[Melanoma metastasis to the gallbladder]

Metastasis to the gallbladder is rare. Malignant melanoma is the tumor that most often metastasizes to this site. For this reason, the finding of solid lesions in the gallbladder wall in patients with advanced stage melanoma should lead to the suspicion of metastatic disease. The aim of this report is to describe and illustrate a case of surgically confirmed malignant melanoma metastasis to the gallbladder and to review the most significant ultrasound findings described in the literature for gallbladder lesions caused by melanoma.

Characterization of focal liver lesions: comparative study of contrast-enhanced ultrasound versus spiral computed tomography

The purpose of this study was to compare the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) with spiral computed tomography (SCT) for the characterization of focal liver lesions (FLL) and to determine the degree of correlation between the two techniques. Seventy-seven FLL (45 hepatocellular carcinomas; 12 metastases; ten hemangiomas; two regenerating/dysplastic nodules; eight focal nodular hyperplasias) detected with ultrasound (US) were prospectively evaluated by CEUS using a second-generation contrast agent and SCT (with an interval of no more than one month between the two techniques). Independent observers made the most probable diagnosis and the results were compared with the final diagnoses (histology n = 59; MRI n = 18). Statistical analysis was performed by the Chi-square and Kappa tests. CEUS provided a correct, specific diagnosis in 69/77 (90%) of the FLL, while SCT did so in 67/77 (87%). The sensitivity, specificity, and diagnostic accuracy for malignancy were 91%, 90%, and 91%, respectively, for CEUS and 88%, 89%, and 88%, respectively, for SCT. No statistically significant difference was found between CEUS and SCT in the characterization of FLL (p > 0.05). In addition, agreement between the two imaging techniques was good (k = 0.75). We conclude that CEUS and SCT provide a similar diagnostic accuracy in the characterization of FLL, with a good degree of correlation between the two techniques.

New aspects of diagnosis and therapy of hepatocellular carcinoma

Hepatocellular carcinoma is one of the major cancer killers. It affects patients with chronic liver disease who have established cirrhosis, and currently is the most frequent cause of death in these patients. The main risk factors for its development are hepatitis B and C virus infection, alcoholism and aflatoxin intake. If acquistion of risk factors is not prevented and cirrhosis is established, the sole option to improve survival is to detect the tumor at an early stage when effective therapy may be indicated. Early detection plans should be based on hepatic ultrasonography every 6 months, whereas determination of tumor markers is not efficient. Upon detection of a hepatic nodule, there is a need to establish unequivocal diagnosis, either through biopsy or through the application of non-invasive criteria based on the specific radiology appearance of the tumor: fast arterial uptake of contrast followed by venous washout. Effective treatment for liver cancer includes surgical resection, liver transplantation and percutaneous ablation. These options provide a high rate of complete responses and are assumed to improve survival that should exceed 50% at 5 years. If the tumor is diagnosed at an advanced stage, the sole option that improves survival is transarterial chemoembolization. Ongoing research should further advance the time at diagnosis and identify new and effective options targeting molecular pathways governing tumor progression.

Is microbubble-enhanced ultrasonography sufficient for assessment of response to percutaneous treatment in patients with early hepatocellular carcinoma?

The objective of this study was to assess the efficacy of contrast-enhanced ultrasonography (CEUS) with SonoVue to evaluate the response to percutaneous treatment (ethanol injection/radiofrequency) of hepatocellular carcinoma in comparison with spiral computed tomography (CT) immediately and 1 month after treatment. Forty-one consecutive cirrhotic patients with early stage tumor (not suitable for resection) were included. Spiral CT and CEUS were performed in all patients before treatment, in the following 24 h, and 1 month later. The results of each examination were compared with the 1-month spiral CT, considered the gold standard technique. The 24-h CEUS and the 24-h spiral CT sensitivity to detect residual disease were 27% and 20%, respectively. The 24-h CEUS and the 24-h spiral CT positive predictive value of persistent vascularization detection were 75% and 66%, respectively. The 1-month CEUS detected partial responses in ten out of 11 cases (91% sensitivity, 97% specificity, 95% accuracy). Spiral CT and CEUS performed in the 24 h following treatment are slightly useful to evaluate therapeutic efficacy. The 1-month CEUS has a high diagnostic accuracy compared with spiral-CT in the usual assessment of percutaneous treatment response.

The use of contrast-enhanced ultrasound in the management of the cirrhotic patient and for detection of HCC

Hepatocellular carcinoma (HCC) is the leading cause of death in liver cirrhosis. Ultrasound (US) is widely accepted as the screening imaging modality of choice for HCC in patients with a history of chronic liver disease. However, the US characteristics of HCCs are non-specific and thus, other imaging techniques or biopsy are usually necessary to characterize focal liver lesions (FLL) and confirm malignancy. Blood flow to HCC is mainly arterial, making dynamic CT and MRI the most commonly used techniques to detect the characteristic arterial hypervascularization. Recently, the development of second-generation US contrast agents and microbubble-specific software has changed the role of US in real-time evaluation of the macro and microvascularization of FLLs. With this technology, the accuracy of US in the diagnosis of HCC and its differentiation from other FLLs such as regenerating nodules has improved dramatically. In addition, contrast-enhanced ultrasound may also be a useful tool in the staging of HCC and in the evaluation of percutaneous treatment.

