Multiple necrotic nodules of the liver simulating liver metastasis

A 70‐year‐old man was referred to our hospital due to anemia and elevated serum tumor marker levels. He had advanced colon cancer, and hepatic lesions were found incidentally. On ultrasonography (US) and computed tomography (CT), the hepatic lesions had a maximum diameter of 20 mm and were located in Couinaud's segments V, VI, VII, and VIII, which suggested liver metastasis. On early‐ and late‐phase CT during hepatic arteriography (CTHA), all of the lesions had rim enhancement. On early‐phase CT during arterioportography (CTAP), all of the lesions were seen as nodules with an irregular perfusion defect, and on late‐phase CTAP, all the lesions gradually became iso‐dense, and their shape and size changed. Based on the CTAP findings, these lesions were thought to be fibrotic tumors. Partial resection of the liver (including the lesions in Couinaud's segments V and VIII) was done. Histological examination revealed that the lesions were necrotic nodules. Thus, CT angiography (CTHA and CTAP) was useful for identifying necrotic nodules, because their appearance on this modality is different from that of liver metastases.     

Segmentectomy of the liver

Segmentectomy is anatomical resection of segments based on the classification of Couinaud. This procedure is performed mainly for hepatocellular carcinoma. Invasion of portal vein and intrahepatic metastases often occur with hepatocellular carcinoma. Thus, it is desirable to perform anatomical resection of the cancer-bearing areas for curative purpose. However, segmentectomy is selected when extensive resection must be avoided to preserve liver function. There are major differences between segmentectomy of the left hemiliver (Sg 2-4) and right hemiliver (Sg 5-8). In the former, the branches (third-order branches) arising from the umbilical portion of the portal vein can be ligated prior to liver resection. In the latter, manipulation is difficult. Therefore, ultrasonically guided segmental staining is performed by puncturing the portal branch and injecting a dye. This report described techniques for segmentectomy.     

Carcinosarcoma of the liver

Herein we present a 73-year-old man with primary carcinosarcoma of the liver, a rare malignant tumor of the liver. The case was followed up due to HBV-related liver cirrhosis. Regular check-up by ultrasound demonstrated a hyperechoic tumor in the left lobe of the liver, and he was referred and admitted to our hospital. Dynamic CT studies revealed a mostly hypoenhancing hepatic mass with a peripheral ring enhancement. Surgical resection was performed, and the resected tumor was macroscopically a simple nodular type, 3 cm in diameter, with a dense fibrous capsule. Microscopically, undifferentiated cells were dominant in the tumor, while moderately differentiated hepatocellular carcinoma (HCC) were also observed. A transitional zone was noted between the undifferentiated tumor and HCC. Tumor tissue with adenocarcinoma, osteosarcoma and chondrosarcoma were also detected. Immunohistochemical studies demonstrated that tumor cells were HepPar 1 positive in hepatocellular carcinoma, and CK19 and partly CK7 positive in adenocarcinoma. Moreover, CD56, chromogranin A and c-kit were occasionally positive in undifferentiated tumor cells. The diagnosis of carcinosarcoma was made based on the concomitant presence of HCC and sarcomatous components, yet it is noteworthy that various types of tumor cells were observed.     

Tuberculoma of the liver

During the period 1973-76 2 patients, neither immigrants, were operated on and found to have tuberculoma of the liver. Both were successfully treated. Tuberculoma of the liver is an uncommon condition and is rarely encountered as a surgical problem. It can, however, present a surgical challenge as it must be distinguished from the more common types of right upper quandrant abdominal lesions such as biliary, gastroduodenal and other hepatic diseases. The occurrence of a tuberculoma of the liver without coexistent tuberculosis elsewhere in the body is extremely rare. Its presence in association with other tuberculous foci, whilst uncommon, has been recorded on a number of occasions.     

Xenotransplantation of the liver

Xenotransplantation of the liver, in its broadest conception, might involve the transplantation of an intact organ or xenogeneic hepatocytes, or the use of an intact xenogeneic liver or cells as an ex vivo "device." The indications for xenotransplantation include not only hepatic failure but also, potentially, the treatment of metabolic diseases. The hurdles to xenotransplantation include immune, physiologic, and infectious complications. New information and progress in experimental systems are bringing xenotransplantation closer to clinical application.     

