Yuk-Ming Tsang

Percutaneous Ethanol Injection Versus Surgical Resection for the Treatment of Small Hepatocellular Carcinoma: A Prospective Study

Objective:To compare disease recurrence and survival among patients with small hepatocellular carcinoma after surgical resection or percutaneous ethanol injection therapy, 2 treatments that have not been evaluated with a prospective study. Methods:A total of 76 patients were randomly assigned to 2 groups based on treatment; all had one or 2 tumors with diameter ≤3 cm, with hepatitis without cirrhosis or Child class A or B cirrhosis without evident ascites or bleeding tendency. Results:Follow-up ranged from 12 to 59 months. Among percutaneous injection patients, 18 had recurrence 1 to 37 months after treatment (true recurrence, 11; original safety margin inadequate, 3; limitation of imaging technology to detect tiny tumors, 4). Three injection therapy patients died of cancer 25, 37, and 57 months after treatment. For the surgical resection group, 15 had recurrence 2 to 54 months after treatment (true recurrence, 12; limitation of imaging, 2; neck metastasis, 1). Five resection patients died of cancer at 11, 20, 23, 26, and 52 months, respectively. By Cox regression model and Kaplan-Meier survival analysis, there is no statistical significance for recurrence and survival between treatment groups. However, tumor size larger than 2 cm and alpha-fetoprotein over 200 ng/mL correlated with higher recurrence rate, and Child class B liver cirrhosis correlated with shorter survival. Conclusions:Percutaneous ethanol injection therapy appears to be as safe and effective as resection, and both treatments can be considered first-line options for small hepatocellular carcinoma.

Small Hepatocellular Carcinoma—A Clinicopathological Study in Thirteen Patients

Abstract To investigate the diagnosis and clinicopathological features of hepatocellular carcinoma at its early stage, 13 patients with carcinoma ≤3.0 × 3.0 cm in size (small hepatocellular carcinoma) were studied with radionuclide scan, celiac arteriography, computed tomography, ultrasonography, and peritoneoscopy. Most of the patients were found from prospective studies in hepatoma high-risk subjects and were asymptomatic, with liver tests showing only mild abnormalities. Hepatitis B surface antigen was positive in all except one who was hepatitis B core antibody positive. Serum α-fetoprotein level was normal in 3 patients and in the remaining patients it increased to an extent far lower than in patients with advanced hepatocellular carcinoma. For detecting small tumors, ultrasonography, computed tomography, and celiac arteriography were superior to radionuclide scan or peritoneoscopy (detection rate: 95%, 94%, 89% vs. 16%, 12%, respectively). Small hepatocellular carcinoma was characterized as a hypoechoic shadow with weak internal echoes on ultrasonography, hypodense lesion on computed tomography, and hypervascular stain in angiography. None of these three examinations detected all the tumors in every patient and thus at least two of the three examinations should be done to avoid missing any tumor. Among them, the real-time ultrasonography was most practical for localizing small hepatocellular carcinoma and the diagnosis could be confirmed by ultrasound-guided biopsy. Ultrasonography was indispensable for identifying the small tumor during laparotomy in 3 patients. Ten patients had a single tumor. The small tumors were resected successfully in 10 patients. The tumor was frequently surrounded by a thin fibrous capsule and the most common cell type was of the trabecular pattern.

Clinical Management of Recurrent Hepatocellular Carcinoma

ObjectiveThe aim of this study was to evaluate the long-term benefits of the aggressive treatments with resection or transarterial chemoembolization (TACE) for recurrent hepatocellular carcinoma (HCC). Summary Background DataPrimary HCC is one of the most fatal malignancies in Taiwan. The result of resection for HCC remains unsatisfactory, primarily due to the high recurrence rate. To improve surgical results, recurrent HCC must be treated with aggressive resection or TACE. MethodsThe authors evaluated the results of repeated hepatic resection among 25 patients with recurrent HCC and of TACE among 12 patients with resectable recurrent HCC. The outcomes of an additional 64 patients with unresectable recurrent HCC were also evaluated. ResultsDuring the follow-up period from 2–112 months, 52% (13/25) of patients receiving repeat resection (group 1) were alive, whereas 42% (5/12) of patients receiving TACE (group 2) were alive. No perioperative deaths within 30 days after surgery occurred in the repeated resection group. The cumulative survival rates at 1,2,3, and 5 years after the first operation were 92%, 84%, 71.6%, and 65.1 % in group 1 and 83.3%, 75%, 75%, and 22.5% in group 2. The survival rates at 6 months and at 1,2, and 3 years after recurrence were 92%, 72%, 64%, and 44.8% in group 1 and 83.3%, 75%, 66.7%, and 48% in group 2.The survival of patients with unresectable recurrent HCC was much worse: 1 -, 2-, 3-, and 5-year survival after surgery was 57.8%, 29.8%, 15.5%, and 0%; and 6-month and 1-, 2-, and 3-year survival after recurrence was 46.5%, 29.2%, 12.5% and 7.8%. ConclusionsMore aggressive treatment with repeated hepatic resection can prolong survival time after recurrence of HCC in selected patients. However, TAGE can also achieve good results although it is not thought of as curative.

Applicability of staging systems for patients with hepatocellular carcinoma is dependent on treatment method – Analysis of 2010 Taiwanese patients

The aim of this study was to compare six prognostic staging systems (Okuda stage, TNM stage, CLIP score, BCLC stage, JIS score and Tokyo score) in predicting survival in patients with hepatocellular carcinoma (HCC). A total of 2010 Taiwanese HCC patients were included. Demographic, laboratory and tumour characteristics were determined at diagnosis. Predictors of survival included serum levels of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, ascites, tumour size and portal vein invasion. The Tokyo score was the most informative one for predicting the survival of HCC patients as a whole, receiving surgical resection, or receiving transarterial chemoembolisation. CLIP score was the best fit system for HCC patients receiving chemotherapy or supportive care. Each staging system showed a significant difference in predicting the probability of survival across different stages. The applicability of staging systems for patients with HCC was dependent on treatment methods.