Pilot study of treatment of biochemotherapy-refractory stage IV melanoma patients with autologous dendritic cells pulsed with a heterologous melanoma cell line lysate

Eleven AJCC stage IV melanoma patients with progressive disease after treatment with biochemotherapy were treated with autologous dendritic cells pulsed with heterologous tumor cell lysates. The vaccine used mature DCs (CD1a+++, CD40++, CD80++, CD83+, and CD86+++) generated from peripheral blood monocytes in the presence of GM-CSF and IL-4. After 7 days, DCs were matured with a defined cocktail of cytokines (IL-1+IL-6+TNF-alpha+PGE2) and simultaneously pulsed with lysates of heterologous melanoma cell lines, for 2 days. A total of 4 x 10(6) DCs was injected monthly under ultrasound control in an inguinal lymph node of normal appearance. The study was closed when all patients died as a consequence of tumor progression. No sign of toxicity was observed during the study. One patient experienced a partial response lasting 5 months, and two patients showed a mixed response which lasted 3 months. The median survival of the whole group was 7.3 months (range 3-14 months). This vaccination program had specific antitumoral activity in highly pretreated and large tumor burden stage IV melanoma patients and was well tolerated. The clinical responses and the median survival of the group of patients, together with the low toxicity of our DC vaccine, suggest that this approach could be applied to earlier AJCC stage IV melanoma patients.

[Evaluation of the efficacy and efficiency of a multidisciplinary unit for the treatment of patients with colorectal cancer]

INTRODUCTION

Because of the increased complexity of the diagnostic-therapeutic approach to colorectal cancer (CRC), these patients should be managed in specialized multidisciplinary units. The aim of this study was to evaluate the efficacy and efficiency of a CRC unit (CRCU) in the diagnostic-therapeutic management of these patients.

PATIENTS AND METHODS

Two groups of 50 patients with colon cancer treated in our center before and after the implementation of the CRCU were selected. Fulfillment with the protocol in terms of tumoral staging, surgical and adjuvant treatment, follow-up, interval until treatment, hospital stay, morbidity and early mortality, and the overall duration of the diagnostic-therapeutic process was analyzed. In addition, clinical workload was evaluated and a cost-minimization analysis was performed.

RESULTS

The CRCU reduced the interval until surgery (20.3 12.0 vs 28.0 20.4 days; p = 0.05), hospital stay (9.8 7.7 vs 14.5 9.3 days: p = 0.01), the time to the start of adjuvant treatment (29.4 10.2 vs 39.7 19.8 days; p = 0.03) and the overall duration of the process (60.4 23,8 vs 82.1 46.1 days; p = 0.05), representing a saving of 978.85 E per patient. This improvement took place despite an increase in clinical workload (24% in 5 years in relation to the number of admissions) and had no effect on morbidity (26 vs 24%; NS) or immediate mortality (6 vs 4%; NS).

CONCLUSION

Specialized multidisciplinary units increase the efficacy and efficiency of the management of patients with CRC.

Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma

Radiofrequency (RF) ablation is an alternative to percutaneous ethanol injection (PEI) for single nonsurgical hepatocellular carcinoma (HCC) and is currently used as adjuvant therapy before liver transplantation. This phase II study assesses the treatment-related complications and response rate of RF for the treatment of single HCC < or = 5 cm. Percutaneous RF was performed under conscious sedation and ultrasound (US) guidance with an electrical generator connected to a single cooled-tip electrode. Neoplastic cells in peripheral blood (reverse transcription-polymerase chain reaction for alpha fetoprotein [AFP] messenger RNA) were analyzed before and after RF. Treatment response was assessed by spiral computed tomography (CT) at 1 month and every 3 months by US or spiral CT thereafter. Thirty-two patients (20 men; age 67 +/- 4 years; 78% hepatitis C virus; 24 Child-Pugh A) with a mean tumor size of 2.8 cm (25 patients < or = 3 cm) were treated by RF (1.25 sessions; mean time, 22.1 +/- 2 minutes). Adjuvant PEI was performed in 9 cases. Complete response was achieved in 21 patients (65%), being significantly higher for HCC < or = 3 cm (76% vs. 29%, P = .03). After a median follow-up of 10 months, 8 patients showed treatment-related morbidity. Four of them (12.5%) showed biopsy-proven needle-track seeding detected between 4 to 18 months. Neoplastic seeding was related to subcapsular location (P = .009), poor differentiation degree (P = .02), and baseline AFP levels (P = .02). Thus, RF ablation with cooled-tip needle for HCC is associated with a high risk of neoplastic seeding. Iatrogenic dissemination was related to subcapsular location or an invasive tumoral pattern, and has to be considered when selecting curative treatments for HCC or adjuvant therapies before liver transplantation.

Early detection of hepatic artery thrombosis after liver transplantation by Doppler ultrasonography: prognostic implications

We assessed the usefulness of routine Doppler ultrasonography for early detection of hepatic artery thrombosis after orthotopic liver transplantation and repercussions in patient prognosis. Seventeen confirmed cases of early hepatic artery thrombosis initially diagnosed by Doppler ultrasonography (10 of them before clinical indication) were reviewed. All patients underwent Doppler ultrasonographic studies in the first 3 days after orthotopic liver transplantation. Twelve cases of hepatic artery thrombosis (70.6%) were detected by this early Doppler ultrasonography. All 10 unsuspected cases of hepatic artery thrombosis and 5 of the 7 cases diagnosed after clinical indication were treated by revascularization. Grafts were salvaged in 80% of asymptomatic patients and in 42.8% of symptomatic patients. Furthermore, biliary complications were less serious in the first group. In conclusion, Doppler ultrasonography performed routinely in the first 3 days after orthotopic liver transplantation may permit early detection of hepatic artery thrombosis, even before clinical indications. This allows hepatic artery repermeabilization before liver function damage, improving graft rescue and patient prognosis.

