Cyclooxygenase-2 expression determines neo-angiogenesis in gallbladder carcinomas

Neo-angiogenesis may have an important role in the poor prognosis of gallbladder carcinoma. An enhanced expression of COX-2 was found in precancerous lesions and in gallbladder carcinoma, likely to be involved in carcinogenesis as well as in angiogenesis. To study the relationships between the COX-2 expression and degree of vascularization, as well as to evaluate their role in the prognosis of patients with gallbladder carcinoma. 27 cases of gallbladder adenocarcinoma were included, classified grading I-III according the WHO classification. The COX-2 and endothelial antigen CD105 expressions were assessed immunohistochemically. COX-2 expression was evaluated according to the percentage and staining intensity of positive cells into "COX-2 positive" and "COX-2 negative" groups. In order to assess tumor microvessel density (MVD), CD105 positively stained microvessels were counted for each specimen in predominantly vascular areas (hot spots) at 200 x magnification. The MVD ranged from 9 to 46 microvessels/field. 15 tumors belonged to the hypervascular group (MVD > or = 25) and 12 to the hypovascular group. There were 16 (59.2%) COX-2 positive cases. There was difference in the degree of angiogenesis between COX-2 positive vs. COX-2 negative group: 11 (68.8%) out of 16 "COX-2 positive" tumors were hypervascular, in comparison with just 4 (36.4%) of "COX-2 negative" tumors. Our data show that the MVD corresponds to the COX-2 overexpression in gallbladder carcinomas. Augmented tumor neovascularization induced by COX-2 might be responsible for the poor prognosis in gallbladder carcinoma patients.

Expression of human telomerase catalytic protein in gallbladder carcinogenesis

BACKGROUND

Telomerase catalytic subunit (hTERT) gene re-expression is a rate limiting step for the activity of telomerase, a key enzyme implicated in cellular immortalisation and transformation.

AIMS

To determine the potential role of hTERT protein in gallbladder carcinogenesis.

MATERIAL/METHODS

hTERT protein was analysed by means of immunohistochemistry in 89 gallbladder tissue samples: 16 normal epithelia, 14 reactive hyperplasias, 15 low grade dysplasias, 16 high grade dysplasias, and 28 adenocarcinomas. At least 200 nuclei were assessed for each slide and the mean number of positive signals for each nucleus was expressed as the hTERT index.

RESULTS

The mean hTERT index increased progressively with the degree of gallbladder epithelial abnormalities: from 0.03 in normal epithelia, 0.04 in hyperplastic epithelia, 0.25 in low grade dysplasia, 0.82 in high grade dysplasia, to 0.93 in adenocarcinoma. Statistical analysis revealed that three different groups of gallbladder epithelial changes can be distinguished according to the number of hTERT signals for each nucleus: (1) normal and regenerative gallbladder epithelium, (2) low grade dysplasia, and (3) high grade dysplasia and adenocarcinoma (p < 0.001).

CONCLUSIONS

The occasional presence of hTERT protein in normal and regenerative gallbladder mucosa reflects their regenerative capacity. Nevertheless, significantly higher hTERT indices in low and high grade dysplastic epithelia and in gallbladder adenocarcinomas are probably a consequence of hTERT re-expression--an early event in the multistep process of gallbladder carcinogenesis.

Acute Fatty Liver of Pregnancy - An Underlying Condition for Herpes Simplex Type 2 Fulminant Hepatitis Necessitating Liver Transplantation

The infrequent occurrence of herpes simplex virus (HSV) hepatitis in healthy women in comparison with the high prevalence of HSV infections suggests that, in addition to deranged immunity, an underlying condition in the liver might be necessary to develop HSV hepatitis. We report the case of a 28-year-old pregnant woman in the 28 (th) week of gestation. Following HSV type 2 infection of the uterine cervix, acute liver failure developed, necessitating urgent liver transplantation. In addition to fulminant HSV type 2 hepatitis, the explanted liver also showed the histological features of acute fatty liver of pregnancy. The presented case suggests a possible pathogenetic role of acute fatty liver of pregnancy in the development of fulminant HSV hepatitis following recurrent infection with HSV in healthy pregnant women. We believe that early histopathological diagnosis, followed by specific antiviral treatment and liver transplantation in selected patients may improve the clinical outcome of otherwise almost uniformly fatal HSV hepatitis.

Treatment of chronic hepatitis C: our experience

BACKGROUND/AIMS

While an optimal treatment of chronic hepatitis C has not yet been established, it has been demonstrated that the interferon alpha/ribavirin combination is more effective than interferon alpha monotherapy.

METHODOLOGY

One hundred and forty-three patients with chronic hepatitis C received the following treatment: eighty patients an 18-month monotherapy (3-month follow-up) and sixty-three patients a 12-month combined therapy (6-month follow-up). Therapeutic efficacy and adverse effects were compared.

RESULTS

In 80 patients in the monotherapy group, complete response was achieved in 49.2%. This was reduced to 27.5% three months after therapy. Significant differences were observed in HCV 3 genotype where complete response was achieved in 12 out of 14 patients (p=0.01). With the combined therapy administered to 63 patients, complete response was achieved in 54.5%. This was reduced to 43.2% after 6 months of follow-up. Among the responders or partial responders, significant differences were observed with regard to age (p=0.0047) and subtype 1b (p=0.012). Comparing the groups of naive patients and relapsers, a statistically significant difference (p=0.027) was found in therapeutic efficacy.

CONCLUSIONS

In the treatment of chronic hepatitis C, combined therapy proved more effective than monotherapy. This is, however, not yet a satisfactory solution.

Does end-stage kidney failure influence hepatitis C progression in hemodialysis patients?

