A step-wise logistic regression analysis of hepatocellular carcinoma. An aspiration biopsy study

Fine needle aspiration biopsy (FNAB) has become a popular method to diagnose mass lesions of the liver. Although several reports have listed FNAB criteria to be used to diagnose both primary and metastatic tumors of the liver, none have separated key cytologic criteria from secondary criteria. We reviewed the FNAB smears from 35 patients with proven hepatocellular carcinoma and 74 patients with proven metastatic tumors in the liver. All specimens were coded as to the presence or absence of the following variables: polygonal cells with centrally placed nuclei; well-defined, granular cytoplasm; large nucleoli; small cytoplasmic vacuoles; large cytoplasmic vacuoles; bile; polymorphonuclear leukocytes; malignant cells separated by sinusoidal vessels; endothelial cells surrounding tumor cell clusters; multinucleated tumor giant cells; basophilic intracytoplasmic inclusions; eosinophilic intracytoplasmic inclusions; and intranuclear cytoplasmic inclusions. A step-wise logistic regression analysis was performed on the data to determine the variables predictive of hepatocellular carcinoma. The statistical analysis selected polygonal cells with centrally placed nuclei, malignant cells separated by sinusoidal capillaries, and bile as the key cytologic criteria for hepatocellular carcinoma. Endothelial cells surrounding tumor cell clusters and intranuclear cytoplasmic inclusions were selected as secondary criteria by this analysis.

The effect of verapamil on cerebral cortical and spinal cord blood flow during proximal descending thoracic aortic occlusion

The mechanism of central nervous system (CNS) protection during proximal descending thoracic aortic cross-clamping (PDTAC) for aortic surgery using calcium channel blocking agents is not known. In order to determine the effect of verapamil on CNS blood flow during PDTAC, we calculated cerebral cortical (CC), proximal spinal cord (PSC), and distal spinal cord (DSC) blood flow using the microsphere method in Grade I beagles. Flow calculations were obtained at baseline (pre-PDTAC), following mobilization of the proximal descending aorta for 5-8 cm by ligating 3-5 pairs of intercostal arteries (ICA), during PDTAC (45 min), and during maximal reperfusion. Two groups were studied: 1) control (Cont) untreated (n = 5); 2) verapamil (Ver) treated (0.4 mg/kg IV just before PDTAC and just before reperfusion) (n = 5).

CONCLUSIONS

I) Proximal ICA ligation produces no compromise to SC blood flow. II) Verapamil may protect the CNS by: 1) maintaining cerebral autoregulation during reperfusion; and 2) dampening hyperperfusion of the distal SC during reperfusion.

Post-ischemia immunosuppression in a miniature swine model

Yucatan miniature swine were the experimental model used to examine the effect of ischemia-injury on post-ischemic monocyte (MO) and immune function. Monocyte plasminogen activator (PA) was depressed while MO tissue factor activity was increased. The ability of porcine monocytes to generate a primary in vitro antibody forming cell (AFC) response to sheep red blood cells (SRBC) also was depressed by ischemic injury. The mechanism by which ischemic injury modulated immunosuppression appeared to be through generation of immunosuppressive serum substances.

Primary aldosteronism: changing concepts in diagnosis and management

Unilateral adrenalectomy for benign causes of primary aldosteronism is an established procedure. The established surgical cure for aldosterone-producing adenoma justifies a thorough preoperative evaluation. No single test accurately identifies aldosterone-producing adenomas in patients with primary aldosteronism. However, a useful algorithm combines postural studies, computerized axial tomography, and adrenal vein catheterization for selective hormonal assay, if computerized axial tomography is negative or equivocal and the suspicion of aldosterone-producing adenoma is high. If an adrenal mass is present and biochemical studies suggest a diagnosis of aldosterone-producing adenoma, resection of the affected gland from a limited unilateral approach is indicated. Cure can be expected in 80 percent of cases. In the uncommon circumstance that the adrenal tumor was not an aldosterone-producing adenoma but a hyperplastic nodule, these patients may still be cured or more easily controlled with antihypertensive medications. Thirty-eight patients who underwent unilateral adrenalectomy are presented and discussed.