Cirrhosis of the liver

An ultrasonographic study about the prevalence of cholelithiasis was performed in 410 cirrhotic patients and in 414 controls matched for age and sex. Gallstone disease was found more often in cirrhotic patients (31.9%) than in controls (20.7%) (P<0.001. The female-to-male ratio of gallstones prevalence in cirrhotic patients approached to 11. Gallstone disease in cirrhotic patients vs controls was significantly higher (30.2% vs 16.5%) (P<0.001 in males only. No difference was found, for gallstone disease prevalence in cirrhosis of different etiology. The prevalence of cholelithiasis increased from Child's A to Child's C with a significant trend P<0.001; this difference was significant in males (12.3% vs 40.5%) P<0.001) but not in females. This study shows that cirrhosis represents a risk factor for the development of cholelithiasis in males. We suggest that high levels of estrogens could play a role in these patients, by an impairment of gallbladder emptying similar to that observed in pregnant women.     

Cirrhosis of the liver

The ancient story of Prometheus, chained to a rock for defying Zeus by stealing fire from Mount Olympus and subjected to daily tearing at his liver by an eagle, attests to the early recognition of the extraordinary regenerative capacity of the human liver. This process had remained an intriguing mystery over the millennia. In the last 20 years, following the pioneering work of Bucher (1) and Moolten et al (2), there has been an explosion of research that has clarified some of the mechanisms underlying the process of hepatic regeneration.Regeneration implies proliferation and regeneration. After the fetal and postnatal growth of the liver is completed, hepatocytes no longer proliferate actively, but they can proliferate in response to cell death or loss (3). Hepatocyte growth responses are of particular research interest because they occurin vivo and involve cells that are normally quiescent.Hepatic regeneration constitutes a highly regulated process that is best shown by the arrest of liver growth following a partial hepatectomy precisely at the moment the hepatic mass reaches the mass of the original intact liver (3). This suggests that hepatic regeneration after a partial hepatectomy is a strictly regulated nonautonomous growth process that is controlled by the same factors that are responsible for the determination and maintenance of hepatic mass in a normal individual. In response to a partial hepatectomy, hepatocytes enter the cell cycle and progress to DNA synthesis and replication but only in number sufficient to restore the hepatic mass. The regeneration response is both synchronized and universal in that it affects all intrahepatic cell lines, including nonparenchymal cells.The first part of the present paper deals with a review of the concepts related to the regulation of growth and regeneration following liver injury. This is followed by discussion of the process of hyperplasia and neoplasia seen in cirrhosis. The second part of this work deals with a new histopathological method used to identify hepatocellular carcinoma (HCC), which is based upon a consideration of dynamic criteria and the lessons learned from a human disease process, alpha-1-antitrypsin (AAT) deficiency.Presented at the Proceedings of the International Meeting on Normal and Neoplastic Growth in Hepatology, Bari, Italy, June 1989.     

Sectionectomy of the liver

Anatomic resection of the liver, which refers to the systemic elimination of the main tumor with micrometastases, preserves liver function and is highly recommended. Tumors located centrally or in the vicinity of major portal pedicles or hepatic veins, however, tend to require extensive hepatectomy. Anatomic sectionectomy of the liver might represent an alternative to such extensive resection. Preoperative simulation, external landmarks, selective devascularization, and intraoperative ultrasound are useful to achieve anatomic sectionectomy. Anatomic resection requires division of the relevant portal vein, hepatic artery, and bile duct. This may be achieved by individual isolation of the three elements or by mass isolation of all three in their surrounding fibrous sheath (Glisson's capsule). Both approaches are equally effective for extensive resections. When sectionectomy is performed, however, the isolation of individual vasculobiliary elements is sometimes difficult and dangerous compared with the isolation of the sectional portal pedicles. By identifying the portal pedicles to individual anatomic sections, it is possible to control the inflow to the section that is intended for resection. Anatomic sectionectomy is a safe alternative to extensive liver resection in selected patients, avoiding unnecessary sacrifice of functional liver parenchyma and increasing the opportunity to perform repeat resections in cases of recurrence.     

Retransplantation of the liver

Since the introduction of cyclosporine-prednisone for primary immunosuppression, retransplantation has become a feasible option for patients whose primary grafts are failing, which may result from primary graft nonfunction, intractable rejection, or consequent to technical complications. Although survival of patients requiring second grafts is less good than in those whose initial graft functions well, 2-year survival rates of 49% have been achieved in retransplanted patients, a record that mandates serious consideration of this approach when the primary graft begins to fail. In general, the retransplant procedure is technically easier, with less blood loss, than is the initial operation. When the reoperation is done electively, it should be done before serious clinical deterioration compromises the chances for success.