Kuo-Feng Hsu

Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class a liver function

PURPOSE In contrast to hepatic resection (HR) for resectable early-stage HCC, the efficacy of transarterial chemoembolization (TACE) is controversial. This study is designed to compare the long-term outcome of TACE using superselective technique with hepatic resection for the treating resectable early-stage HCC and Child-Pugh class A liver function. METHODS In total, 185 consecutive patients with resectable early-stage HCC and Child-Pugh class A liver function were included: 73 patients received superselective TACE (group I) and 112 patients underwent HR (group II). We evaluated the therapy-related recurrence and long-term outcome and in both groups. The risk factors of recurrence and mortality were assessed by Coxs model. RESULTS The mean survival time of group 1 patient was similar to that of group 2 patient (40.8±19.8 vs 46.7±24.6 months respectively, p=0.91). The 1-, 3-, and 5-year overall survival rates after TACE (group I)and HR (group II) were 91%, 66%, and 52% and 93%, 71%, and 57%, respectively (p=0.239). The 1-, 3-, and 5-year recurrence-free survival rates in groups 1 and 2 were 68%, 28%, and 17% and 78%, 55%, and 35%, respectively (p<0.0001). Serum albumin, tumour size, tumour number and recurrence interval were independent risk factors for mortality. Serum albumin level, tumour size, tumour number, and treatment modality of TACE or HR could predict HCC recurrence. CONCLUSION TACE is an efficient and safe treatment for resectable early-stage HCC with overall survival rates similar to that of HR. Thus, TACE is indicated in selected patients with resectable early-stage HCC.

Malignant Perivascular Epithelioid Cell Tumor of the Mesentery: A Case Report and Literature Review

Background: Perivascular epithelioid cell tumors (PEComas) are very rare mesenchymal neoplasms, and have been found in various organs such as the liver, kidney, falciform ligament, uterus, uterine cervix, and both the small and large bowel. However, only 3 cases of mesenteric PEComa have been described in the literature so far. The treatment and prognosis of malignant mesenteric PEComas are discussed. Case Report: We report the case of a 59-year-old man diagnosed with PEComa. He underwent segmental resection of the jejunum and tumor resection. Malignant mesenteric PEComa was confirmed on the basis of clinicopathological features. Tumor resection was followed by concurrent chemoradiotherapy. Conclusion: Besides surgery, no effective treatment for malignant PEComa has been established thus far because of the rarity of this tumor. Here, we report our experience of treating a malignant mesenteric PEComa using surgery and subsequent adjuvant therapy, which effectively controlled disease progression and prevented local recurrence.

Hürthle cell carcinoma of the thyroid with contralateral malignant pleural effusion.

Background: Thyroid cancers with pulmonary metastases have been well documented. However, malignant pleural effusion has rarely been reported. Case Report: We present a 77-year-old patient who had Hürthle cell carcinoma of the thyroid with contralateral malignant pleural effusion. The diagnosis was based on consistency in the histopathological and immunohistochemical features of pleural fluid cytology and the final pathology of the thyroid tumor. Results: The patient was treated with total thyroidectomy and postoperative radioactive-iodine ablation. Unfortunately, he died for recurrent pleural effusion and pulmonary complication 6 months later. Conclusion: Identifying the origin of malignant pleural effusion is important to provide treatment guidance. In this report, we review the literature on diagnosis and treatment of thyroid cancer with malignant pleural effusion.

Rare rectal mucocele mimic tumor following hemorrhoidectomy in an adult patient

Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. There are case reports of rectal mucoceles following Hartmann’s procedure, and secon dary to high anal sphincter tone following spinal trauma (1,2). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (3,4). Scarring of the mucus fistula, or failure to create a mucus fistula are other described contributing factors. We report a case of small rectal mucoceles following hemorrhoidectomy which caused scarring and stricture of the anal canal.

Gallstone ileus with spontaneous resolution

Gallstone ileus is an unusual cause of intestinal obstruction. It is caused by impaction of one or more gallstones that enter the intestinal lumen via a cholecystoenteric fistula. Gallstone ileus is sometimes a challenge clinically and delayed diagnosis could carry a significant rate of complication and mortality. Resolution of gallstone ileus by spontaneous evacuation of gallstone is extremely rare. We present a case of gallstone ileus patient with a severe co-morbidity, treated with conservative treatment successfully by spontaneous evacuation of gallstone.

A paraduodenal hernia (Treitz's hernia) causing acute bowel obstruction

Paraduodenal hernias, also called Treitz’s hernia, are unusual causes of intestinal obstruction and account for 0.9% of all intestinal obstructions (1). Paraduodenal hernias constitute half of all internal abdominal hernias and occur when the small bowel herniates into the paraduodenal fossa with manifestation of intestinal obstruction (2). Specific clinical signs are often absent, leading to the frequent delay of correct diagnosis, with bowel necrosis resulting in up to 20% of patients (3). Herein, we present our case to increase the awareness of Treitz’s hernia and suggest the early CT scan intervention may be helpful to make the preoperative diagnosis of paraduodenal hernia.

