrhage. The patient was discharged 8 d after the surgery, without further complications or complaints, and the patient’s condition was found to have improved during follow-up.     

A case of verrucous squamous cell carcinoma of the esophagus

We report a rare case of verrucous squamous cell carcinoma (VSC) of the esophagus. A 73-year-old woman presented to our hospital with dysphagia. On gastrointestinal endoscopy, a white mass with a cauliflower-like appearance (3.5 cm in diameter) was detected in the upper esophagus at 23 cm from the incisors. Histological examination of a biopsy specimen revealed squamous epithelial hyperplasia and no malignancy. During 17 months of follow-up by repeated endoscopy, the lesion showed no marked changes in appearance. However, reexamination of the specimen obtained by partial endoscopic mucosal resection (EMR) using a jumbo biopsy forceps revealed very well differentiated squamous cell carcinoma corresponding to VSC. The clinical and histopathological characteristics of esophageal VSC are discussed on the basis of the published literature.