Chaur-Shine Wang

Intra-arterial carbon dioxide-enhanced ultrasonogram of hepatocellular carcinoma treated by transcatheter arterial embolization and percutaneous ethanol injection therapy

The purpose of this study was to investigate the value of carbon dioxide‐enhanced ultrasonography (CO2‐US) in the evaluation of viable hepatocellular carcinomas (HCC) which were treated by transcatheter arterial embolization (TAE), percutaneous ethanol injection (PEI), or a combination treatment (TAE and PEI). Forty‐one patients with 66 HCC were included in the study. They underwent CO2‐US and angiography were performed in all tumours after they were treated by TAE, PEI or a combination treatment. Forty‐six tumours were positively enhanced by CO2‐US and 40 of them were positive by angiography. These 46 tumours were proved to be viable tumours either by biopsy or by follow‐up studies. The positive predictive value was 100% for CO2‐US and 87.8% in angiography. Twenty tumours were negative by CO2‐US and these were also negative by angiography. Carbon dioxide‐enhanced ultrasonography is a more reliable method for detecting the viable portion of the treated HCC compared with conventional angiography.

Carbon dioxide-enhanced ultrasonography of liver tumors

CO2 gas‐enhanced ultrasonography was performed in 37 patients (47 studies) for the purpose of detecting small tumors and evaluating differential diagnosis. With conventional ultrasonography, 62 lesions were identified in 25 patients with HCC, 13 tumors were identified in eight patients with hemangioma, and multiple tumors were found in four patients with metastatic adenocarcinoma. CO2‐enhanced ultrasonography detected five additional hemangiomas, 12 additional nodules in HCC, and the same number of metastatic nodules. The patterns of CO2 enhancement were characterized as homogeneous, heterogeneous, rim, internal spotted, negative, and mixed (more than one pattern in one lesion). The rim enhancement pattern was found to be specific for hemangioma. The internal spotted enhancement pattern was found exclusively in HCC. All the lesions that demonstrated negative enhancement were treated HCC. All the metastatic tumors demonstrated the mixed rim and internal spotted enhancement pattern. We suggest that CO2‐enhanced ultrasonography is a useful tool in detecting small liver tumors. It can also help in the differentiation among various hepatic tumors.

Long-Term Survival of Taiwanese Patients with Hepatocellular Carcinoma after Combination Therapy with Transcatheter Arterial Chemoembolization and Percutaneous Ethanol Injection

BACKGROUND AND PURPOSE Several studies have shown a superior effect of combination therapy with transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) compared with either monotherapy for the treatment of advanced hepatocellular carcinoma (HCC), but there have been no reports on combination treatment from Taiwan. This study investigated the long-term survival and prognostic factors of HCC patients treated with TACE/PEI combination therapy. METHODS A total of 153 consecutive HCC patients, with tumor sizes between 2 and 3 cm in 47 patients, between 3 and 5 cm in 66 patients, and between 5 and 13 cm in 40 patients, who received TACE/PEI combination therapy were included in this retrospective study. The mean follow-up duration was 23 +/- 17 months (range, 1 to 78 months). RESULTS The 1-, 2-, 3-, 4-, 5-, and 6-year cumulative survival rates for the patients were 78%, 54%, 40%, 22%, 12%, and 5%, respectively. Multivariate analysis using Coxs proportional hazards model showed that the stage of cirrhosis (Childs class B or C vs class A) was the only factor that significantly affected the survival rate (p = 0.02) [relative risk, 2.10; 95% confidence interval, 1.12 to 3.96]. Univariate analysis showed that survival was poorer in patients with tumors greater than 5 cm than in patients with tumors 2 to 5 cm in largest dimension; this difference was not significant in the multivariate analysis. No serious complications were observed during or after treatment. CONCLUSIONS TACE combined with PEI is an alternative treatment for patients with larger HCC who are not suitable for surgical resection. A superior outcome can be expected in patients with Childs class A cirrhosis.

MR cholangiopancreatography: prospective comparison of 3-dimensional turbo spin echo and single-shot turbo spin echo with ERCP.

