Orthotopic liver transplantation in primary liver tumors

Among 283 orthotopic liver transplantations made during the last 6 years at our institution, 22 (7.77%) were done on 19 patients with unresectable hepatic malignant tumors [hepatocellular carcinoma (17), angiosarcoma (1), and cholangiocarcinoma (1)]. None of them showed extrahepatic invasion, and only one had lymph node involvement. Cyclosporin A, corticosteroids, and azathioprine were administered for 3 months after the procedure, and maintenance therapy involved the first two drugs. Acute rejection rate and hospital stay were not significantly different compared with non-tumoral grafted patients. Three patients were retransplanted, one with uncontrolled acute rejection and two with chronic rejection. Intraoperative mortality was zero. Eight patients (42.1%) were alive at a mean follow-up of 31 months (range, 6-74). Four 22.2%) died with tumor recurrence, three of sepsis, two of respiratory insufficiency, one of hepatitis recurrence with cirrhosis, and one of primary lung neoplasia. If adequately selected, primary liver tumor patients may benefit from liver transplantation. Future research with adjuvant therapies will improve the results.

Liver transplantation in chronic viral B and C hepatitis

Liver transplantation is a valid treatment in chronic viral B and C hepatitis. But disease recurrence is very frequent in HBV hepatitis after the procedure, and its prevention and treatment are unresolved problems. Hepatitis C recurrence in the graft seems also to be common, and further studies of its pathobiology are needed.

[Nodular regenerative hepatic hyperplasia associated with primary biliary cirrhosis]

An Hepatic Regenerative Nodular Hyperplasia (RNH) linked to a stage I Primary Biliary Cirrhosis (PBC) is presented. The scientific literature backing such association in reviewed. The pathogenic relationship between the two lesions and the role of RNH in the onset of portal hypertension in the initial stages of PBC is discussed.

[Prospective study of cytomegalovirus infection in liver transplant recipients]

BACKGROUND

Cytomegalovirus (CMV) infection is an important cause of morbidity and mortality in liver transplant recipients. The aim of this study was to determine the incidence, clinical characteristics, risk factors and response to treatment of CMV infection in liver transplant recipients.

METHODS

Fifty-nine adult patients who underwent a liver transplant in our hospital were prospectively studied. Cell cultures were used to document CMV infection and disease. Ganciclovir treatment was only given to patients with documented CMV disease.

RESULTS

Active infection was shown in 47 of 59 patients (80%), and symptomatic infection (disease) in 17 (29%). The most frequent clinical presentation was hepatitis (9 cases) followed by flu-like syndrome (6 cases) and pneumonitis (4 cases). The average time from transplant to the diagnosis of CMV disease was 36 days. The seronegative recipients of seropositive donors developed symptomatic infection more frequently (66%) than other patients (p < 0.05). As well as the CMV serologic status before transplantation, the use of anti-OKT3 antibodies was the only risk factor related to CMV disease (p < 0.01). The treatment with ganciclovir was successful in 17 of 19 symptomatic episodes.

CONCLUSIONS

Active and symptomatic CMV infection in recipients of liver transplantation were very frequent in our study. The transplant from seropositive to seronegative and the use of anti-OKT3 antibodies increased the incidence of CMV disease. Ganciclovir appeared as a safe and, apparently, highly efficient drug.

Malignant lymphoma of jejunum with common variable hypogammaglobulinemia and diffuse nodular hyperplasia of the small intestine. A case study and literature review

We report a patient with common variable hypogammaglobulinemia and diffuse nodular lymphoid hyperplasia of the small intestine complicated by a jejunal malignant lymphoma. Immunopathological and histological studies showed a polymorphous centroblastic lymphoma with intracytoplasmatic IgM immunoglobulin and lambda light chains. Some mucosal nodules separate from the tumor mass showed atypical lymphoid cell populations similar to lymphoma cells, suggesting a transition between hyperplastic nodules and lymphoma nodules. Four similar cases, and six other patients with malignant lymphoma of the small intestine, associated with diffuse nodular lymphoid hyperplasia, but without immunodeficiency, have already been described. All these cases suggest that nodular lymphoid hyperplasia increases the risk of small intestine lymphoma.

The role of histopathology in hepatic transplantation

In hepatic transplantation, the recipient and the graft must manage a difficult symbiosis. The causes that can unbalance the mutual adaptation are various, but the clinical-biochemical hepatic graft syndromes they produce are not specific. Morphological study of the graft shows a distinct pattern for each type of dysfunction etiopathogeny. Such study may find: (1) immune attack: acute rejection or chronic rejection; (2) technical complications in the biliary tract or in the blood perfusion of the graft; (3) nonspecific cholestasis secondary to graft cold ischemia or preceding development of chronic rejection; (4) recurrence of the previous illness: graft infected by hepatitis virus; (5) opportunistic viral infections (cytomegalovirus, Epstein-Barr virus, herpesvirus, adenovirus); (6) reactions to drugs and toxics; and (7) combinations of several etiologies. Morphological knowledge enables the pathologist to collaborate in hepatic transplantation programs: elaborating protocols, selecting patients, diagnosing hepatic graft dysfunction, and assessing program quality.

