Jung-Ta Chen

Liver resection for hepatocellular carcinoma in octogenarians.

BACKGROUND Liver resection is risky in patients aged > or = 80 years. Because of short life expectancies and improved nonoperative modalities, the role of liver resection in octogenarians with hepatocellular carcinoma (HCC) is unclear. METHODS A retrospective review of the operative results of 260 patients with HCC between 1991 and 1997 was performed. According to the age at the time of operation, these patients were divided into 2 groups. Group 1 comprised 21 patients aged > or = 80 years, and group 2 comprised the other 239 younger patients. The backgrounds, pathologic features of the tumor, and operative results of the patients were compared. RESULTS Octogenarians had a higher incidence of associated medical diseases, a higher incidence of negative serum hepatitis B surface antigen, a lower alpha-fetoprotein level, and a higher indocyanine green retention rate. Although octogenarians had a longer postoperative hospital stay, there were no significant differences between the 2 groups regarding operative morbidity and mortality. The 5-year disease-free and actuarial survival rates for octogenarians and younger patients were 50.6% and 35.3% (P = .15) and 40.9% and 59.3% (P = .46), respectively. CONCLUSION Under meticulous preoperative assessments and postoperative care, liver resection for HCC is justified in selected octogenarians, with short- and long-term results comparable to those of younger patients.

Mesohepatectomy for centrally located hepatocellular carcinoma: an appraisal of a rare procedure

BACKGROUND For centrally located hepatocellular carcinoma (HCC), extended major hepatectomy is usually recommended, but the risk of postoperative liver failure is high when liver function is not sound. Mesohepatectomy (en bloc resection of Goldsmith and Woodburnes left medial and right anterior segments or Couinauds segments IV, V, and VIII) is a rare procedure, so its role in treating HCC is unclear. STUDY DESIGN We retrospectively reviewed 364 patients who underwent a curative resection for HCC. Among them, 15 patients were treated by mesohepatectomy. Their nontumorous liver revealed cirrhosis in 11 and chronic hepatitis in 4. The mean tumor diameter was 12.8 cm. In 10 of the 15 patients, HCC also invaded adjacent organs. The operative results of another 25 patients with different disease extent who underwent extended major hepatectomy were compared. RESULTS The hepatic inflow occlusion time for mesohepatectomy was longer than for extended hepatectomy (p = 0.01). The mean operative blood loss, amount of blood transfusion, operating time, and postoperative hospital stay in the mesohepatectomy group were 2,450 mL, 1,100 mL, 7.9 hours, and 14.9 days, respectively. In the extended-hepatectomy group, the values were 1,863mL, 768mL, 5.8 hours, and 16.8 days, respectively (all p>0.05 compared with mesohepatectomy). No patient died after mesohepatectomy, but after extended hepatectomy there was one death from liver failure. The Union Internationale contre le cancer (UICC) TNM stages of patients who underwent mesohepatectomy were as follows: stage II in 1, stage III in 4, and stage IVA in 10. All patients who underwent extended hepatectomy presented with stage IVA disease. The 6-year disease-free and actuarial survival rates after mesohepatectomy were 21% and 30%, respectively. The 6-year disease-free survival rate after extended hepatectomy was 9% (p = 0.11 compared with mesohepatectomy). CONCLUSION Although mesohepatectomy is time-consuming, it is justified for selected patients with centrally located large HCC in a diseased liver.

Histologic study of effects of radiation synovectomy with Rhenium-188 microsphere

Rhenium-188 microsphere is a relatively new radiation synovectomy agent developed for the treatment of rheumatoid arthritis. It has been shown that the levels of unwanted extra-articular radiation are negligible with this agent. A histologic study was conducted to assess the effect of radiation synovectomy on synovium and articular cartilage after intra-articular injection of various doses of Re-188 microspheres into the knee joints of rabbits. Intra-articular injection of Re-188 microspheres into rabbit knee joints resulted in mild reactive inflammation and thrombotic occlusion of vessels which subsided rapidly. Sclerosis of subsynovium could be seen 12 weeks after injection. No evidence of damage to articular cartilage was noted. There was no significant difference in the articular pattern after injection of 0.3 or 0.6 mCi Re-188 microspheres. This study suggests that a treatment dose of Re-188 microspheres causes transient inflammation of synovium without any detectable damage to the articular cartilage of knee joint.

