Correlation between clinical indication for treatment and liver histology in HBeAg‐negative chronic hepatitis B: a novel role of α‐fetoprotein

Background: It is unclear whether clinical indication for antiviral treatment is in agreement with histological indication in HBeAg‐negative chronic hepatitis B (CHB). This study aimed to clarify this relationship and identify factors associated with liver histology. Patients and methods: We investigated 152 consecutive, treatment‐naïve, HBeAg‐negative CHB patients who had undergone liver biopsies at a tertiary medical centre in Taiwan. Clinical indications for treatment included a serum alanine aminotransferase level more than twice the upper limit of normal and an hepatitis B virus DNA level >2000 IU/ml. Factors associated with the histological indication (Ishak's grade ≥7 and/or stage ≥2) were analysed. Results: The association between the clinical and the histological indications was significant (P=0.011). However, the agreement was poor (κ value=0.197). In patients satisfying the clinical indication, age >52 years [odds ratio (OR)=2.669, P=0.042], serum α‐fetoprotein (AFP) level >7 ng/ml (OR=7.070, P<0.001) and platelet count <130 × 10⁹/L (OR=11.720, P=0.025) were identified to be independent factors associated with histological indication. In patients who did not satisfy the clinical indication, multivariate analysis revealed that only an AFP level >7 ng/ml (OR=10.345, P=0.021) was independently associated with histological indication. Combining the clinical indication and/or AFP level >7 ng/ml to predict liver histology, the sensitivity and the negative predictive value could improve from 86 to 94.4% and 66.7 to 81% respectively. Conclusion: AFP level is associated with liver histology in HBeAg‐negative CHB. Serum AFP level can serve as a surrogate indicator to identify patients who need antiviral treatment.     

Major gastrointestinal manifestations in lupus patients in Asia: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy

Gastrointestinal (GI) symptoms are common in patients with systemic lupus erythematosus (SLE) and may be due to the disease itself, side-effects of medications, or non-SLE causes. However, GI manifestations of lupus attract far less attention than the other major organ involvements, are infrequently reviewed and rarely documented in published lupus databases or cohort studies including those from countries in Asia. According to three reports from two countries in Asia, the cumulative prevalence of SLE GI manifestations range from 3.8% to 18%. In this review, we focus on three major GI manifestations in patients from Asian countries: lupus enteritis, intestinal pseudo-obstruction, and protein-losing gastroenteropathy, for which early recognition improves outcome and reduces morbidity and mortality.     

Subclinical atherosclerosis in systemic lupus erythematosus (SLE): the relative contribution of classic risk factors and the lupus phenotype

OBJECTIVES: We aimed to examine the strength of association between traditional cardiovascular risk factors and carotid plaque development in systemic lupus erythematosus (SLE) patients and controls. We also aimed to determine which lupus-related factors are associated with carotid plaque and whether SLE sensitizes patients to the effects of traditional factors. METHODS: We studied 200 women with SLE and 100 controls. Demographic and risk factor data were collected and SLE features, including autoantibody profiles and therapy were noted. All subjects had B- mode ultrasound of their carotid arteries examined for the presence and distribution of plaque. RESULTS: SLE patients <55 years old had more plaque (21% vs 3% P < 0.01) and more SLE patients had plaque in the internal carotid artery (11% vs 4%; P < 0.05). Traditional risk factor models performed less well in SLE compared with controls [area under Receiver Operator Characteristic curves (AUC ROC) = 0.76 vs 0.90; P < 0.01]. A multivariable model using SLE factors only, performed significantly better (AUC ROC = 0.87; P < 0.01). The final model in SLE included age and cigarette pack-years smoking as well as azathioprine exposure ever, antiphospholipid antibodies (APLA) and previous arterial events (AUC ROC = 0.88). CONCLUSIONS: SLE patients have a higher prevalence and different distribution of carotid plaque than controls. SLE factors perform significantly better than traditional risk factors in their association with atherosclerosis in SLE and these factors add to the influence of traditional risk factors rather than sensitizing lupus patients to traditional factors. The SLE phenotype helps identify patients at increased risk of atherosclerosis.     

Aggressive pancreatic resection for primary pancreatic neuroendocrine tumor: is it justifiable?