[Serum aminoterminal procollagen type-III peptide in the diagnosis of chronic hepatopathies]

BACKGROUND

The aims of the present study were to 1) compare the serum levels of the aminoterminal peptide of procollagen type III (PIIIP) in patients with different chronic liver diseases, 2) correlate their concentrations with histologic features in liver biopsy and 3) evaluate their use in the diagnosis of liver diseases and in recognition of fibrosis.

METHODS

With these aims PIIIP was determined in 57 patients with different chronic liver diseases and in 50 healthy donors.

RESULTS

PIIIP was significantly elevated in patients with chronic active hepatitis (18.3 +/- 5.5 ng/ml; p less than 0.01) and with liver cirrhosis (27.8 +/- 11.7 ng/ml; p less than 0.001). The serum levels of this peptide related significantly with the severity of liver disease (p less than 0.001) in addition to the degree of morphometric liver fibrosis (Rs: 0.736; p less than 0.001) and with the degree of histologic activity (Rs: 0.78; p less than 0.001). The correlation between PIIIP and fibrosis was due to the relation between the same and inflammation. The levels of this peptide which were higher than 15 ng/ml were a sensitive test for the diagnosis of active liver disease (0.80) and cirrhosis (0.87) permitting differentiation between chronic and persistent active hepatitis. The differentiation between chronic active hepatitis and cirrhosis was only possible when 24 ng/ml were taken as a discriminative level.

CONCLUSIONS

The comparison of serum levels of the aminoterminal peptide of procollagen type III (PIIIP) in patients with different chronic liver diseases can predict moderate or high degrees of inflammatory activity when PIIIP are higher than 15 ng/ml. This test is of use for evaluating chronic hepatopathies although the levels reflect the activity of inflammation better than the degree of hepatic fibrosis.

Nodular regenerative hyperplasia of the liver in early histological stages of primary biliary cirrhosis

Nodular regenerative hyperplasia (NRH) is a condition characterized by hepatocytic nodules distributed throughout the liver without perinodular fibrosis. The etiology is unknown, but it has been reported in patients with a variety of diseases, including autoimmune diseases and primary biliary cirrhosis (PBC). In this study, the liver biopsies of 64 patients with PBC were reviewed. Thirty-five biopsies in histological stages I or II belonging to 30 patients were suitable for study. NRH was found in 43% of biopsies (47% of patients). In 80% of these biopsies, nodular transformation was focal, while it was diffuse in the remaining 20%. Splenomegaly was more common in patients with NRH. Laparoscopy displayed evidence of portal hypertension in two of these patients and endoscopy showed esophageal varices in one patient. Serum levels of gamma-glutamyl transpeptidase were also higher in these patients. Lesions in small intrahepatic vessels, florid bile duct lesions, and portal granulomas were found more frequently in biopsies with NRH. We conclude that nodular hyperplastic changes are very common in early histological stages of PBC, and consequently, this disease should be considered in the etiology of NRH. These changes may contribute to early development of portal hypertension in these patients.

[Wilson's disease. A retrospective analysis of 12 cases]

We reviewed retrospectively 12 patients with Wilson's disease diagnosed during a 16-year period (1974-1989). The prevalence rate was 0.6 per 100,000 individuals. Clinical onset was hepatic (50%) or neurologic (50%), but at diagnosis (6.4 years later) 67% of patients showed several clinical manifestations: hepatic, neurologic, renal and haematologic. Among the essential diagnostic indices we find false negative results for Kayser-Fleischer ring (25%), serum ceruloplasmin (8%) and total serum copper (34%). Ten patients were treated with penicillamine. This drug was effective and well tolerated, although one patient (10%) developed membranous nephritis and required to change successively to BAL and trien. In a 61 months follow-up 5 patients (42%) died from severe liver failure. Patients with poor prognosis had a diagnostic delay and a liver failure degree significantly greater than patients with good prognosis. Our results suggest the following conclusions: a) in Spain the prevalence rate of Wilson's disease is near the lower reported rate; b) the early diagnosis of Wilson's disease is rare; c) diagnosis should be made only when several essential indices are positive; d) early hepatic transplantation showed carried out in patients with acute or chronic severe liver failure.

