Diagnosis of small-bowel metastasis of hepatocellular carcinoma by double-balloon enteroscopy

INTRODUCTIONHepatocellular carcinoma (HCC) is a major cause of cancer-related deaths around the world. Nearly half of patients with HCC display metastatic disease at the time of initial diagnosis, frequently involving the liver, bone, brain, lungs, and adrenal glands, but gastrointestinal involvement is rare. Melena occurring secondary to a metastatic tumor from HCC is particularly rare. Herein, we present a case of melena secondary to metastatic HCC after chemoradiation to lung and brain metastases from HCC, diagnosed preoperatively by double-balloon enteroscopy. To the best of our knowledge, this represents the first such case to be reported.PRESENTATION OF CASE60-Year-old man had been diagnosed with hepatitis B virus-associated hepatocellular carcinoma (HCC). He was readmitted for investigation of general fatigue and iron-deficiency anemia. Esophagogastroduodenoscopy, total colonoscopy, and CT failed to identify any cause for gastrointestinal bleeding. Double-balloon enteroscopy, however, revealed small bowel metastasis from HCC preoperatively. After 5 days of conservative management, segmental small bowel resection and end-to-end anastomosis were performed. The histological appearances were considered typical for moderately differentiated HCC.DISSCUSSIONEndoscopic findings of gastrointestinal metastasis from HCC vary, such as raised and centrally ulcerated lesions, polypoid tumors, or submucosal tumors. Immunohistochemical findings are thus key to differentiating HCC from adenocarcinoma in the diagnosis of GIT metastasis. Some patients with gastrointestinal bleeding remain undiagnosed even after upper endoscopy and total colonoscopy, and most such patients will display bleeding sites in the small bowel. Video capsule endoscopy and DBE have been introduced recently for the evaluation of the small bowel. DBE, which was developed by Yamamoto et al.,⁵ allowed us to obtain biopsy specimens, circumventing one limitation of capsule endoscopy. In this case, DBE contributed significantly to diagnosis and treatment.CONCLUSIONDBE thus seems to represent a valuable method, particularly in the preoperative setting, due to the possibility of precisely identifying the tumor site and achieving preoperative diagnosis.     

Intrahepatic cholangiocarcinoma: relationship between tumor imaging enhancement by measuring attenuation and clinicopathologic characteristics

Purpose

Arterial enhancement of intrahepatic cholangiocarcinoma (ICC) has been noted. To precisely identify the characteristics of tumor enhancement patterns, we examined the relationship between CT attenuation in the tumor and clinicopathological parameters or prognosis.

Methods

Subjects were 42 ICC patients who had undergone hepatectomy. microvessel density (MVD) determined by CD34 staining was compared with imaging. Attenuation was calculated in images from multidetector CT of tumor and non-tumorous regions. Enhancement patterns were divided into two groups: arterial enhancement with higher attenuation (>16 HU; Hyper group, n = 12); and arterial enhancement with lower attenuation (Hypo group, n = 30).

Results

Univariate analysis identified high tumor marker level, increased size, less-differentiation, incomplete resection, increased bleeding, and lower MVD as significantly associated with poor survival (p < 0.05). Increased attenuation throughout the whole ICC correlated significantly with radiological findings and MVD. Concomitant hepatitis, well-differentiation, and smaller tumor were more significantly frequent in the Hyper group than in the Hypo group (p < 0.05). Postoperative early recurrence was significantly less frequent in the Hyper group, and overall survival was significantly better in the Hyper group (p < 0.05).

Conclusions

Increased CT attenuation correlated with ICC tumor vascularity. Increased tumor enhancement in the arterial phase was associated with chronic hepatitis, lower malignancy, and better survival.     

Physiologic stress responses to laparoscopic cholecystectomy

Background: Differences in the physiological stress response to pneumoperitoneal (PP) and gasless abdominal wall-lifting (AWL) procedures used for laparoscopic cholecystectomy have not been properly evaluated. Methods: We compared leukocyte count, interleukin-6 (IL-6) levels, arterial blood gases, creatinine clearance, plasma renin activity, cardiothoracic ratio, and clinical outcome in 27 patients without systemic complications who underwent laparoscopic cholecystectomy, including 11 by AWL and 16 by PP. Results: Transient leukocytosis and high IL-6 levels were observed at POD 1 (postoperative day) in both groups, but both values returned to baseline by POD 2. IL-6 levels correlated significantly with operation time (p < 0.01). Changes in blood gases, creatinine clearance, plasma renin activity, and cardiothoracic ratio were not different for the two groups. The clinical outcome was similar for both groups. Conclusions: Our results indicate that both PP and AWL are appropriate for patients without serious complications.     