Abdominal sonographic study of autosomal dominant polycystic kidney disease

PURPOSE

The purpose of this study was to determine whether kidney size in patients who have autosomal dominant polycystic kidney disease (ADPKD) is related to renal function, hypertension, or extrarenal manifestations of the disease and to sonographically evaluate the abdominal manifestations of ADPKD.

METHODS

Between 1994 and 1998, 400 individuals from 85 families with a history of ADPKD were examined. There were 213 persons with ADPKD and 187 unaffected family members; there were 182 males and 218 females, 1-82 years old (mean, 39.3 years). We obtained a complete medical history, performed a physical examination, measured the arterial blood pressure and serum creatinine levels, and performed abdominal sonography on each subject. The sonographic features that were studied were renal length and the presence and number of cysts on the kidneys, liver, and pancreas.

RESULTS

There was a relationship between kidney size and age (p < 0.05), kidney size and renal function (p < 0.001), and kidney size and hypertension (p < 0.001). The overall prevalence of hepatic cysts in patients with ADPKD was 67%, and the prevalence increased with age. The presence of hepatic cysts was related to the severity of renal disease. Females had more severe polycystic liver disease, and massive polycystic liver disease (ie, hepatomegaly with innumerable cysts) was seen only in females. The prevalence of pancreatic cysts in the 187 persons in whom the pancreas was well evaluated sonographically was 5%.

CONCLUSIONS

Kidney size in patients with ADPKD is related to renal function, hypertension, and extrarenal involvement and can be used to predict the outcome of the disease. Hepatic cysts are very common in patients with ADPKD and are related to age and renal function; pancreatic cysts are infrequent in these patients.

Sonographic appearance of a retained surgical sponge in the neck

We report the sonographic appearance and clinical course of a retained surgical sponge in the neck beginning 6 months after a partial thyroidectomy. Sonograms showed a subcutaneous curvilinear hyperechoic interface with marked acoustic shadowing obscuring the left side of the neck. Three months later, a fistulous tract could be seen. Surgical exploration revealed a florid foreign tissue reaction due to a retained surgical sponge. Early diagnosis of retained sponges is important to enable expeditious removal before complications develop.

Randomized controlled trial of interferon treatment for advanced hepatocellular carcinoma

The aim of this randomized controlled trial was to assess the efficacy of interferon alfa-2b (IFN) for the treatment of advanced hepatocellular carcinoma (HCC). Fifty-eight patients with HCC who were not suitable for resection, transplantation, ethanol injection, or arterial embolization were stratified according to their Okuda stage and randomized to receive IFN (3 x 10(6), 3 times a week, for 1 year) (n = 30) or symptomatic treatment (n = 28). Both groups were identical in terms of age, sex, performance status, presence of constitutional syndrome, Child-Pugh class, Okuda stage, multinodularity, portal thrombosis, and extrahepatic spread. Adhesion to IFN treatment was adequate in 27 patients, with a mean duration of treatment of 8 +/- 3 months. However, IFN treatment was associated with side effects in 23 patients, leading to treatment discontinuation in 13 patients. Two of the 30 patients (6.6%) presented a partial response with greater than 50% size reduction and normalization of alpha-fetoprotein levels. The survival at 1 and 2 years according to intention to treat was not different between the 2 groups (58% and 38% vs. 36% and 12%, respectively, Breslow P =. 19, log rank P =.14) and the absence of difference was maintained when dividing patients according to their Okuda stage. The probability of presenting tumor progression (P =.17), or deterioration of Child-Pugh class (P =.37), performance status (P =. 07), or Okuda stage (P =.44) was not modified by IFN treatment. These results indicate that IFN is not properly tolerated in patients with cirrhosis and advanced HCC and that its administration prompts no benefit in terms of tumor progression rate and survival.

Autosomal dominant polycystic kidney disease types 1 and 2: assessment of US sensitivity for diagnosis

PURPOSE

To estimate the sensitivity and specificity of ultrasonography (US) in the diagnosis of autosomal dominant polycystic kidney disease (ADPKD) types 1 and 2, as compared with those of genetic linkage analysis.

MATERIALS AND METHODS

A renal US and DNA analysis for ADPKD was performed in 319 patients who were at risk, 161 of whom were younger than 30 years, from 54 families with ADPKD. The sensitivity of US for diagnosis was estimated by comparing the US results with genotypes inferred from linkage studies.

RESULTS

The sensitivity of US in individuals younger than 30 years who were at risk was 95% for ADPKD type 1 but only 67% for ADPKD type 2. The sensitivity of US for either ADPKD type 1 or ADPKD type 2 in individuals aged 30 years or older who were at risk was 100%. The overall sensitivity in individuals younger than 30 years was 93%. For both ADPKD types 1 and 2 in all patients, US demonstrated a sensitivity of 97%, a specificity of 100%, and an accuracy of 98%.