[Wilson's disease. A histological review of 7 patients and the value of histological copper positivity in relation to other hepatopathies]

BACKGROUND

Wilson's disease is an infrequent entity. Biopsy is essential for establishing its presence and degree of hepatopathy but it lacks diagnostic specificity. It is necessary to know the significance of positivity or negativity of histochemically demonstrated copper when faced with the diagnosis of Wilson's disease and cholestatic diseases.

METHODS

Nine hepatic sample from 7 patients with clinical-biochemical Wilson's disease were reviewed. The rodanine histochemical technique was used for demonstration of copper in the samples aforementioned and in another 3 kinds of liver diseases: 16 biopsies of primary biliary cirrhosis, 86 biopsies of cholestatic hepatopathies (serum bilirubin greater than 68 mumol/l) and control biopsies with serum bilirubin less than 42.5 mumol/l.

RESULTS

Among the 7 patients with Wilson's disease, 6 were diagnosed with cirrhosis and one chronic active hepatitis. The incidence of erosive necrosis (86%), Mallory hyaline (86%), macrovacuolar steatosis (71%), glucogenated nuclei (71%) and giant mitochondria (29%) was evaluated. Histologic copper deposit with Shikata orcein was objectified in 3 cases (43%) and with rodanine in 5 (83%). Positivity with rodanine was 69% among the series of primary biliary cirrhosis, 20% among the cholestatic hepatopathies and 0 in the control series.

CONCLUSIONS

Histology of Wilson's disease remains without definitive diagnostic criteria. The disease is diagnosed in a late phase in Spain. The sensitivity of the histochemical demonstration of copper with rodanine is high (6/7) but its specificity is low, being positive in 68% of primary biliary cirrhosis and 19% of other cholestatic hepatopathies.

Effectiveness of histopathological diagnoses in dysfunction of hepatic transplantation. Review of 146 histopathological studies from 53 transplants

In 47 patients who underwent 53 liver transplantations and immunosuppression with cyclosporine (cyclosporin A), methylprednisolone sodium succinate, and antithymocyte globulin, 146 histopathological studies were performed (138 biopsies, six hepatectomies, and two autopsies). The following microscopical diagnoses were made: 43 acute rejections (29.4%), six chronic rejections (4.1%), 18 liver blood perfusion changes (12.3%), 15 biliary changes (10.2%), 10 cases of functional cholestasis (6.8%), two drug reactions (1.3%), two hepatitis B virus recurrences (1.3%), 11 opportunistic viral infections (7.5%), 18 minimal changes (12.3%), two nonclassifiable changes (1.3%), and 19 plurietiological changes (13%). A histopathological diagnosis of acute rejection was made in 31 transplants (58.4%). In 22 (71%) of them, acute rejection was diagnosed with the protocol biopsy specimen that was obtained during the second posttransplant week. Leukocyte counts and serum bilirubin and enzyme levels were obtained on the same day that the hepatic biopsy specimens were taken. There was no significant statistical difference between the mean serum data that accompanied each histopathological diagnosis, allowing identification of a characteristic biochemical profile for the causes of graft dysfunction. We report a detailed description of the microscopical findings of each diagnosis and the following conclusions: (1) Acute rejection is the most frequent cause of hepatic dysfunction and has an early appearance during the posttransplant period. (2) Histopathological findings can identify the causes of the dysfunction. (3) There is no specific biochemical pattern to differentiate these causes. This may be due to the frequent combination of etiological factors in every dysfunction episode.

[Sixteen-year experience with gallbladder cancer. Review of 120 cases]

We reviewed retrospectively 120 patients with histologically diagnosed gallbladder carcinoma and collected during 16-years (1974-1989). Age and sex, annual distribution, predisposing factors, histological findings, clinical manifestations, complementary diagnostic methods, therapeutic measures and follow-up of patients were analyzed. Our results suggest the following conclusions: a) the annual incidence of gallbladder carcinoma remains unchanged; b) there is a close association with gallstones; c) the late diagnosis is due to unspecificity of clinical manifestations and low diagnostic effectivity of complementary methods; d) computed tomography and laparoscopy are the more effective complementary diagnostic methods in advanced gallbladder carcinoma; e) early gallbladder carcinoma is only diagnosed casually in cholecystectomy pieces; f) only the early carcinoma (grade I or II) is curable.

Senior-Loken syndrome (nephronophthisis and pigmentary retinopathy) associated to liver fibrosis: a family study

We present two sisters with nephronophthisis and pigmentary retinopathy (Senior-Loken syndrome) and associated liver fibrosis. Clinical and histological findings are discussed, as well as the importance of family studies. A comparative analysis with previous published cases is made; we found only three other references with this triad. Our report underlines the need to investigate liver disorders in all patients with nephronophthisis and the existence of liver fibrosis as an element of the hereditary 'nephronophthisis complex.'