BACKGROUND AND PURPOSE Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive technique for examination of the biliopancreatic tract. Respiratory-triggered 3-dimensional turbo spin echo (3DTSE RT) and breath-hold thick slab single-shot turbo spin echo (ssTSE BH) are both useful MRCP techniques. The purpose of this study was to compare these 2 sequences with endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract disease. METHODS Forty four patients with suspected biliary obstruction were recruited to receive MRCP within 3 days before ERCP. MRCP was performed using both 3DTSE RT with maximum intensity projection images and ssTSE BH. ERCP was performed and assessed by 2 endoscopists. RESULTS MRCP was successfully performed in all patients, whereas ERCP failed in 6 patients (13.6%). MRCP was effective in detecting the presence of choledocholithiasis in 13 of 14 patients, ERCP in 12 of 12, and 2 failed ERCP. MRCP was effective in detecting benign biliary obstruction in 18 of 19 patients, and ERCP in 15 of 15, but 4 patients failed ERCP and choledocholithiasis was misdiagnosed by MRCP in 1 patient. Both MRCP and ERCP correctly diagnosed malignant bile duct obstruction in 10 of 11 patients, and both misdiagnosed that condition as benign obstruction in 1 patient. There was no significant difference between MRCP and successful ERCP in detecting lesions. MRCP was significantly better than ERCP when both successful and failed ERCP were encountered (p = 0.0498). Both 3DTSE RT and ssTSE BH produced the same results in depicting the biliary ducts and lesions in 37 patients (84.1%). Four patients (9.1%) showed better images on 3DTSE RT, whereas 3 patients (6.8%) showed better images on ssTSE BH. CONCLUSIONS 3DTSE RT and the ssTSE BH were complementary to each other in MRCP studies. Using these 2 techniques, MRCP has a high successful rate and diagnostic accuracy when compared with ERCP in detecting bile duct disease.

Percutaneous radiofrequency ablation of liver malignancies

OBJECTIVE To describe the safety and efficacy of percutaneous radiofrequency ablation (PRFA) to treat liver cancer. METHODS One hundred patients with histologically or clinically confirmed primary or metastatic malignancies were treated percutaneously under ultrasound guidance using LeVeen multipolar array needle electrode and RF 2000 generator between October, 1999 and October, 2000. All patients were followed up to assess complication, treatment response, recurrence and curative effect. RESULTS PRFA was performed in 76 patients with primary liver cancer and 24 patients with metastatic liver cancer. AFP positive of small hepatic cancer (inoperative) became AFP negative in 75.0% patient (21/28). The rate of completely concrete necrosis of small hepatic malignancies shown by MRI was 85.9%(61/71). CONCLUSIONS PRFA as a local thermal therapy is a kind of new palliative treatment for hepatic malignancies. It is minimally invasive, safe and effective especially for small hepatic tumors and can also be used in conjunction with TACE for larger ones.

Anticardiolipin antibody-related Budd-Chiari syndrome: report of a case.

We report a case of a 37-year-old female who suffered from upper abdominal pain, progressive abdominal distention, shortness of breath, palpitation and pitting edema of lower legs for more than one month. Abdominal sonography showed small caliber of hepatic veins, mild hepatosplenomegaly and moderate ascites. Computed tomography of abdomen disclosed extensive thrombi in bilateral femoral veins, ovarian veins and inferior vena cava. Ascites was transudate with normal cell count. Laboratory data showed hypoalbuminemia, mild elevation of total bilirubin and iron deficiency anemia. Anti-cardiolipin antibody was positive and antinuclear antibody was negative. The histopathological features, including sinusoidal dilatation with atrophic change of adjacent hepatocytes, slight congestion and hemosiderin-like material within the cytoplasm of Kupffer cells, were compatible with the criteria of Budd-Chiari syndrome. Heparin was intravenously administered immediately to prevent further progression of thrombosis. The ascites was successfully controlled with diuretics (spironolactone and furosemide). After a two-week course of treatment, she was discharged in good condition and on warfarin anti-coagulant medication.