Primary coexistent adenocarcinoma and choriocarcinoma of the stomach : A case report and review of the literature

We report a case of primary gastric choriocarcinoma with liver metastasis. The mixed histologic patterns included adenocarcinoma, undifferentiated carcinoma, and choriocarcinoma. Immunohistologic staining for the beta-subunit of human chorionic gonadotrophin (beta-HCG) showed positive results in the choriocarcinoma, adenocarcinoma, and normal mucosal gland. However, positive HCG cells were present at different intensities in the choriocarcinoma, adenocarcinoma, and normal mucosal gland. The level of HCG was significantly increased in serum. This unusual tumor probably resulted from dedifferentiation of a primary adenocarcinoma or developed directly from the mucosal glands.

Discordance between Uterine Cervical Cytology and Biopsy: Results and Etiologies of a One - Year Audit

To investigate the etiologies of discrepancies between cervicovaginal smear and corresponding cervical biopsy results, a total of 15,474 cervicovaginal smears were sampled in a one-year period. Among these, 427 patients were diagnosed with atypical squamous cells of undetermined significance (ASCUS), dysplasia, or malignancy. The screen positive rate was 2.8%. All of the positive cases had histologic follow-up. Forty-nine of the 427 patients had a discrepancy of at least two grades (the grades are divided to negative, ASCUS, mild dysplasia, moderate dysplasia, severe dysplasia and invasive carcinoma), between the cytologic and histologic diagnoses. The discrepancy rate was 11.5%. Ten of these discrepant cases had poorly-preserved slides or a not definitely final diagnosis. A total of 39 cases (79.6%) of discrepancy were reviewed in this study. In thirty (77%) of the 39 discrepant cases, the errors were cytologic and in 9 cases (23%) the errors were histologic. Cytologic error was the major cause of cytohistologic discrepancy. The etiologies of cytohistologic discrepancy included: cytologic interpretation error, 17 cases (44%); cytologic sampling error, 10 cases (25%); biopsy sampling error, 6 cases (15%); cytologic screen error, 3 cases (8%); and biopsy interpretation error, 3 cases (8%). The major etiology of cytohistologic discordances was cytologic interpretation error. In this retrospective study, we determined the etiologies of cytohistologic discrepancies. This information can be useful for improving diagnostic accuracy and the quality of patient care.

Colorectal Mesenchymal Tumor: A Clinicopathologic Study of 25 Cases

Background: It is important to distinguish gastrointestinal stromal tumors (GISTs) from other gastrointestinal mesenchymal tumors (GIMTs), because of the malignant potential of GISTs and the availability of molecular targeted therapy. GISTs represent the most common subgroup of GIMTs, and rarely occur in the colon and rectum. The first objective of our retrospective study was to reclassify colorectal mesenchymal tumors, from files collected over 20 years, to determine if, based on immunohistologic features, the lesions were truly GISTs. The second objective was to identify the relationship between clinicopathologic features and prognostic factors of GISTs in the colon and rectum. Methods: We evaluated all cases of colorectal mesenchymal tumor identified from the database of the Department of Surgical Pathology at Taichung Veterans General Hospital for the period 1983‐2001. For 25 patients, clinical data, and information about tumor characteristics, surgical procedures, and survival outcomes, were obtained and analyzed. Histopathologic evaluations, and appropriate immunohistochemical markers, were used to distinguish between various GIMT subtypes. The relationship between KIT expression and clinicopathologic features was investigated. Results: The following variables were significantly associated with different CD117 results: symptomatic presentation, location, gross features, tumor size, mitotic count, cellularity, and type of surgery. Only 18 tumors were identified as GISTs. For these, the following variables were significantly associated (by univariate analysis) with increased lethality: tumor size (p = 0.049); mitotic count (p = 0.019); nuclear atypia (p = 0.019); and tumor necrosis (p = 0.045). However, only mitotic activity showed a significant difference in the survival analysis (p = 0.0304; log‐rank test). Conclusion: Two clinicopathologically different categories were identified from our colorectal mesenchymal tumors: intramural GISTs and polypoid submucosal leiomyomas. Our study suggests that GIST is a better categorization than smooth muscle tumor because of the malignant potential. Prognosis is strictly related to the number of mitoses. However, tumor size, nuclear atypia and tumor necrosis are probably also significant predictive factors of lethality. Future studies with DNA analysis and larger patient numbers are essential to evaluate the prognostic significance of our findings.