CONCLUSION

US is the first-line imaging technique that should be used in the diagnosis of ADPKD. The sensitivity in individuals aged 30 years or older is 100%, but if there is a clinical suspicion of ADPKD type 2 in individuals younger than 30 years, linkage analysis should also be considered.

Natural history of untreated nonsurgical hepatocellular carcinoma: rationale for the design and evaluation of therapeutic trials

This study analyzed the natural history and prognostic factors of patients with nonsurgical hepatocellular carcinoma (HCC). Twenty variables from 102 cirrhotic patients with HCC who were not treated within prospective randomized controlled trials (RCT) were investigated through uni- and multivariate analyses. None of them was suitable for radical therapies (surgical resection, liver transplantation, or ethanol injection) or presented end-stage disease as reflected by an Okuda stage 3 or a Performance Status >/=3. Sixty-five patients were Child-Pugh A, 34 were B, and 3 were C. Most of them exhibited a preserved Performance Status Test (PST) (0 = 56; 1 = 38; 2 = 8). Tumor was solitary in 26 (</=5 cm in 16) and multinodular/massive in 76. After a median follow-up of 17 months, 79 patients died, the 1-, 2-, and 3-year survival being 54%, 40%, and 28%. The multivariate study identified PST (P =.01), constitutional syndrome (P =.04), vascular invasion (P =.001), and extrahepatic spread (P =.04) as independent predictors for mortality. The 1-, 2-, and 3-year survival for the 48 patients without adverse factors (Stage 0) was 80%, 65%, and 50%, respectively, and 29%, 16%, and 8% in the 54 patients with at least one adverse parameter (Stage I). Therefore, Stage 0 would correspond to an intermediate stage, while Stage I would represent an advanced status, before reaching an end-stage phase. In conclusion, the outcome of nonsurgical HCC is not homogeneously grim and may be predicted by assessing the presence of symptoms and of an invasive tumoral pattern. Therapeutic trials should be designed and evaluated considering these characteristics.

Liver transplantation for small hepatocellular carcinoma: the tumor-node-metastasis classification does not have prognostic power

Tumoral recurrence rate and survival of patients with hepatocellular carcinoma (HCC) treated by orthotopic liver transplantation (OLT) depend on tumor stage. Thereby, from the beginning of our program, we selected only patients with solitary tumors < or = 5 cm without vascular invasion, thus avoiding the use of the tumor-node-metastasis (TNM) staging system as a selection tool. The present study reports the results obtained in 58 consecutive patients (52 +/- 8 years, 47 males) with HCC (7 incidentals) transplanted between 1989 and 1995. Transplantation was indicated because of tumor diagnosis in 40 cases and advanced liver failure in 18. Mean tumor size at staging was 28.2 +/- 12.1 mm. No adjuvant treatment was applied during the waiting period (58.9 +/- 45.1 days). The pathological tumor-node-metastasis (pTNM) classification allocated 15 patients to stage I, 19 to stage II, 11 to stage IIIA, and 13 to stage IVA showing preoperative understaging in 43% of the cases with known tumor. After a median follow up of 31 months, only two patients have shown tumor recurrence and fifteen have died, the 1-, 3-, and 5-year survival being 84%, 74%, and 74%. All HCV+ patients remain infected and 94% showed significant liver disease (6 cirrhosis). Six patients have had a second transplant. In conclusion, the application of restrictive criteria not following the TNM staging system prompts excellent results for liver transplantation in patients with HCC, both in terms of survival and disease recurrence, even without applying adjuvant treatment; however, the survival data should be tempered by the appearance of complications that may worsen the long-term prognosis.

Transarterial embolization versus symptomatic treatment in patients with advanced hepatocellular carcinoma: results of a randomized, controlled trial in a single institution

This randomized, controlled trial assessed the effect of transarterial embolization (TAE) (without associated chemotherapy) on the survival of patients with nonsurgical hepatocellular carcinoma (HCC). Eighty consecutive patients were randomized to treatment with embolization (Group A, n = 40), or to symptomatic treatment (Group B, n = 40), there being no differences between both groups regarding the degree of liver function impairment and tumor stage. Eighty-two percent of the patients presented a self-limited postembolization syndrome, without treatment-related mortality. Fifty-five percent of the treated cases exhibited a partial response, which resulted in a lower probability of tumor progression during follow-up (57% vs. 77% at 1 year; P < .005). However, after a median follow-up of 24 months (30 deaths in each group), there are no differences in survival (Group A: 49% and 13%; Group B: 50% and 27%, at 2 and 4 years, respectively; P = .72). The absence of differences was maintained even when dividing patients according to Child-Pugh's grade, Okuda stage, or performance status test (PST). Furthermore, there were no differences in the probability of complications or in the need of hospital admissions. In conclusion, TAE has a marked antitumoral effect associated to a slower growth of the tumor, but it does not improve the survival of patients with nonsurgical HCC.

Schistosomiasis of the male genital tract: transrectal sonographic findings

PURPOSE

Schistosomal infection of the prostate and seminal vesicles is seldom found in clinical practice and rarely mentioned in the radiological literature. However, the presence of schistosoma eggs has been reported in 50% of postmortem studies of the prostate and seminal vesicles performed in endemic areas.

