Jong Hwan Choi

Fanconi's Syndrome Associated with Prolonged Adefovir Dipivoxil Therapy in a Hepatitis B Virus Patient.

Adefovir dipivoxil (ADV) is commonly used as an antiviral agent in the treatment of chronic hepatitis B or human immunodeficiency virus infection. Nephrotoxicity has been shown to occur at daily dosages of 60-120 mg. Fanconis syndrome is a generalized dysfunction of the renal proximal tubular cells, which is usually accompanied by complications. Here we report a case of Fanconis syndrome in a chronic hepatitis B patient who had been treated with a prolonged regimen of ADV at 10 mg/day. A 47-year-old man complained of severe back and chest-wall pain. He had chronic hepatitis B and had been treated with ADV at a daily dose of 10 mg for 38 months. He was hospitalized because of severe bone pain, and laboratory and radiologic findings suggested a diagnosis of Fanconis syndrome with osteomalacia. After discontinuation of the ADV, he recovered and was discharged from hospital. His laboratory findings had normalized within 2 weeks. This case indicates that Fanconis syndrome can be acquired by a chronic hepatitis B patient taking ADV at a conventional dosage of 10 mg/day. Therefore, patients treated with long-term ADV should be checked regularly for the occurrence of ADV-induced Fanconis syndrome.

Efficacy of Helicobacter pylori eradication therapy in chronic liver disease

BACKGROUND/AIMS Peptic ulcers occur more commonly in patients with liver cirrhosis (LC). Helicobacter pylori is recognized as the most important etiology in the pathogenesis of peptic ulcers. We investigated the efficacy of proton pump inhibitor (PPI)-based triple therapy in patients with chronic liver disease and peptic ulcer. PATIENTS AND METHODS One hundred sixty-three patients with LC or chronic hepatitis (CH) with a peptic ulcer and proven H. pylori infection were included. The combination of PPI, amoxicillin (1.0 g), and clarithromycin (500 mg), each given twice daily, was administered for 1 or 2 weeks. The eradication of H. pylori was determined by the rapid urease test, histology, or the 13C-urea breath test at least 4 weeks after completing the treatment. RESULTS The eradication rate of H. pylori was similar between the LC and CH groups; 82.6% and 88.1%, respectively. In addition, there were no significant differences in eradication rates between the patients with Child-Pugh class A and Child-Pugh class B/C disease. The side effects in each group were generally mild. Only the serum ALT levels showed a significant correlation with the success of H. pylori eradication in both the LC and CH groups. CONCLUSION The PPI-based triple therapy achieves high eradication rates for H. pylori infection, in patients with chronic liver disease, without significant side effects.

Value of the model for end-stage liver disease for predicting survival in hepatocellular carcinoma patients treated with transarterial chemoembolization

Objective. The aim of this study was to evaluate the prognostic value of the model for end-stage liver disease (MELD) and its modified forms, and to compare these scoring systems with other staging systems for hepatocellular carcinoma (HCC) patients treated with transarterial chemoembolization (TACE). Material and methods. A total of 325 patients who underwent TACE for the initial treatment of HCC between January 2000 and May 2007 were enrolled in the study. Before TACE was carried out, MELD, MELD-Na, Child-Pugh score, Okuda stage, CLIP score, JIS score, BCLC stage, and UICC stage were checked. After one month, ▵MELD and ▵MELD-Na were calculated. Results. Mean MELD/MELD-Na/▵MELD/▵MELD-Na scores were 7.5±3.7, 8.0±4.7, −0.2±3.5 and 0.04±4.5, respectively. MELD (p=0.009) and MELD-Na (p=0.017) significantly correlated with survival, but ▵MELD and ▵MELD-Na did not (p >0.05). The Child-Pugh score and other staging systems correlated significantly with survival (p <0.05). The AUROC values for 3, 12, and 36 months’ survival were 0.633, 0.545, and 0.615 for MELD; 0.655, 0.555, and 0.612 for MELD-Na; 0.639, 0.616, and 0.691 for Child-Pugh score; 0.714, 0.662, and 0.717 for the Okuda score; 0.837, 0.86, and 0.792 for the CLIP score; 0.859, 0.814, and 0.808 for the JIS score; 0.846, 0.833, and 0.749 for BCLC stage; and 0.878, 0.812, and 0.735 for UICC stage, respectively. Conclusions. MELD and MELD-Na showed good correlations with survival, especially for patients with early-stage disease. However, these were not superior to those of other staging systems or Child-Pugh score. These parameters should only be used as supportive data.

Pancreatic mucinous cystadenoma of borderline malignancy associated with clonorchis sinensis