Giant Axillary Lipoma

Lipomas, which are benign tumors composed of mature lipocytes, are the most common mesenchymal soft tissue tumors. They rarely grow beyond 10 cm in their cutaneous localization, which is most often on the trunk and extremities. It is unusual for lipomas to grow larger than a few grams or to present on the axillary region. In such cases, mammography and ultrasonography are typically considered for complete assessment of giant axillary masses. Herein, we report on a 60-year-old woman who presented with an asymptomatic, huge soft tissue mass on the right axillary region. She underwent wide-excision surgery, and the mass was confirmed to be benign lipoma on pathological analysis. In this report, we present our case and review the literature concerning rare giant axillary lipomas.

Application of marionette technique for 3-port laparoscopic liver resection.

Background: Laparoscopic liver resection has become a feasible and safe procedure for liver tumor, but it requires experienced surgeons in the case of hepatobiliary and laparoscopic surgeries. More minimally invasive laparoscopic techniques of liver surgery are developed. We here report our experience of using a marionette technique for 3-port laparoscopic liver resection. Methods: Between June 2009 and December 2010, 7 patients underwent 3-port laparoscopic liver resection with the use of marionette technique. Five patients had hepatocellular carcinoma. Two patients with prior abdominal operations for colon cancer had colorectal liver metastasis. The procedure of marionette technique was performed as below: after insertion of the 3 trocars, a 2-0 nylon straight needle line was inserted through the abdominal wall, and using the needle holder, it was allowed to traverse the liver edge twice. Then, the straight needle line was forced out of the abdominal wall and clamped using mosquito for traction. Another straight needle line was similarly created at the opposite side of the liver edge. Results: None of the patients had to be converted to open surgery. The mean operative time was 96.7±63.2 minutes (range, 45 to 195 min), and the mean volume of blood loss was 45.6±27.9 mL (range, 30 to 100 mL). The mean pain score recorded on the visual analog scale was 2.7±0.8. The mean hospital stay was 5.6±1.7 days (range, 4 to 9 d). Currently, all the 7 patients are alive, and the tumors have not recurred (Supplementary Digital Content video 1 http://links.lww.com/SLE/A67). Conclusions: Our experience demonstrated that the simple marionette technique procedure could help surgeons ease laparoscopic liver resection and achieve better postoperative results.

Acute appendicitis with superior mesenteric vein septic thrombophlebitis.

Septic thrombophlebitis of the superior mesenteric vein (SMV) is rarely caused by acute appendicitis. The clinical symptoms of SMV thrombophlebitis are varied and atypical, so the diagnosis is commonly delayed, resulting in a reported mortality rate of 30%-50%. We report a case of SMV septic thrombophlebitis caused by acute appendicitis in which the patient was successfully treated with surgical intervention, appropriate antibiotics, and anticoagulation therapy. A follow-up abdominal computed tomography scan after 3 months of treatment showed that the SMV thrombosis had been resolved.

Leukemoid reaction with metachronous tumors.

A 50-year-old female presented with a three-day history of watery diarrhea and frequently abdominal distension. She also complained the incomplete evacuation sensation following defecation. There were no changes in her appetite and body weight. In the medical history, she had diabetes mellitus but no gastrointestinal disease. Her vital signs revealed temperature of 36.8 °C, pulse of 84 /min and blood pressure of 127/76 mmHg. Physical examination showed one palpable mass over right lower quadrant abdominal region with mild tenderness. There is no remarkable finding on digital examination. The blood tests showed white blood count of 32 x 10 9 /L with 65% segmented neutrophils. Tumor markers, such as the α-fetoprotein (AFP) level, the carcinoembryonic antigen (CEA) level, and the carbohydrate antigen 19–9 (CA19-9) level, were within the normal range. Barium studies showed marked segmental luminal narrowing with mucosa destruction over the proximal ascending colon and cecum. Computed tomography (CT) of abdomen revealed one huge heterogeneous mass lesion over cecum. Colonoscopy disclosed a 5.5 cm submucosal mass in cecum with firm consistency, locating at 130cm from the anal verge and biopsy report showed hyperplastic polyp of the colon tissue. Therefore, the patient underwent right hemicolectomy and a huge submucosal tumor about 8 x 7 x 5.5-cm 3 in size over cecum with central necrosis was found at operation. The pathological findings revealed undifferentiated carcinoma located in the cecum from submucosal layer to pericolonic fat. The postoperative course was uneventfully and the WBC count gradually decreased to 20 × 10 9 /L postoperatively. Two months after the surgery, Unfortunately, ultrasonography of abdomen showed hypoechoic target-like lesion about 6.9 x 5.3 cm at segment 7of liver with his leukocyte counts ranging from 15 to 52 x 10 9 /L. Computed tomography (CT) of abdomen revealed a well-defined tumor about 6.4 x 5.5 x 6 cm at segment 7 and 8 of liver with portal vein tumor thrombi. She underwent right lobectomy of liver. Pathology report showed poor differentiated hepatocellular carcinoma (HCC). The postoperative course was uneventfully and the WBC count gradually decreased to 12 x 10 9 /L postoperatively. At approximately three months after surgery, recurrences were detected in the segment 2 of liver with WBC count up to 24 x 10 9 /L. The patient underwent wedge resection of segment 2 of liver. The patient was discharged in a stable condition 5 days after surgery. Two months later, the WBC count gradually decreased to 5.4 x 10 9 /L. The diagnosis of leukemoid reaction was finally established after surgical resection of the tumor was followed by normalization of the leukocyte count (Fig. 1). However, the patient died of tumor recurrence and multiple metastases one year later.