MATERIALS AND METHODS

We report the results of transrectal studies of the prostate and seminal vesicles performed in 9 white travelers (age less than 35 years) who complained of hemospermia. Diagnosis was confirmed by positive identification of parasites in the urine and semen.

RESULTS

Prostatic calcification was observed in 7 cases, hyperechogenic foci in 2, increase in prostate size in 2, calcifications in the seminal vesicles in 1 and dilatation of the seminal vesicles and ejaculatory ducts in 1. After treatment, prostate size and hyperechogenic foci were reduced. In some cases, calcified lesions diminished during followup.

CONCLUSIONS

Prostatic and seminal calcifications should alert physicians to the possibility of schistosoma infection when they are found in young patients who have been in endemic areas. Parasitological study of semen as well as urine confirms and increases the number of diagnoses.

[Schistosomiasis imported by Spanish travelers: clinico-epidemiologic study of 80 cases]

BACKGROUND

Swimming in rivers or lakes is a risk activity, in areas where the life cycle of schistosomiasis occurs. This report presents and analyzes the clinical presentation and epidemiological data of 80 Spanish travellers.

PATIENTS AND METHODS

Descriptive longitudinal and retrospective study that includes clinicoepidemiological and the laboratory data and imaging diagnosis. Patients were seen at the Section of Tropical Medicine, Hospital Clínic i Provincial, Barcelona.

RESULTS

Most patients acquired the infection in the Dogon country of Mall. 25% of them presented with symptoms related to the genital tract. In some groups, 45% of travellers that swam, contracted the infection. The most prevalent species diagnosed was S. haematobium and 10 travellers presented with mixed infections.

CONCLUSIONS

The trip to the Dogon country should be considered as "a risk activity". Travellers Advice Clinics should include the subject of swimming in infected waters in their routine counselling. Genital tract localizations were registered for three species of schistosome. The classical clinical presentation of schistosomiasis in the endemic areas differs considerably from that seen in travellers.

Hepatocellular carcinoma and cirrhosis. Results of surgical treatment in a European series

OBJECTIVE

The authors analyze the outcomes of patients with hepatocellular carcinoma (HCC) and cirrhosis who underwent liver resections.

BACKGROUND

Liver resection is the best option for HCC arising from hepatic cirrhosis. The experience of Western centers with these patients is shorter than the Asian series.

METHODS

Forty-eight consecutive patients with cirrhosis and HCC who underwent liver resections were studied after a similar diagnostic and therapeutic process. Survival and cumulative recurrence were calculated according to pathologic findings.

RESULTS

Factors influencing survival at 3 years were as follows: type of resection, absence of vascular invasion, size of the tumor, absence of satellite nodules, and the number of nodules. Factors influencing the rate of recurrence at 3 years were the presence of vascular invasion and the presence of satellite nodules. Patients with favorable prognostic factors have a good survival rate with an acceptable recurrence rate.

CONCLUSIONS

Identification of prognostic factors may help in the selection of the appropriate treatment for these patients with HCC and cirrhosis.

[Prostatic abscess: diagnosis and treatment]

Prostatic abscesses are an infrequent pathology, probably due to a better and early management of prostatic infections. Predisposing factors in this pathology are diabetes mellitus, urethral catheterism or manipulation, and immunodepressed states like AIDS. Nowadays, ultrasonography is an excellent diagnostic method of this pathology, and serves as a guidance of directed drainage. We present five cases in which the size of the abscess was determining in relation to the therapeutic attitude. Abscesses of less than 2 cm, measured by transrectal ultrasonography, can be evacuated by directed puncture, followed by antibiotic treatment. When the diameter of the abscess is greater than 2 cm, we realize a perineal drainage with a catheter placed with transrectal ultrasonography. Currently, TUR and other methods seems to be overcome.

Treatment of hepatocellular carcinoma with tamoxifen: a double-blind placebo-controlled trial in 120 patients

BACKGROUND & AIMS

The progression of hepatocellular carcinoma may be influenced by estrogens. This has offered the rationale for evaluating the therapeutic usefulness of estrogen-receptor blockers; it is being debated whether long-term tamoxifen administration improves survival in patients with this neoplasm. The aim of this study was to assess the efficacy of tamoxifen administration in the treatment of hepatocellular carcinoma.

METHODS

One hundred twenty patients with this neoplasm who were not suitable for surgery, ethanol injection, or transarterial embolization were included in a placebo-controlled trial and randomized to tamoxifen, 20 mg/day per os, (group A, n = 58) or placebo (group B, n = 62). Patients with terminal diseases were excluded.

RESULTS

Both groups were similar with regard to sex, age, liver function (Child-Pugh's score, 6.5 +/- 1.4 vs. 6.4 +/- 1.4), baseline performance status, and tumor stage. Tamoxifen had no antitumoral effect with no differences in the survival between groups (1- and 2-year actuarial rate: group A, 51% and 27%; and group B, 43% and 29%; P = 0.75), even when stratifying patients according to baseline status. Furthermore, there were no differences in the probability of disease progression (P = 0.46) and baseline performance status maintenance (P = 0.93) during follow-up.

CONCLUSIONS

Tamoxifen has no efficacy in the treatment of patients with advanced hepatocellular carcinoma.