Bile duct hamartomas : A report of two cases

Bile duct hamartomas (von Meyenburgs complexes) of the liver are usually detected at laparotomy or autopsy as an incidental finding, and usually they are multiple. We report two cases of proved bile duct hamartomas of the liver. The first was in a 65-year-old man whose initial sepsis and many hepatic lesions were interpreted as microabscess of the liver. The second patient was a 39-year-old man, a hepatitis B surface antigen carrier, in whom an incidental hepatic tumor was found. We suggest that liver biopsy be done in hepatic lesions with uncertain clinical features, because the histologic findings may change the treatment plan.

N-butyl Cyanoacrylate Embolization as the Primary Treatment of Acute Hemodynamically Unstable Lower Gastrointestinal Hemorrhage

PURPOSE To evaluate N-butyl cyanoacrylate (NBCA) embolization as the primary treatment for patients with severe and acute hemodynamically unstable lower gastrointestinal bleeding. MATERIALS AND METHODS Twenty-seven patients with acute, unstable hemodynamics caused by lower gastrointestinal bleeding underwent therapeutic NBCA microcatheter embolization over a period of 27 months. The inclusion criteria were hematochezia or melena and hypotension refractory to conservative treatment and requiring blood transfusion. Bleeding was localized to the rectum, colon, or small intestine in all nine such cases. Fifteen patients had severe underlying comorbidities, including sepsis, respiratory failure, malignancy, or renal failure. RESULTS The procedure was technically successful in all patients. Twenty-six patients were treated solely with NBCA, and one required microcoil embolization. Embolization was performed at the level of the arteria recta or as close as possible to the point of bleeding. Immediate hemostasis occurred in all cases. Four patients experienced repeat hemorrhage, one of whom died. The other three were treated successfully with repeat NBCA embolization. None of the surviving patients had evidence of bowel ischemia. In addition, none of the patients with severe underlying disease died during the follow-up period (range, 3 mo to 2 y). CONCLUSIONS The present findings suggest that NBCA embolization may be a safe alternative treatment for the management of lower gastrointestinal bleeding. Further studies are warranted to confirm the findings.

Primary adrenal leiomyosarcoma.

Leiomyosarcomas of adrenal origin occur infrequently, always present as huge abdominal masses, and are associated with poor prognoses when other organs are invaded. Radiologic images of small adrenal leiomyosarcomas have not been published. This report presents magnetic resonance images of a 3-cm left adrenal leiomyosarcoma from a 49-year-old male. Ten months after adrenalectomy, the patient was alive without tumor recurrence.

Bacterial Infections Associated with Hepatic Arteriography and Transarterial Embolization for Hepatocellular Carcinoma: A Prospective Study

Sepsis and liver abscess are serious complications following transarterial embolization (TAE) for hepatocellular carcinoma (HCC). However, the exact incidence and the necessity of antibiotic prophylaxis remain undetermined. Between November 1996 and November 1997, we prospectively studied bacterial infections in 231 HCC patients who underwent 287 angiographic procedures without antibiotic prophylaxis, including 176 TAEs and 111 hepatic arteriographies (HAs). Four of the 111 HAs were complicated by transient asymptomatic bacteremia. Of the 176 TAEs, 2 were associated with asymptomatic bacteremia, and 7 (4%) were associated with symptomatic bacterial infection, including 3 cases of sepsis, 2 of liver abscess, and 2 of infected biloma. For patients with HCC, TAE was associated with a higher risk of developing symptomatic bacterial infections than was HA (4% vs. 0, respectively; P = .03). Previous gastrectomy was the only possible risk factor for liver abscess. Finally, early diagnosis and treatment of these infectious complications usually result in successful outcome.

On Concise 3-D Simple Point Characterizations: A Marching Cubes Paradigm

The centerlines of tubular structures are useful for medical image visualization and computer-aided diagnosis applications. They can be effectively extracted by using a thinning algorithm that erodes an object layer by layer until only a skeleton is left. An object point is ldquosimplerdquo and can be safely deleted only if the resultant image is topologically equivalent to the original. Numerous characterizations of 3-D simple points based on digital topology already exist. However, little work has been done in the context of marching cubes (MC). This paper reviews several concise 3-D simple point characterizations in a MC paradigm. By using the Euler characteristic and a few newly observed properties in the context of connectivity-consistent MC, we present concise and more self-explanatory proofs. We also present an efficient method for computing the Euler characteristic locally for MC surfaces. Performance evaluations on different implementations are conducted on synthetic data and multidetector computed tomography examination of virtual colonoscopy and angiography.

Hepatic metastases: Rat models for imaging research

Improved rat liver tumor models with solitary or multiple metastatic tumors were developed for radiological imaging research. Unlike previous studies which employed trocar inoculation of tumor fragments, an enzymatically disaggregated cell suspension of mammary cancer was injected by fine needle either directly into the liver to produce solitary cancer nodules, or indirectly via the spleen or mesenteric vein to produce multiple liver metastases. Tumor size was proportional to the time elapsed after implantation. The operative mortality of direct liver, splenic parenchymal, and mesenteric inoculations were 8%, 4%, and 27%, respectively. MR tissue characteristics, image contrast, and pharmaceutical enhancement of these tumors closely resembles human hepatic metastases. The availability of reproducible, inexpensive animal models of metastatic cancer allows efficient evaluation of new liver imaging techniques.