Obstructive jaundice due to hepatocarcinoma with intraductal growth. Report of a successful resection

We present a patient with hepatocellular carcinoma causing obstructive jaundice due to intraductal growth, diagnosed intraoperatively by cholangiography and histological examination, and radically treated by left lobectomy, extrahepatic biliary tract resection and Roux-en-Y hepaticojejunostomy. Survival after operation was 13 months. Other similar cases reported in the literature are reviewed.

Budd-Chiari syndrome associated with nodular regenerative hyperplasia of the liver

The Budd-Chiari syndrome due to membranous obstruction of the hepatic blood outflow tract is a rare condition in western countries, and its association with nodular regenerative hyperplasia of the liver has never been described. We present the case of a 34-year-old woman with membranous obstruction of hepatic veins and nodular regenerative hyperplasia of the liver. Although webs have been difficult to demonstrate by sonography, we were able to image a structure in the hepatic vein near the junction with the inferior vena cava, suggesting a membranous nature.

Diffuse nodular regenerative hyperplasia of the liver (DNRH). A clinicopathologic study of 24 cases

The authors report 24 cases of diffuse nodular regenerative hyperplasia of the liver (DNRH) seen in a General Hospital during the last 9 years (prevalence: 3'1/100,000, incidence: 0'34/100,000). DNRH was diagnosed in 0.52% of the liver biopsies and 0.72 of the autopsies. These results suggest that DNHR is probably more frequent than suspected, and 1 DNRH was seen for each 39 biopsied cases of liver cirrhosis. Fourteen patients did not have hepatic symptoms. Portal hypertension was present in 9 cases. The biochemical disturbance most frequently found was a moderate elevation of GGT and APh, associated with slight elevation of SGOT, SGPT and bilirubin levels. Normal liver function tests could be seen (3 cases). Previous exposure to potentially hepatotoxic drugs or chemicals was discovered in 15 cases (62.5%). Diseases associated were circulatory disturbances (6 cases), autoimmune disease (5 cases), hemopathies (5 cases), and visceral carcinomas (4 cases). Two patients were recipients of renal transplant. Nodules distributed through the whole liver tissue were found in 16 cases, while 8 patients showed areas of normal parenchyma in their livers. Impairment of small hepatic vessels was detected in 16 cases. Some uneven cytologic findings were discovered: clusters of small basophilic cells (4 cases), large clear cells (8 cases), and dysplastic hepatocytes (10 cases), which suggests that DNRH could be a preneoplastic condition.

Hepatic artery anastomotic stenosis after transplantation: treatment with percutaneous transluminal angioplasty

Two orthotopic liver transplant recipients underwent percutaneous transluminal angioplasty (PTA) for stricture of the hepatic arterial anastomosis. In both, arterial revascularization was effected by end-to-end anastomosis between the donor common hepatic artery and the recipient's hepatic artery. Both patients had elevated liver enzyme levels, abnormal results on duplex Doppler images, and severe stricture on angiograms. In one patient, percutaneous biopsy revealed graft ischemia. PTA was performed successfully without complications. PTA produced substantial improvement in biochemical, duplex Doppler, histologic, and angiographic patterns. Both patients were asymptomatic 5 and 6 months after PTA.

[Necrosis of the bile ducts as an expression of uncontrollable rejection in the liver transplant between ABO incompatible groups]

Two cases are presented of liver transplantation in adult patients with fulminant liver failure using grafts from incompatible blood group donors due to the urgency of the situation. The patients evolved well as first but later both developed ischemia and necrosis of the bile tract secondary to severe rejection. It is concluded that the use of incompatible grafts can save the patient's life in acute irreversible liver failure, but in most cases retransplantation may be necessary as the definitive treatment of postoperative complications.

Pseudomelanosis of the duodenum. Endoscopic, histologic, and ultrastructural study of a case

We present the endoscopic, microscopic, and histochemical studies of a patient with pseudomelanosis of the duodenum. The pigment was located mainly in the lysosomes of macrophages in the lamina propria and was heterogeneous, showing features of melanin, pseudomelanin, and hemosiderin. The origin of this pigment remains unknown, but antihypertensive medication may have played a role.

Nodular regenerative hyperplasia of the liver in renal transplantation

In our series of RT three cases of diffuse NRH of the liver were found. This rare entity is characterized by nodules of regenerative hepatocytes distributed throughout the liver without fibrosis. The incidence was 12.5% and probably is underestimated. Clinically, hepatomegaly, moderate thrombopenia and an elevation of GGT were present, but no case was previously suspected. NRH can lead to PH, and we should think of this entity in the differential diagnosis of PH following RT.