Phase II study of transarterial embolization in European patients with hepatocellular carcinoma: need for controlled trials

Our uncontrolled phase II study was aimed at assessing the efficacy of transarterial embolization in patients with hepatocellular carcinoma and to determine the parameters associated with a favorable response to treatment, improved survival or both. Fifty consecutive patients (25 corresponding to Okuda's stage I and 25 to stage II) with hepatocellular carcinoma (41 being multinodular or massive) were included. Transarterial embolization induced a self limited postembolization syndrome that was well tolerated. Nevertheless, three patients died shortly after the procedure because of tumor progression (two cases) or progressive liver failure. A favorable response (extensive necrosis with reduction of tumor area greater than 50%) was achieved in 81% of the cases, and this result was independently (p < 0.05) related to a preserved performance status and to a lower alpha-fetoprotein concentration. The survival of the patients at 1 and 2 yr was 65% and 38%, respectively, better than the expected survival according to a mathematical model obtained from a historical series of untreated cases (42% and 20%, respectively). Cox regression analysis disclosed that both a favorable therapeutic response and a preserved physical condition (reflected by performance status of 0 or 1) were independently associated with better survival (regression coefficient -2.248 and 0.869, respectively). These data indicate that transarterial embolization has a marked antitumoral effect in patients with inoperable hepatocellular carcinoma and that the therapeutic success is associated with improved survival. Nevertheless, because the potential benefit for survival observed in this uncontrolled study appears to be moderate, prospective controlled trials to ascertain the real usefulness of this therapeutic approach are mandatory.

Hematospermia: a new etiology of clinical interest

Ten Spanish male tourists developed hematospermia and ultrasonographic evidence of involvement of the prostate and/or seminal vesicles after recreational exposure in bodies of fresh water in the Dogon country of Mali. Schistosoma eggs were detected in the ejaculate of five men, in the others, eggs were observed in the urine or feces. Three different species were observed: S. intercalatum, S. haematobium, and S. mansoni. Hemospermia and clinical prostatitis may be frequently unrecognized clinical manifestations of the early stages of infection in previously nonexposed persons. Travelers to endemic areas should be advised on the potential dangers of swimming and other exposure in bodies of freshwater.

Treatment of small hepatocellular carcinoma in cirrhotic patients: a cohort study comparing surgical resection and percutaneous ethanol injection

This study was intended to compare the survival rates of two contemporary cohorts of patients with solitary hepatocellular carcinomas < or = 4 cm subjected to surgical resection (n = 33) or percutaneous ethanol injection (n = 30). Outcomes in a third cohort, 21 patients with hepatocellular carcinoma who underwent orthotopic liver transplantation, were also assessed. Surgical and ethanol-treated patients were similar with regard to age and tumor stage, differing only in liver function; 30 of the 33 surgical patients were of Child-Pugh class A, whereas only 7 of the 30 ethanol-treated patients were of class A (p < 0.05). Surgical resection was successful in 30 cases; ethanol injection achieved initial success in 23 patients. Tumor recurrence rate at 2 yr was 45% in the surgical group and 66% in the ethanol group. The difference was significant only for cases with tumors between 3 and 4 cm. Despite poorer liver function, the 1-, 2-, 3- and 4-yr survival rates of ethanol-treated patients (83%, 66%, 55% and 34%, respectively) were not different from those of surgically treated patients (81%, 73%, 44% and 44%, respectively). The 1- and 2-yr survival rates of patients given liver transplants were 81% and 66%, without tumor recurrence, after 16-mo follow-up. These data confirm that ethanol injection is a useful treatment for patients with solitary small hepatocellular carcinomas and suggest that surgical resection and liver transplantation may achieve better results only after strict candidate selection to reduce mortality and tumor recurrence during follow-up.

Sonographic diagnosis and hemodynamic correlation in veno-occlusive disease of the liver

This study evaluated the role of duplex Doppler sonography in the diagnosis of VOD of the liver after bone marrow transplantation. Sixteen patients with clinical criteria of VOD were studied. The final diagnosis was achieved by transjugular liver biopsy, and the hepatic venous pressure gradient was measured during the procedure to estimate portal pressure. Nine patients (56.2%) had histologically proved VOD. Gallbladder wall thickening was present in 75% of patients with VOD, but in none of those without it (P = 0.01). Gallbladder wall thickening and ascites were present only in patients with portal hypertension. Nine patients (five with VOD and four without it) also were evaluated with duplex Doppler sonography, and no obvious flow abnormalities were detected in the portal vein and hepatic veins. These results suggest that sonography is useful in detecting early signs of portal hypertension pointing to the diagnosis of VOD in patients with bone marrow transplantation.

Fine-needle aspiration biopsy of portal vein thrombus: value in detecting malignant thrombosis

OBJECTIVE

The purpose of this study was to assess the usefulness of fine-needle aspiration biopsy of portal vein thrombus to identify or exclude tumor.

SUBJECTS AND METHODS

A series of 18 consecutive patients with portal vein thrombosis underwent fine-needle aspiration biopsy of the thrombus. Sixteen had underlying cirrhosis. Fifteen had clinical, biochemical, and imaging evidence of neoplastic invasion of the vein. Two patients had metastatic involvement of the left lobe of the liver, and the others had multinodular (eight cases) or diffuse (five cases) hepatocellular carcinoma. In four cases, the tumor was not clearly identified at sonography.

