Sun-Yen Chou

Pulmonary metastasis of hepatocellular carcinoma associated with transarterial chemoembolization.

UNLABELLED Recent advances in both diagnosis and treatment of hepatocellular carcinoma have improved the prognosis and changed the clinical significance of the subsequently increasing distant metastases. Pulmonary metastasis of hepatocellular carcinoma associated with transcatheter arterial chemoembolization has rarely been reported. METHODS To evaluate whether transcatheter arterial chemoembolization increases the risk of pulmonary metastasis of hepatocellular carcinoma, 230 patients were studied. Among them, 156 received transcatheter arterial chemoembolization with an interval of 12-16 weeks, the remaining 74 cases refused transcatheter arterial chemoembolization and received only conservative treatment. All patients were followed up with chest x-ray films taken before transcatheter arterial chemoembolization, during admission or in the out-patient department. The mean follow-up interval was 3.37 +/- 1.51 months. RESULTS Pulmonary metastasis was found in 25.6% (40/156) and 8.1% (6/74) of the patients with and without transcatheter arterial chemoembolization (p = 0.002). The median interval between initial diagnosis and pulmonary metastasis was 3.39 +/- 0.08 and 11.72 +/- 2.91 months among patients with and without transcatheter arterial chemoembolization (p = 0.001). The mean age, sex, existence of cirrhosis, severity of cirrhosis, presence of collateral arterial circulation, amount of lipiodol and agent of anti-cancer drugs were not associated with the development of lung metastasis. However, factors predisposing to lung metastasis included: solitary tumor with tumor size > 10 cm, multiple tumors with main tumor > 5 cm or diffuse hepatocellular carcinoma, intrahepatic portal vein thrombosis, arterioportal or arteriovenous shunt, and the presence of incomplete tumor necrosis after transcatheter arterial chemoembolization (especially combined with necrotic area > 50% main tumor size). CONCLUSIONS Pulmonary metastasis associated with transcatheter arterial chemoembolization has a strong adverse impact on patient survival.

Retroperitoneal Tuberculous Lymphadenitis Mimicking a Pancreatic Head Tumor: Report of a Case

This reported case concerns a 28-year-old male suffering from fever of unknown origin. An intraabdominal tumor was found at the pancreatic head portion by ultrasonography. A pancreatic head tumor was suspected initially. Abdominal computed tomography and endoscopic ultrasonography also revealed a pancreatic head lesion. Laparotomy was performed later and an enlarged lymph node around the pancreatic head was noted. The pathology report was consistent with the diagnosis of tuberculous lymphadenitis. Anti-tuberculous therapy was given and the patient became afebrile. This case is the first that we have encountered. The clinical features, pathogenesis and treatment of the retroperitoneal tuberculous lymphadenitis are described with a brief review and discussion.

Serum Amylase and Lipase Levels in Acute Patients with Pancreatitis Versus Nonpancreatic Abdominal Pain

The serum amylase level may be elevated in acute pancreatitis, as well as other conditions which may present with abdominal pain. Conversely, normoamylasemia in acute pancreatitis is not uncommon. Some authors have suggested that serum lipase is a better serum masker for the diagnosis of acute pancreatitis. We conducted a study to evaluate: (1). the differences in serum amylase and lipase levels between patients with acute pancreatitis and those with nonpancreatic abdominal conditions. (2). the diagnostic accuracy of serum amylase and lipase levels between these two groups. The serum amylase and lipase levels were estimated in 47 patients with acute pancreatitis and 30 patients with nonpancreatic abdominal pain. Four (8.5%) patients had normoamylasemia in the acute pancreatitis group, however, almost all the patients in this group had elevated serum lipase levels. Elevated serum amylase levels in eleven (36.7%) and serum lipase levels in four (13.3%) patients were noted in the nonpancreatic abdominal pain group. Ten (33.3%) patients in the nonpancreatic abdominal pain group had serum amylase levels that overlapped those found in the acute pancreatitis patients. Only one (3.3%) patient in this group had serum lipase level that overlapped those found in acute pancreatitis patients. The sensitivity, specificity and the accuracy of the serum lipase levels in the diagnosis of acute pancreatitis were 100%, 86.7% and 94.8%, respectively. These were better than those of the serum amylase levels of 91.5%, 63.3% and 80.5%, respectively. If a higher cutoff value was chosen, that was 1.3 times the upper limit of normal, the sensitivity, specificity and the accuracy for serum lipase would be 100%, 96.7% and 98.7%, respectively and serum amylase 89.4%, 90% and 89.6%, respectively.