To the Editor, The prevalence of pancreatic cystic neoplasm (PCN) has been increasing due to advances in diagnostic technology, including ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography and endoscopic ultrasound. When PCN is found incidentally, pancreatic cystic lesions may represent a malignant or premalignant neoplasm and require diagnostic evaluation [1]. Generally, cystic mucin-producing pancreatic neoplasms do not communicate with the pancreatic duct and are classified as benign adenomas or borderline, low-grade malignant and non-invasive or invasive carcinomas according to the grade of epithelial dysplasia. These tumors occur almost exclusively in females aged 50 to 60 years [1]. Mucinous cystic neoplasms (MCNs) are characterized by an ovarian-type stroma that typically forms a band of densely packed spindle-shaped cells beneath the malignant epithelium [1]. Although there are several hypotheses of their origin, the pathogenesis of pancreatic MCNs remains unclear because MCNs are rare and molecular studies are difficult since the tumors often contain only a small number of malignant cells [2]. Clonorchiasis is a parasitic disease common in Far Eastern countries, such as Korea and China. Its symptoms are diverse, although the majority of patients are asymptomatic. The parasite may damage bile duct epithelial cells, causing cholangitis and cholangiocarcinoma. The severity of the disease is proportionate to the number of the infectious parasites and the infection period [3]. Infection with a large number of parasites can result in invasion of the pancreatic duct [3] and the parasites may damage ductal epithelial cells and cause inflammation in the pancreas and the bile duct, leading to clonorchiasis-induced pancreatitis. There are reports associating clonorchiasis and pancreatic malignancies with biliary malignancies, including one case of clonorchiasis-associated pancreatic adenocarcinoma [4]; however, clonorchiasis-associated pancreatic MCN has not been reported. Here, we report a case of pancreatic mucinous cystadenoma of borderline malignancy infested with Clonorchis sinensis found incidentally in a 53-yearold male with rectal cancer. The patient presented with lower abdominal pain and hematochezia lasting 3 months. The patient often ate freshwater fish and was not a heavy drinker. His medical history was unremarkable except for chronic hepatitis B reactivation treated with 0.5 mg/day entecavir for 1 month. His mother also had chronic hepatitis B patient and succumbed to hepatocellular carcinoma. On admission, the patients body temperature, heart rate, respiratory rate, and blood pressure were 37.1℃ 70/min, 22/min, and 100/60 mmHg, respectively. Physical examination of the neck, chest, and abdomen showed no abnormal findings. Digital rectal examination revealed a non-tender, fixed, hard mass at the posterior rectum, 6 cm from the anal verge. An initial complete blood count revealed a hemoglobin count of 13.3 g/dL, a platelet count of 245,000/µL, and a white cell count of 5,700/µL. Biochemical testing showed a blood urea nitrogen of 11 mg/dL, creatinine of 0.6 mg/dL, total protein of 7.1 g/dL, albumin of 3.4 g/dL, aspartate amino transferase of 41 IU/L, alanine transaminase of 37 IU/L, alkaline phosphatase of 69 IU/L, uric acid of 4.4 mg/dL, total calcium of 8.7 mg/dL, phosphorus of 5.1 mg/dL, lactate dehydrogenase of 233 IU/L, carcinoembryonic antigen of 1.4 ng/mL, carbohydrate antigen 19-9 22.0 U/mL, and α-fetoprotein of 62.9 ng/mL. A chest X-ray evaluation showed no specific findings. Gastroscopic examination showed no specific abnormality. Colonoscopic examination revealed a large ulcerofungating mass at the distal rectum, and he was diagnosed with adenocarcinoma of the rectum. Abdomen and pelvis CT showed an asymmetric contrast enhancement in the posterior wall of the distal rectum. In addition, a 4.3-cm, heterogeneous, solid and cystic mass on the distal pancreas was found incidentally (Fig. 1A and 1B). Abdominal MRI showed a multi-septated cystic tumor in the pancreas tail and a fibrotic component was found with mild contrast enhancement after gadolinium injection (Fig. 1C and 1D). There was no dilatation of the pancreatic duct in the tail portion, and there was no dilatation of the common bile duct or the intrahepatic bile duct. On day 2 of hospitalization, an ultra-lower anterior resection and distal pancreatectomy was performed. Gross examination of the resected pancreas presented a well-circumscribed cystic mass, measuring 4.4 × 4.4 × 3.7 cm. Sectioning revealed a multilocular cyst filled with mucinous and necrotic material (Fig. 2). Microscopically, the multilocular cyst was lined by tall-columnar, mucin-secreting cells with stratification and papillary growth, and mild to moderate nuclear atypia, without stromal invasion. These findings were consistent with a mucinous cystadenoma of borderline malignancy. In addition, there was a papillary growing, nodular lesion embedded in the myxoid and fibrotic stroma with numerous eggs, morphologically considered to be C. sinensis, The eggs were surrounded by epithelioid histiocytes or found within multinucleated giant cells (Fig. 3). The rectal sample obtained from the low anterior resection showed moderately differentiated adenocarcinoma invading the muscle layer, but without lymph node metastasis. Figure 1 Contrast-enhanced computed tomography and magnetic resonance imaging. (A) There was a 3.6-cm cystic mass with a suspicious biloculation in the pancreatic tail that extended to the spleen. (B) No pancreatic ductal dilatation was observed

A case of metastatic hepatocellular carcinoma of the rib, treated by transcatheter arterial chemoembolization

Bone is a common site of metastasis in patients with hepatocellular carcinoma (HCC). We report a rare case of rib metastasis from HCC treated by transcatheter arterial chemoembolization (TACE). A 55-year-old man with liver cirrhosis presented with right lower chest pain. The diagnosis was an HCC with a bone metastasis in the right eighth rib. Intra-arterial injections of doxorubicin mixed with Lipiodol and Gelfoam particles were instituted through the right eighth intercostal artery. Computed tomography and a Tc(99)-labeled scan performed 2 months after the third TACE revealed no viable HCC in the right eighth rib.