P53 Protein Presentation of Colorectal Adenomas and Carcinomas in Taiwan: Experience of Two Hospitals

Objective: We first attempted to determine if the p53 protein presentation of colorectal adenomas and carcinomas showed any difference between Taiwanese and other populations. Second, as incompletely polypectomized or biopsied adenomas of the colorectum are a troublesome issue in routine practice, we sought to determine if p53 protein is a helpful indicator for clinicians in deciding the subsequent therapeutic mode for incompletely removed tumors. Materials and Methods: We studied formalin-fixed tissue, include-ing 110 adenomas, 46 adenocarcinomas arising from adenomas, and 62 frank adenocarcinomas with routine immunohistochemical staining and statistical analysis. Results: The average ages of patients with adenomas, adenomas, adenomas, adenocarcinomas arising from adenomas, and frank adenocarcinomas were 63.3, 67.1, and 69.3 years. The p53 protein-positive rates of these 3 groups were 6.4%, 28.3%/32.6% (adenomatous part/adenocarcinomatous part), and 71.0%, respectively. Conclusions: First, there was no statistical differ-ence in colorectal p53 protein presentation between Taiwanese and other populations. Second, histologically, the villous morphol-ogy and dysplastic severity of the adenoma were not correlated with p53 protein expression. Third, the sequential increase in p53 protein overexpression from adenomas to frank adenocarcinlmas supports the hypothesis of an adenoma-carcinoma sequence in polypoid colorectal tumors. The transformation duration frome adencmas to carcinomas is about 6 years. Fourth, an incompletely polypectomized adenoma, which shows low dysplasia or a small villous component but p53 protein overexpression, should be aggressively completely resected.

Removal of Renal Cell Carcinoma Extending into Supradiaphragmatic Inferior Vena Cava Using Cardiopulmonary Bypass with Deep Hypothermic Circulatory Arrest - A Report of 2 Cases

Cardiopulmonary bypass with deep hypothermic circulatory arrest has been established as a useful method in the surgical management of patients with rend cell carcinoma and large infe-rior vena caval tumor thrombi. We present our experience with 2 cases of renal cell carcinoma extending into the supradiaphragmatic inferior vena cave using cardiopulmonary bypass with deep hypothermic circulatory arrest. (j Urol R.O.C., 10:173-176,1999)

Melanoma in Urology: Experience and Review of Literature

Primary melanoma of the genitourinary tract is uncommon. Rare cases have been described in most organs of genitourinary tract. The majority of reports show that penis and urethra are frequently involved. Unfortunately, early diagnosis is not the rule and current therapeutic modalities most often fail. Secondary involvement of genitourinary tract with malignant melanoma is a common autopsy finding, but rarely evident clinically. We report three primary cases and one secondary case involving kidney and psoas muscle between 1983 and 1996. The average age of the patients was 66 years (range, 61-73 years). All the four victims were male and died due to multiple metastases. All the available managements including conservative treatment, radical surgery, chemotherapy (dacarbazine) and immunotherapy (interferon, Bacillus Calette-Guerin) were tried. But it confirms the consensus of available reports that, irrespective of what type of therapy being used, the prognosis usually is unsatisfactory. More developed immunotherapy and biological therapy as adjuvant treatment is expectant. We also briefly review the literature of current treatments.