A case of advanced esophageal cancer with suspected tracheoesophageal fistula that responded to chemoradiotherapy

Chemoradiotherapy combined cisplatin, 5-FU and radiation was carried out in an advanced esophageal cancer with suspected tracheoesophageal fistula after insertion of an expandable metallic stent. Regression of the primary tumor was observed, and oral intake could be started. Chemoradiotherapy after insertion of the expandable metallic stent was useful in this case of advanced esophageal cancer with suspected tracheoesophageal fistula.     

Undifferentiated spindle-cell carcinoma of the gallbladder: an immunohistochemical study

A case of undifferentiated spindle-cell carcinoma of the gallbladder is described. A 72-year-old man presented with right hypochondralgia and fever. Imaging studies revealed a well-demarcated solid tumor (with a necrotic center) in the gallbladder that invaded the liver and transverse colon. On gross examination of the surgical specimen, the cut surface of the polypoid tumor showed nodular invasive growth. Microscopically, the tumor was composed of atypical spindle-shaped tumor cells that proliferated in a whirling or interlacing pattern. The tumor also showed foci with a malignant epithelial component that simulated a carcinosarcoma. Immunohistochemically, the biphasic differentiation of the tumor was highlighted by the different immunoreactivity to antibodies against cytokeratins, epithelial membrane antigen (EMA), and vimentin shown by the malignant epithelial components and the spindle-cell components. However the latter showed faint positivity for cytokeratin antibody. These results suggested that the spindle-cell carcinoma of the gallbladder originated from cholecystic mucosa and showed sarcomatous reaction or dedifferentiation, as indicated by the presence of vimentin-positive cells. The proliferation index, as detected by ki-67, in the spindle-cell component was higher than that in the epithelial component, which may account for the more aggressive biological behavior of the spindle-cell component.     

Predictive factor for photodynamic therapy effects on oral squamous cell carcinoma and oral epithelial dysplasia

Objective

The aim of this study was to investigate the correlation between the immunohistochemical expression of proliferating cell nuclear antigen (PCNA), factor VIII, and CD34 (markers of endothelial cells), and vascular endothelial growth factor (VEGF) and the recurrence of oral squamous cell carcinoma (OSCC) and oral epithelial dysplasia (OED) subjected to photodynamic therapy (PDT).

Design

Twenty-one biopsy specimens (14 cases of OSCC and 7 cases of OED) before PDT were immunohistochemically investigated in terms of their expressions of PCNA, factor VIII, CD34 and VEGF. The percentages of the total sample area that were immunopositive for factor VIII (percentage factor VIII immunopositive area: PFIA) CD34 (PCIA) and VEGF (PVIA) were calculated using computer-assisted image analysis for quantitative assessment of endothelial cells or VEGF expression in the lesions. The PCNA labelling index (LI) was evaluated as a proliferation marker.

Results

Five cases of OSCC and one case of OED recurred 4 to 30 months after PDT. We found that the average PVIA was 14.5% in the no-recurrence group and 1.7% in the recurrence group. The difference between these values was statistically significant (P = 0.0483). On the other hand, the average PCNA LI was 30.3% in the no-recurrence group and 24.3% in the recurrence group; the average PFIA was 3.7% in the no-recurrence group and 1.6% in the recurrence group; and the average PCIA was 2.0% in the no-recurrence group and 1.4% in the recurrence group. There were no significant differences between the two groups for any of these markers (P = 0.3379, P = 0.1195, P = 0.4835, respectively).

Conclusions

These results provide clinical data indicating that VEGF expression may be a useful predictive marker for the effects of PDT in OSCC and OED.     

Adult case of an omphalomesenteric cyst resected by laparoscopic-assisted surgery

This report describes an extremely rare adult case of an omphalomesenteric cyst resected by laparoscopic-assisted surgery. A 29-years-old Japanese man was referred and admitted to Kyushu University Hospital because of an abdominal mass and an elevated serum CEA (carcinoembryonic antigen) level (21.3 ng/mL) in August 2001. Abdominal CT and US demonstrated a cystic mass with septum and calcification. Laparoscopy showed a large mass to be attached to his abdominal wall, measuring 110 mm x 70 mm x 50 mm and filled with mucus. The mass was resected by laparoscopic-assisted surgery. The histological findings of its wall showed fibromuscular tissue, adipose tissue, calcification, and an intestinal structure. It was finally diagnosed to be an omphalomesenteric cyst.     