Management of injuries to the porta hepatis

The management of injuries to the porta hepatis is challenging and controversial. Although definitive, anatomic reconstruction of injured ductal or vascular structures is optimal, porta hepatis injuries are universally accompanied by injuries to other organs (3.6 in this series), which often precludes initial repair. Moreover, frequent injury to the inferior vena cava, aorta, or other major blood vessels in addition to the structures of the porta hepatis results in these injuries being treated in conjunction with exsanguinating hemorrhage. For that reason, control of hemorrhage is the initial management priority, with the initial operation requiring expeditious, if less than anatomically exact, operations. Eighteen of 31 patients survived porta hepatis injury. Hepatic artery injuries were treated by ligation. Complex injuries to bile ducts frequently required enteric-ductal anastomoses as secondary procedures. Of 29 patients with portal vein injuries, six were treated by ligation, 22 by lateral repair, and one with splenic vein interposition graft. As in earlier reports, the structure of the porta hepatis associated with the highest morbidity and mortality rates when injured was the portal vein.

Dextran as a modulator of immune and coagulation activities in trauma patients

Low Mr dextran has been utilized as a prophylactic therapy in treatment of coagulopathy. There is evidence that monocyte dysfunctions are important contributors to hypercoagulability episodes, as well as to immunoincompetence post-trauma. Dextran is a known monocyte modulator. Consequently, we evaluated the efficacy of dextran infusion in moderating immune dysfunction, monocyte aberrations, and hypercoagulability episodes. Twenty-eight trauma patients were randomly divided into two groups. One group of 15 received dextran at 1 g/kg wt/24 hr for 5 days in addition to standard resuscitation and treatment. The control or nontreated patient group received only standard treatment. Trauma patients in the two groups were retrospectively matched by injury severity score (ISS) to ensure comparability. Blood samples were collected daily for some studies and at 3-day intervals for other assays. In vivo coagulation status was evaluated by assessing the changes in intravascular fibrinopeptide A (FPA). Immune reactivity to the mitogen phytohemagglutinin (PHA) was also evaluated. Both monocyte production of plasminogen activator (PA) and monocyte production of procoagulant activity (PCA) have been shown to correspond to and be augmented by monocyte-T lymphocyte interactions. Consequently, monocyte production of plasminogen activator and procoagulant activity were assessed as measures of monocyte immune activity as well as indicators of monocyte function in controlling the balance between fibrinolysis and coagulation. Only patients with ISS of greater than 25 experienced significant immune, coagulation, or monocyte aberrations. Of those having an injury severity score (ISS) score of 25-35, all of the control and two of the dextran patients had significant perturbations in their immune and monocyte functions.(ABSTRACT TRUNCATED AT 250 WORDS)

Selective nonoperative management of blunt liver injury using computed tomography

Computed tomographic (CT) scans are used to evaluate victims of blunt trauma for abdominal injury when reasons for immediate laparotomy are not present. Twenty-four patients whose CT scans showed liver injuries that were small parenchymal lacerations or intrahepatic hematomas were managed without laparotomy. Intra-abdominal blood was absent or estimated to be less than 250 mL in volume. None of the patients were in shock; six patients required transfusions, none for acute abdominal bleeding. None of these patients subsequently required laparotomy or showed hepatobiliary problems at a follow-up examination less than one year later. Five follow-up scans showed varying degrees of resolution. Two patients died of severe head injury, but the liver injury did not contribute to the cause of death. Other patients with more severe blunt liver injury who were treated nonoperatively developed significant complications that required delayed surgery. It seems that patients with limited liver injury diagnosed by CT scan and selected by strictly applied criteria can be managed safely without laparotomy in a setting where rapid evaluation and treatment of any potential complication is available.

Determinants of survival after vena caval injury. Analysis of a 14-year experience

The records of 70 patients with vena caval injuries who were treated from 1970 through 1983 were reviewed to define factors determining patient survival. Fifty-two percent of patients survived, with the highest mortality in patients with blunt or shotgun injuries. The primary determinants of survival were the mechanism and type of injury, the initial BP, the hemodynamic response to fluid resuscitation, the location of the vena caval injury, the presence of multiple other vascular and solid organ injuries.

The role of packing and planned reoperation in severe hepatic trauma

Liver lacerations are the most common intra-abdominal injury that leads to death, and control of hemorrhage remains the primary problem in lowering mortality from severe hepatic trauma. We retrospectively reviewed operative trauma cases in which liver packing and planned reoperation were used as temporizing measures in hemodynamically unstable patients. These cases were compared to patients closely matched for age, sex, type of trauma, and associated injuries but who did not undergo liver packing and planned reoperation. Preliminary data support our contention that liver packing and planned reoperation is a valuable adjunct for the management of hemorrhage from severe hepatic injury without incurring increased morbidity or mortality. This technique is useful for the experienced trauma surgeon to arrest hemorrhage and gain hemodynamic stability before attempting definitive care and for the community hospital surgeons who after gaining hemodynamic control would like to transfer the patient to a tertiary care facility.