BACKGROUND: Benign and malignant pancreatic neuroendocrine tumors (PNETs) are rare, and long-term outcome is generally poor without surgical intervention. The aim of the study was to assess whether aggressive pancreatic resection is justifiable for patients with PNET. METHODS: All consecutive patients who had undergone major pancreatic resection from January 1997 through January 2005 were reviewed and analyzed. RESULTS: There were 33 patients (16 male and 17 female) with a mean age of 53 years. Five patients had multiple endocrine neoplasms syndrome, and 1 patient had von Hippel-Lindau syndrome. There were 20 benign (9 functional) and 13 malignant (6 functional) neoplasms. Mean tumor size was 4.2 cm, and multiple tumors were noted in 10 patients. Eight patients (25%) underwent pancreticoduedenectomy, and 25 patients (76%) underwent distal pancreatectomy (extended distal pancreatectomy in 4 and splenectomy in 20 patients). Regional lymph node involvement was present in 10 patients (30%), and 6 patients (18%) had liver metastasis. Four patients (12%) underwent concurrent resection of other organs because of disease extension. Median intraoperative blood loss was 500 mL. Perioperative morbidity was 36%, and mortality was 3%. Symptomatic palliation was complete in 93% (14.15 patients) and partial in 1 patient because of nonresectable hepatic disease. Median hospital stay was 11.5 days. After median follow-up of 36 months, there were no local recurrences. The 1-, 3-, and 5-year overall survival rates for patients with benign versus malignant neoplasms were 100% vs. 92%, 89% vs. 64%, and 89% vs 36% (P = .01), respectively. The 1-, 3-, and 5-year disease progression rates for patients with malignant neoplasms were 13%, 63%, and 100%, respectively (P < .0001). CONCLUSIONS: Aggressive pancreatic resection for PNET can be performed with low perioperative mortality and morbidity. Unlike available nonoperative therapy, this approach offers an excellent means of symptomatic palliation and local disease control. In patients with malignant PNET, metastatic recurrence is not uncommon and will usually require additional multimodality therapy. When possible, an aggressive approach to PNET is justified to optimize palliation and survival.     

Improving B mode ultrasound evaluation of breast lesions with real-time ultrasound elastography--a clinical approach

Ultrasound elastography using the extended combined auto-correlation method of tissue elasticity allows for real-time strain image visualisation using a free-hand probe with concurrent conventional B mode imaging. Four hundred and fifteen consecutive women with 550 breast lesions confirmed on B mode ultrasound were assessed with elastography using the elasticity score. There were 119 malignant and 431 benign lesions. The elastography sensitivity was 78.0%, specificity was 98.5% and overall accuracy was 93.8%. The median score for malignancy was 5 and that for benign lesions was 2. There was good correlation with B mode BIRADS category. 98.6% of lesions with an elasticity score of 2 or below (95%CI=96.8-99.4) were benign. BIRADS 3 lesions with an elasticity score of 2 or below may be re-classified as BIRADS 2 lesions. We found that 15.3% of BIRADS 2 and 3 lesions with an elasticity score of 3 were malignant. Real-time ultrasound elastography is user-friendly with a high accuracy rate, thereby improving B mode ultrasound assessment.     

Pathologic complete response in renal cell carcinoma brain metastases treated with stereotactic radiosurgery

Renal cell carcinoma (RCC) is often regarded as a radiation-resistant tumor. However, radiation therapy (RT) in the form of stereotactic radiosurgery (SRS) or whole-brain irradiation has been used to treat brain metastases from RCC. To date, there have been no clinical pathologic correlative findings before and after RT. Herein, we present a case of a patient with brain metastases from RCC treated with SRS. The diagnosis of clear-cell RCC was made in 2001 after right radical nephrectomy. He was also found to have lung metastases at diagnosis. He presented with neurologic symptoms in 2004, and magnetic resonance imaging showed 3 brain lesions with a significant amount of edema consistent with brain metastases. The largest lesion caused a midline shift and was surgically resected. Pathology revealed metastatic RCC. The other 2 smaller brain lesions were treated at 20 Gy respectively with shaped-beam SRS using the BrainLab Novalis® system. No whole-brain irradiation was delivered. However, the patient had difficulty weaning off his steroids, and a magnetic resonance imaging performed 6 months after SRS was read as “progression of the lesions.” He then underwent resection of both the irradiated brain lesions. Pathologic examination revealed necrotic tissues without any viable tumor identified. The patient has since been doing very well, now 18 months after SRS and 5 years from the Initials diagnosis. This is the first reported case that demonstrates that precise high-dose radiation in the form of SRS can cause significant tumor cell death (pathologic complete response) in radiation-resistant brain metastases from RCC. This finding also provides a rationale to deliver stereotactic body RT for primary and metastatic RCC extracranially. A prospective clinical trial using stereotactic body RT for primary and metastatic RCC is under way.