RESULTS

Aspiration biopsy was positive for malignant tumor in 14 cases and negative for malignancy in one. In the three patients with benign portal vein thrombosis, fine-needle aspiration biopsy yielded only hepatocytes, fibrin, and blood cells. No results were false-positive. No complications were detected.

CONCLUSION

Fine-needle aspiration biopsy is safe and sensitive for establishing the benign or malignant nature of portal vein thrombosis. This technique may be useful in selecting patients for liver transplantation.

Tumor size determines the efficacy of percutaneous ethanol injection for the treatment of small hepatocellular carcinoma

This study was aimed at defining the therapeutic value of percutaneous ethanol injection in patients with solitary hepatocellular carcinoma less than 4 cm. Ultrasound-guided ethanol injection was performed in 24 cirrhotic patients (9 Child A, 10 Child B and 5 Child C), with hepatocellular carcinoma not suitable for surgical treatment. Its efficacy was assessed by repeated ultrasound, computed tomography and tumor biopsy during a follow-up ranging between 4 and 41 mo. Ethanol injection did not achieve a complete tumor necrosis in five cases after a minimum of 12 injections. Seven of the remaining 19 cases, with initial success, have shown recurrence during follow-up, thus resulting in 50% success rate, which was significantly related to baseline tumor size. The six patients with nodules less than 2 cm achieved a complete response, whereas this was recorded in 2 of the 7 with tumor size between 2 and 3 cm, and in only 1 of the 11 cases between 3 and 4 cm. The 1- and 2-yr survival of Child's A and B patients was 87% and 70%, respectively. These results indicate that percutaneous ethanol injection is a useful treatment for hepatocellular carcinoma, especially in tumors less than 3 cm. The high survival rate among patients with nonadvanced liver disease suggests that this therapeutic approach can be considered an alternative approach to surgical resection for tumors smaller than 3 cm.

Calcifications in the portal venous system: comparison of plain films, sonography, and CT

We describe 10 patients with long-standing portal hypertension and calcifications in the splenoportal and mesenteric venous systems or collateral vessels. The patients were examined with abdominal plain films (n = 10), sonography (n = 10), and CT (n = 9). Calcium was seen on CT scans in nine cases, on sonograms in seven, and on abdominal plain films in five. Calcifications appeared to be located in the wall of the vein in all cases. Sites of detection included the main portal, splenic, superior mesenteric, coronary, and peripancreatic veins. CT was more sensitive than sonography, and both were more sensitive than plain films, in showing portal venous calcification. Detection of such calcifications may influence surgical or percutaneous therapy of portal hypertension.

Surgical resection and survival in Western patients with hepatocellular carcinoma

In a retrospective study the survival of 28 patients with hepatocellular carcinoma, 25 of them with underlying cirrhosis, submitted to surgical resection was compared with the survival of 28 untreated patients, matched for variables known to bear independent prognostic value and therefore sharing the same baseline prognosis. Diagnosis was made in the same time period for both groups of patients. In addition, to further evaluate the effects of tumor resection on survival, the outcome of operated patients was also compared to their expected survival. This was derived from a mathematical model which takes into account the regression coefficients of the variables previously shown to be independently related to the survival of untreated patients with hepatocellular carcinoma. The median survival for resected patients was 27.1 months, which was significantly better than untreated controls (12.4 months; p less than 0.003). Median survival for patients submitted to resection and with tumors smaller than 5 cm was 35.8 months, while the median survival for untreated cases was 14.6 months p less than 0.0005. The comparison of observed survival (82% at one year and 73% at two years) and statistically expected survival (58% and 34%, respectively) further indicated that surgical resection effectively improves prognosis in Western patients with hepatocellular carcinoma. Thus, early detection of small tumors in the population at risk appears to be justified.

[Accessory spleen: ultrasonographic and tomographic characteristics]

The failure of fusion of splenic tissue results in the formation of accessory spleens. This entity normally appears in post-mortem examinations. The purpose of this work was to determine the incidence of the accessory spleen and to compare the ultrasonographic and tomographic features of the accessory spleen and the main spleen in a group of one thousand patients affected with several abdominal pathologies. Five hundred of these patients were studied by ultrasonography and five hundred patients by computed tomography. The ultrasonographic and tomographic features of the accessory and main spleen were similar. Its diagnosis is specially important in certain groups of patients with hematologic disease or abdominal trauma with splenic tear. This is due to the fact that the hypertrophy of the accessory spleen can produce a relapse of the disease.

[8 cases of ectopic localization of schistosomiasis in Spanish travelers]

In this article 8 patients with ectopic features due to skin or prostatic deposition of ova of different schistosomal species are reported. The clinical, pathological and radiological features of these lesions are described. It is to be remarked that 7 patients had traveled to Mali and had bathed in the Bandiagara District, which is included in several tourist routes such as "Travel to Dogon country".

Ultrasonography and computed tomography in adrenal myelolipoma

We report 2 cases of adrenal myelolipoma with sonographic and computerized tomographic findings. Characteristic radiologic signs of this rare clinical entity must be known to avoid unnecessary surgical procedures.