Hepatocellular carcinoma: assessment of resectability by computed tomography and ultrasound

A retrospective review of the CT and ultrasound scans from examinations of 30 patients who had hepatocellular carcinoma (hepatoma) was undertaken with special emphasis placed on evaluation of hepatic distribution of tumor, vascular invasion, and extrahepatic spread. Although both CT and ultrasound detected hepatoma in 29 of 30 patients (96%), CT showed more extensive hepatic parenchymal involvement in eight of the patients. Vascular invasion was seen more frequently with ultrasound than with CT. Invasion into the main portal vein was seen by ultrasound in 11 of 30 patients (37%). Extrahepatic spread of tumor was much more frequently detected by CT and was present in 21 of 30 patients (70%). A reasoned approach to the diagnostic workup of hepatomas that will minimize invasive procedures and unnecessary surgery is presented.

Oriental cholangitis

Oriental cholangitis is a poorly understood syndrome consisting of intrahepatic pigment stone formation with chronically recurrent exacerbations and remissions. Endemic to Asia, it is being encountered more frequently in the United States due to increased immigration of asians. Twenty-one patients with oriental cholangitis (9 men and 12 women), 19 to 84 years of age, all of whom immigrated from asian countries, were treated between 1970 and 1983. All had histories of episodic abdominal pain, most with jaundice, chills, and fever. Laboratory results were nonspecific but frequently included leukocytosis and hyperbilirubinemia. All patients were operated on with 15 having cholecystectomy, common duct exploration, and a bilioenteric anastomosis. E. coli was cultured from specimens obtained from the biliary tracts of all patients, and 13 patients had more than one organism. Four patients had a previous history of parasitic infection, and four different patients had parasites identified in the biliary tract intraoperatively. Early recognition and appropriate operation will decrease morbidity and mortality.

Hepatocellular carcinoma. Changing concepts in diagnosis and management

We studied 86 cases of hepatocellular carcinoma treated between 1968 and 1982. All other liver tumors were excluded. There were 73 male and 13 female patients (average age, 59 years). The most frequent symptoms were pain (73%), weight loss (56%), and increased abdominal girth (23%). The alpha 1-fetoprotein level was elevated in 23 of 32 patients, and the hepatitis B surface antigen was positive in 15 of 36. Significant differences in the hematocrit reading and total bilirubin and total protein levels were found between those patients with resectable and unresectable tumors. Forty-six patients underwent laparotomy, with a resection rate of 48%. There were six right hepatic lobectomies, four left hepatic lobectomies, and 12 trisegmentectomies . The long-term survival in patients who underwent laparotomy and biopsy only was 4.2 months, while those who underwent resection had an average longevity of 18.7 months (the longest was 11.5 years). Using new imaging techniques, the extent of tumor involvement and operability can be determined with greater accuracy. Criteria for resectability include (1) the absence of vena caval occlusion, (2) the lack of spread between lobes, (3) the absence of portal vein obstruction, and (4) the lack of extrahepatic metastasis.

Morbidity and mortality in hepatic trauma. A 5 year study

The records of 443 cases of liver trauma operated on at San Francisco General Hospital from 1976 to 1981 were reviewed. Forty-two percent of the injuries were due to blunt trauma, 32 percent to stabbings, and 26 percent to gunshot wounds. Seventy-two percent of the patients were treated by simple repair and only 8 percent of patients had to undergo major resection. Infections and pulmonary problems were the most common complications, and the overall morbidity was 38 percent. Associated injuries occurred in 84 percent of patients. Our overall mortality was 9 percent; mortality for blunt trauma was 14 percent, for gunshot wounds 8 percent, and for stab wounds 2.8 percent. Most deaths were intraoperative (58 percent), with the primary cause of death being exsanguination. Multiple organ failure accounted for most of the postoperative deaths. Our 5 years study and comparison with previous studies reaffirms our belief in a conservative approach to the traumatized patient with liver injury. Utilizing the aforementioned principles, we have managed to show a continual decrease in mortality in spite of treating a more severely traumatized group of patients. We believe that continued improvement in mortality and morbidity is possible through the prevention of trauma, adherence to our basic guidelines, and the implementation of new technological advances now on the horizon.

Atrial-caval shunting (ACS) after trauma

Since 1968 the atrial-caval shunt (ACS), along with inflow occlusion at the porta hepatis, has been used at San Francisco General Hospital in 18 trauma patients to control massive hemorrhage from the inferior vena cava, hepatic veins, or liver. Thirteen patients died from irreversible shock. Five patients survived their initial injuries; one of them died 45 days later from the complications of shock and sepsis. No patients survived who sustained blunt trauma and were admitted in cardiac arrest. Only one of ten patients with BP less than 70 mm Hg after resuscitation survived, whereas four of eight with BP greater than 70 mm Hg survived. ACS was used to control caval injuries in seven patients (one survivor), severe hepatic parenchymal fractures in four patients (two survivors), and combined hepatic and caval injuries in seven patients (two survivors). Survivors had an average of 5.75 associated injuries; nonsurvivors had 3.8. No complications of ACS occurred in the surviving patients.