Modified Japan Integrated Staging is currently the best available staging system for hepatocellular carcinoma patients who have undergone hepatectomy

Background We previously reported the effectiveness of the modified Cancer of the Liver Italian Program (CLIP) score in hepatocellular carcinoma (HCC) staging. To determine the best predictive staging system for HCC patients, we conducted a comparative analysis of prognosis using multivariate analysis in 230 Japanese HCC patients following hepatic resection. Methods We compared overall survival as predicted by different staging systems: the tumor node metastasis (TNM) system by the Liver Cancer Study Group of Japan, the Japan Integrated Staging (JIS) score (Japanese TNM and Child-Pugh classification), the modified JIS score using liver damage grade, the CLIP score, and our modified CLIP score using protein induced by vitamin K absence or the antagonist II (PIVKA-II). Results By a univariate analysis the PIVKA-II level (cut-off level, 400 mAU/ml) was significantly associated with patient survival (P = 0.031); however, alpha-fetoprotein level was not related to survival. Liver damage grade was significantly associated with patient survival (P = 0.039), although Child-Pugh classification was not related to survival. Univariate analysis showed that prediction of survival, according to disease stage, was better with the modified JIS score than with the TNM system, CLIP, modified CLIP, or JIS score. Multivariate analysis showed the modified JIS score showed the best ability to predict overall survival according to disease stage (Hazard ratio, 1.77; P = 0.002), and its Akaike information criteria statistic was the lowest (634.3). Conclusions The modified JIS score, a staging system that combines tumor factors and hepatic function, is a better predictor of prognosis than other systems in HCC patients who have undergone hepatic resection.     

Detection of acute HIV infection by serum HIV-1 RNA quantification

To assess the merit of serum HIV-1 RNA quantification in detecting acute HIV infection, we reviewed the results of HIV-1 RNA assay and antibody tests in all patients who received those tests at our hospital from August 1999 to December 2004. Of 3530 such patients, five were sero-negative and PCR-positive with more than 105 copies/ml at initial examination. Four of them had HAART and followed a favorable course; they were later confirmed to be sero-positive by Western blotting. The other one, positive only by CLEIA, was lost to follow-up. This reconfirms the importance of using PCR in the initial assessment of HIV infection in high-risk patients.     

Nuclear medical PET-study in the causal relationship between mastication and brain function in human evolutionary and developmental processes

The principal author (Kubote 1995, 1997, 1998, 1999, 2000a, b) has proposed that chewing food well from infancy will lead to a clear-headed and robust person, following which the same concept has been presented to the general public by the mass media. Unfortunately, however, there does not yet seem to be any direct evidence to support this claim. It is thus necessary to review mastication from the standpoint of the new concept of evidence-based medicine (EBM) and to create a new direction in medicodental research and treatment from the viewpoint of human evolution, because the causal relationship between mastication and brain function has never been clarified either in fossil science research or in the modern scientific bibliography.

To confirm the human historical fossil record in regard to the causal relationship between the development of mastication and brain function in human evolutionary processes, the effect of gum chewing on brain reaction was examined in humans by means of a positron-emission tomography (PET) camera (Momose et al. 1997) after an antecubital intravenous injection of H₂¹⁵O.

Powerful activation of the cortical cells was demonstrated in multiple cortical areas involving the marginal areas of the bilateral central sulci of the cerebral cortex (Fig. 1), and the activated areas coincided with our previous results in region of interest (ROI) analysis (Momose et al. 1887). Three-dimensionally, numerous cortical cells were shown to form nuclei on relief maps (Fig. 2).

As diets and feeding habits changed in a stepwise manner from frugivorous to omnivorous via herbivorous and carnivorous over the lengthy progress of evolution, the brain concomitantly grew and the cranial capacity gradually increased in volume from 500 cm³, food from plant sources to animal sources (700 cm³), and then to both (1500 cm³), during the human evolutionary and developmental processes.

Gradual increases in the cranial capacity of human fossils during the developmental stage have been demonstrated also by PET images of the human brain acquired by means of a PET camera and an antecubital intravenous injection of H₂¹⁵O during mastication that showed powerful activation of cortical cells in multiple areas. It could be concluded that human fossils give us concrete information on how to feed our children in the modern human life style from infancy to adulthood, so that we should bring children up by adhering to images of the principal feeding habits discovered during this research on human evolutionary and developmental processes.