Disseminated lymphatic tuberculosis in acquired immunodeficiency syndrome: computed tomography findings

There is an increased frequency of disseminated tuberculosis in patients with acquired immunodeficiency syndrome (AIDS). The authors reviewed 6 thoracic and 10 abdominal computed tomography scans from 11 patients who had AIDS and disseminated tuberculosis. All scans demonstrated multiple, large, mediastinal or retroperitoneal lymph nodes, or both; low-density centers within enlarged nodes were identified in seven patients (63%). The scans also showed a diffuse miliary pattern (three patients), pericardial effusion (three patients), mild hepatomegaly (six patients), moderate splenomegaly (seven patients), hypodense splenic lesions (one patient), peritoneal fluid (four patients), bowel involvement (two patients) and dilatation of the biliary tract (two patients). Infection with Mycobacterium tuberculosis was demonstrated in all cases. The findings of this study show that lymph-node enlargement and nodes with low-density centers in patients who have AIDS are suggestive of disseminated tuberculous infection.

Prognostic factors of hepatocellular carcinoma in the west: a multivariate analysis in 206 patients

To investigate the prognostic factors in Western patients with hepatocellular carcinoma, 206 patients with confirmed diagnoses of hepatocellular carcinoma were studied in terms of survival. All patients were diagnosed between 1983 and 1987. A multivariate survival analysis (Cox regression model) using clinical, biochemical, ultrasonographical and pathological data obtained at diagnosis disclosed that bilirubin (p = 0.0001), ascites (p = 0.0001), toxic syndrome (defined by the presence of weight loss greater than 10% premorbid weight, malaise and anorexia) (p = 0.009), blood urea nitrogen (p = 0.025), tumor size (p = 0.001), gamma-glutamyltranspeptidase (p = 0.0006), age (p = 0.0005), serum sodium (p = 0.003) and presence of metastases (p = 0.002) were independent predictors of survival. According to the contribution of each of these factors to the final model, a prognostic index was constructed allowing division of patients in different groups according to their relative risk of death: RRD = EXP (Age x 0.03 + Ascites x 0.8281 + BUN x 0.0137 + Serum sodium x (-0.0538) + gamma-Glutamyltranspeptidase x 0.0019 + Bilirubin x 0.0734 + Tumor size x 0.33 + Toxic syndrome x 0.4965 + Metastases x 0.55). These results facilitate the stratification of hepatocellular carcinoma patients to design and evaluate future controlled trials.

Natural history of hepatocellular carcinoma in Spain. Five year's experience in 249 cases

In this study we attempted to define the clinical pattern and prognosis of hepatocellular carcinoma (HCC) patients in Spain. Two hundred and forty-nine patients were included in the study. One hundred and eighty-seven were male and 62 female, with their mean age being 62.5 +/- 0.6 years. The majority of patients (92.8%) had an underlying cirrhosis. In most of the patients, the disease appeared as decompensated liver disease. Only 18.5% of the HCC cases were asymptomatic. Only 8.2% of the cases were HBsAg positive. alpha-Fetoprotein reached diagnostic values in only 37.2% of the patients. Surgical treatment was successfully performed in 14 patients: one underwent orthotopic liver transplantation and the 13 others complete tumor resection. Chemotherapy was administered to 38 subjects, while percutaneous ethanol injection was applied in seven cases. Patients receiving only symptomatic treatment, comprised 76.7%. Survival was related to tumor size and liver function. While the median survival of the whole series was 3.3 +/- 0.4 months, it was 14.5 +/- 2.2 months in patients with preserved liver function and small tumors. These results reflect that in Spain HCC patients are diagnosed at a moderately advanced phase. Since early diagnosis is the only way to increase the proportion of patients suitable for curative treatment, early detection plans are mandatory in the population at risk.

Diagnostic accuracy of fine-needle aspiration biopsy in patients with hepatocellular carcinoma

The present study was undertaken to investigate the diagnostic usefulness of fine-needle aspiration biopsy (FNAB) in a large series of patients with hepatocellular carcinoma (HCC) seen over a 1-year period. During 1986, ultrasonographically guided percutaneous FNAB was performed in 72 patients with suspected HCC. A final diagnosis of HCC was made in 58 patients. The presence or absence of HCC was ascertained by histological examination and/or by other diagnostic procedures (alpha 1-fetoprotein, computed tomography, arteriography) and by clinical follow-up (repeated ultrasonographic controls) and/or by surgery or necropsy. A total of 61 FNABs were carried out in these 58 patients. Only 42 (69%) of the 61 FNABs allowed the diagnosis of HCC. This moderate diagnostic sensitivity was not related to tumor size. Only one false positive result was observed in the non-HCC group. Therefore, the diagnostic specificity of FNAB for HCC was 93%, with a positive predictive value of 97% and a negative predictive value of 40%. These results show that FNAB is a useful diagnostic technique in patients with HCC. However, these data also show that there is a large proportion (31%) of subjects with false negative results. Therefore, we suggest that further efforts should be made to improve the diagnostic accuracy of this procedure.

Traumatic lung cyst

We report a patient with a traumatic lung cyst, documenting its radiological evolution: the formation of the pneumatocele, the appearance posteriorly of an intracavitary hematoma, and the spontaneous resolution of the radiological abnormalities.

[First radiological description of Morgagni's hydatid. Laparoscopic confirmation]

The authors explain the clinical case of a female patient suffering from secondary sterility; she was submitted, among other test, to the H.S.G. in order to study the possibility of a among other tests, to the H.S.G. in order to study the possibility of a cervical failure. The radiological findings obtained of Morgagni's Hydatis, not described previously in literature and their laparoscopic confirmation justify, we believe, its publication.