Retroperitoneal Liposarcoma: Report of a Case

Liposarcoma is one of the most common adult soft tissue sarcomas, and comprises several subtypes ranging in behavior from non-metastasizing neoplasms to high-grade sarcomas with full metastatic potential. Due to its varied and diverse appearances, liposarcoma causes much concern among clinicians. We report a case of an 80-year-old man suffering from retroperitoneal liposarcoma with an initial presentation of abdominal distension, protruded umbilicus, and bilateral lower leg swelling. Abdominal sonographic examination showed a giant tumor with multiple cyst-like structures over his right lower abdomen. Subsequent abdominal computed tomography revealed a huge, abdominal, mixed cystic and solid mass. Later the patient received debulking and jejunum segmental resection. Pathologic examination confirmed that the tumor was retroperitoneal liposarcoma. We also review the classification, clinical presentation, prognosis, and management of liposarcoma.

Hepatocellular Carcinoma Extending within the Biliary Tract without Detectable Primary Hepatic Tumor: Report of a Case

A very rare case of hepatocellular carcinoma (HCC) extending within the common bile duct (CBD) and left intrahepatic duct (IHD) with no detectable primary hepatic tumor in a 52-year-old Taiwanese man is reported. The patient was hospitalized with a one-month history of jaundice, abdominal fullness, and poor appetite. Imaging studies revealed a hepatic tumor at the medial segment of the left hepatic lobe with bilateral IHD dilatation, and cholangiocarcinoma was suspected. Extended left hepatic lobectomy was performed. Subsequent pathological examination revealed HCC in hepatic bile ducts and CBD. No tumor invasion into the surrounding liver was noted. The postoperative clinical course was good, and the patient was free of symptoms and disease 15 months after the operation. To our knowledge, this has not been previously reported in Taiwan.

Carbon Dioxide Enhanced Ultrasonography of Hepatic haemangiomas

The purpose of this study was to characterize the imaging manifestations of carbon dioxide enhanced ultrasonography (CO2US) in hepatic haemangiomas. CO2US was performed for 52 haemangiomas in 25 patients and for 352 various hepatic nodules in 192 patients. Characteristic enhancement patterns for hepatic haemangiomas were noted. All 39 large haemangiomas (> 1 cm) demonstrated peripheral nodular enhancement in the early and parenchymal phases associated with delayed washout character (> 30 min). Centripetal fill-in of CO2 was noted in 82.1% of large haemangiomas. Two enhancing patterns were noted in 13 small haemangiomas (< 1 cm): peripheral nodular (69.2%) and homogeneous (30.8%). Delayed washout was also noted in all small haemangiomas. Centripetal fill-in of CO2 was hard to define in small haemangiomas. None of the other 352 hepatic nodules had the same imaging features. In conclusion we found that CO2US is valuable in differentiating hepatic haemangiomas from other liver tumours in clinically doubtful cases.

Drug-induced liver disease - A review of 14 cases

The clinical and pathological features of 14 cases of acute drug-induced liver disease (DILD) were analyzed using the French group method for drug reaction assessment. Among them, 8 were of the cytotoxic type, 4 were of the cholestatic type and 2 were of the mixed type. Serum alkaline phosphatase (ALP) levels of the cytotoxic type DILD were all < 1.8 times the normal value, while those of the cholestatic type DILD > 1.8 times (P < 0.05). The alanine aminotransaminase and aspartate aminotransaminase (ALT and AST) levels of the cholestatic type were all < 13.1 times the normal value, while those of the cytotoxic type varied from 2.2 to 118 times the normal value. We found that steatosis was the major feature in the cytotoxic type with ALT and AST < 2.5 times the normal value. Piecemeal necrosis was noted only in all the cases with ALT and AST > 20 times the normal value. In the cholestatic type, the pathological features of the oral contraceptive-related DILD showed mainly cholestasis, whereas chlorpromazine-related DILD revealed additional portal inflammation. Meticulous taking of patient history and clinical assessment are mandatory for the diagnosis of DILD. The ALP levels were helpful in distinguishing different types of DILD. There are some correlations between biochemical changes and pathological features, and both are helpful in distinguishing different etiologies of DILD when the inciting drug is in doubt.