Management of acute civilian vascular injuries

Vascular trauma continues to be an exciting and formidable challenge to surgeons. Increasing numbers of survivors of major vascular trauma such as suprarenal aortic and caval injuries are being reported in the literature. Successful repair of venous injuries rather than ligation is being achieved in significant numbers of cases. Combined team approaches utilizing new techniques of microvascular surgery and orthopedic fixation have dramatically improved the results of revascularization in extremity injuries and subsequent restoration of limb function.

Generation of tissue factor by patient monocytes: correlation to thromboembolic complications

Thromboembolic complications are often a common pathological consequence of severe soft tissue trauma. Recent demonstration that monocytes (M0) produce tissue factor (TF) has led to the suggestion that these TF producing M0 might play a role in coagulopathy. We have previously demonstrated that trauma patients with splenectomy develop aberrant monocyte function and this patient group is also known to be at high risk of hypercoagulability episodes. This paper is an initial report on the use of M0 TF as an indicator of and/or correlated to clotting episodes. Monocytes isolated form the Ficoll-Hypaque purified mononuclear cells of 46 normal individuals, 17 trauma patients and 6 surgical controls were assayed at 3 day post-injury intervals for their levels of TF activity. Changes in monocyte TF activity were correlated to increases in the fractional catabolic rate (FCR) of 125 I-fibrinogen. Trauma patients were retrospectively divided into those whose FcR was elevated to a level indicative of coagulopathy and those whose FCR levels were not associated with coagulation abnormalities. All trauma patients who exhibited significantly increased FCR experienced thromboembolic episodes and had monocytes whose TF activity was increased an average of 300% (mean = 47 units vs mean = 12 units) over surgical controls. These increase in monocyte TF activity occurred at 6-13 days post injury and preceded clinical manifestation of coagulopathy by 4-6 days. The increased monocyte TF activity demonstrated in this study was significantly correlated to detection of pathologically increased FCR (R = 0.850) and compared to other indices of hypercoagulability.

Injuries sustained from high velocity impact with water: an experience from the Golden Gate Bridge

Over 720 persons are reported to have died jumping from the Golden Gate Bridge. A review of 100 consecutive autopsies showed that, in the majority of cases, massive pulmonary contusion, pneumothorax, laceration or perforation of the heart, great vessels, or lungs by displaced ribs were the causes of immediate death. Irreparable fractures of the liver or spleen were the most common abdominal injuries. The persons fatally injured appeared to have entered the water in a horizontal position, experiencing maximal deceleration. In contrast, six survivors entered the water feet first with more gradual deceleration. These survivors remained conscious but sustained similar injuries of lesser degree; only one sustained rib fractures. Fifty per cent had fractures of the liver or spleen requiring operative therapy. Fifty per cent sustained lung contusions and subsequent pneumothoraces. Suspicion of underlying injuries to the liver, spleen, and lungs is essential during resuscitation of those who survive impact with water.

Is splenic salvage safe in the traumatized patient?

Thirty-three patients with splenic injuries were treated with splenic salvage techniques. These patients were seriously injured trauma victims, often with multiple organ system damage. Hemostasis of the spleen was achieved with topical agents in 26 patients. Six patients required suture repair, with one hemisplenectomy. The postoperative complication rate was 37%; however, none of the complications could be attributed to the splenic repair. No patient required reoperation for control of bleeding. There were no subphrenic abscesses, and delayed rupture of the spleen could not be established. Splenic salvage can be done safely in selected patients. Young patients, those with isolated splenic injuries, and those in whom the repair will not unduly complicate the operation should be considered for this procedure.

Management of portal vein injuries

Injuries to the portal vein are associated with a high mortality because of a high incidence of concomitant injury to surrounding structures and refractory shock. Repair of the portal vein injury is often difficult or impossible because of massive hemorrhage. The key to successful management of a portal vein injury is rapid blood volume resuscitation and obtaining rapid and adequate exposure. The optimal exposure for repair consists of reflection of the hepatic flexure of the colon with mobilization of the root of the mesentery, pancreas, and duodenum. Lateral venorrhaphy is the preferred method of management, but in hemodynamically unstable patients, ligation of the portal vein is an acceptable method of treatment.