Concomitant Digestive Malignancy in Pregnancy

Cancer of the digestive organs occurring during pregnancy is uncommon. To date, there have been fewer than 250 cases of pregnancy associated with alimentary tract carcinoma presented in the literature, the estimated incidence being one in 100,000 pregnancies. From January 1983 through April 1992, we enrolled in our study 13 cases of digestive tract cancer during pregnancy including 8 cases of colorectal cancer, 2 cases of gastric cancer, and 3 cases of hepatocellular carcinoma. Herein, the clinical manifestations, diagnosis, treatment, and prognosis of each pregnant patient as well as the fetus are reviewed. The presenting symptoms in these patients, including nausea, vomiting, abdominal fullness or pain, non-specific dyspepsia, constipation, and rectal bleeding, were often confused with the physiological features of pregnancy. Therefore, the major difficulty in diagnosis of cancer is that the presenting symptoms of pregnancy overshadow the non-specific symptoms of early alimentary tract cancer. This report may help to remind clinicians of the possibility of cancer during pregnancy.

Detection of Antibiotic-Associated Colitis Using the Clostridium Difficile Toxin Test

Twenty five patients with antibiotic-asssociated colitis were evaluated. Thirteen of them were tested with the latex agglutination test for Clostridium difficile toxin (CDT). The positive rate of the CDT test was 30.8%, which was higher than that for stool cultures. Pseudomembranes were observed in 96% of the patients. They underwent colonic endoscopy, which is still the main tool in the diagnosis of antibiotic-associtated colitis. There was one patient who did not have pseudomembranes on the rectosigmoid colon but was tested postive for CDT. The CDT test is complementary to the clinical diagnosis of antibiotic-associated colitis.

The Significance of the Polypoid Lesion of the Gallbladder

自從超音波掃描術廣泛使用之後，膽囊息肉樣病變(Polypoid lesion)極為常見。本文擬對此種病變之超音波徵象及其臨床意義加以探討，以了解何種情況較有可能為膽囊癌，從而判斷何種病例適於接受膽囊切除術。 本系列選擇病人之條件為：(1)超音波掃描發現膽囊壁之息肉狀隆起病變，它不造成音影，亦不隨病患改變姿勢而移動位置；(2)每位病患者皆具症狀，且推測膽囊病變是其症狀發生之主要來源；(3)切除後之膽囊皆經過仔細之病理檢查。 總共有10位男性3位女性病例，年齡由27歲至28歲。有8例其膽囊中只有一個病變，其餘5例則有3個以上之病變。病變大小由2mm至13mm不等。其中只有2例其病變大於10mm，也證實為膽囊癌的唯有2例，其他病例的診斷為慢性膽囊炎3例，膽醇沉著症5例，腺瘤2例。病患之自覺症狀為體重減輕2例，類似急性膽囊炎之腹痛2例，右上腹鈍痛9例。 本系列病患以男性為多，且不乏年紀小於40歲之病例。而併有膽結石的只佔23%。因此，似可推斷膽囊息肉樣病變之發生機轉與膽結石之形成沒有很密切之關連。由于膽囊癌2例中，1例只有一個病變，另1例則有3個病變，至於其他良性病變也不一定為單發或多發。因此，病變數目多寡不能據以判斷是否有膽囊癌之可能。但是大於10mm以上之息肉在本系列中皆為惡性。因此，大於10mm以上之病變應是絕對的膽囊摘除適應症。介於5～10mm之間者，尤其併有症狀時，亦以切除為佳。至於小於5mm者，可藉助超音波作密切之追蹤觀察。