BACKGROUND/AIMS

The influence of end-stage kidney failure on the progression of liver disease in patients infected with hepatitis C virus and treated with hemodialysis is still controversial.

METHODOLOGY

Liver histology of 154 hepatitis C virus infected non-uremic patients was compared with liver histology of 13 hepatitis C virus infected uremic patients treated with hemodialysis.

RESULTS

In either group of altogether 167 patients, no normal liver histology was found. Each patient had at least a low-grade lobular and/or portal inflammation. However, statistically significant differences were observed between hepatitis C virus infected uremic and non-uremic patients in the extent of intralobular changes, portal inflammation, and degree of fibrosis.

CONCLUSIONS

Non-uremic hepatitis C virus infected patients appear to have more active and progressive liver disease than hepatitis C virus infected patients on hemodialysis. Regular follow-up of uremic patients, associated with earlier detection of hepatitis C virus infection, so as suggested uremia-associated impaired immunoreactivity and increased levels of hepatocyte growth factor described recently, might be implicated in a more favorable course of hepatitis C virus infection in uremic patients. In addition, due to the absence of normal liver histology in either group of hepatitis C virus infected patients, we propose liver biopsy to be mandatory in all these patients, provided that no contraindications exist clinically.

Efficacy of chronic hepatitis C therapy with interferon alpha (IFN-alpha) in Slovenia

BACKGROUND/AIMS

Eighty Slovene patients with chronic hepatitis C were included in a prospective study conducted in the period 1997-1998 with the purpose to establish the efficacy of interferon alpha therapy. The average age of the patients was 39 years. In more than half of the patients (52%) the mode and time of onset of the infection were unknown. Two thirds of the patients were males. The plasma viral load exceeded 2 x 10(6) copies/mL in only three patients and in more than half of the cases (54%) HCV genotype 1b was present.

METHODOLOGY

The 18-month treatment with 3 MU interferon alpha three times a week was concluded in 53 patients and, after doubling the initial dose of interferon alpha from 3 MU to 6 MU, in 5 patients. In 11 patients, the treatment was discontinued prematurely, after six months, due to therapeutic failure (despite doubling the initial dose of interferon alpha Eleven patients withdrew from the treatment: six of them due to side effects and five due to personal reasons.

RESULTS

Complete response to therapy with disappearance of HCV from the blood was observed in 34 patients (49%), while in 24 the response to therapy was partial, i.e., the biochemical tests showed normalization of values but viremia persisted. There was a significant relation between the therapeutic response and those patients with the genotype 3 (p = 0.01). After three months of follow-up, complete therapeutic response was still observed in 19 patients (28%), most of them with genotype 3. Despite persistent viremia there was no progression of liver inflammation in eight partial responders, as evidenced by liver rebiopsy. Thus, it was confirmed that treatment is justified in these patients.

CONCLUSIONS

During the continuation of the follow-up period we shall record further course of the disease and make an attempt in a subsequent study to improve the efficacy of the treatment by introducing a combination of interferon alpha and ribavirin into therapy.

Pancreatic leiomyosarcoma: clinicopathohistological presentation of a rare tumor

A smooth muscle tumor originating from the pancreas is an extremely rare neoplasm characterized by peculiar histopathologic features and progressive clinical course. We report a case of such a pancreatic neoplasm occurring in a 57-year-old female who underwent surgical resection. The tumor was histologically as well as immunocytochemically analyzed. The spindle cell pattern, vimentin and actin reactivity confirmed smooth muscle differentiation. On the basis of the degree of cellular atypias and the mitotic counts, the malignant potential of the tumor was assessed. Sharp demarcation of the growth appearing characteristic for this type of pancreatic neoplasia with no invasion into the surrounding organs enabled complete excision in spite of the large dimensions of the tumor.

Solid papillary-cystic tumor of the pancreas

BACKGROUND/AIMS

Clinical diagnosis and histopathological findings of a solid papillary-cystic tumor (SCT) of the pancreas may be unrecognized due to difficult differentiation between exocrine and endocrine pancreatic neoplasms, such as acinar cell carcinoma. Surgeons should be aware of this benign but rather uncommon lesion because complete excision is possible and successful.

METHODOLOGY

The clinical course, surgical treatment and morphological findings of 3 patients with SCT are analyzed. The cases comprised 2 females and 1 male ranging in age from 49-72 years. The tumors were identified by histopathologic examination including immunostaining.

RESULTS

The tumors, which were localized in the head, body and tail of the pancreas expressed a distinct immunostaining such as focal alpha1-antitrypsin in cases 1 and 2, and diffuse vimentin in all 3 cases. Keratin reactivity appeared positive in case 2 and 3, and neuroendocrine markers in case 2. The diversity of immunostaining emphasizes the tumor cell phenotype expressing epithelial, mesenchymal, and endocrine lines. After pancreatic resection 2 patients recovered successfully and 1 died. No lymph node or distal metastases were found at autopsy.

CONCLUSIONS

Considering the favorable prognosis, the pancreatic SCT should be recognized by clinicians and pathologists, and surgically removed.

Fulminant Wilsonian hepatitis unmasked by disease progression: report of a case and review of the literature

Among various hepatic manifestations of Wilson's disease, fulminant hepatic failure is the most uncommon entity and requires a detailed clinicopathological analysis for correct diagnosis. Left unrecognized and without proper therapy, in time the disease rapidly progresses to death. We describe a 24-year-old woman who died within five weeks of the onset of Wilson's disease, which presented with a dramatic course. Discriminating features of the disease are discussed with regard to the literature.

Interobserver agreement in the assessment of gastritis reversibility after Helicobacter pylori eradication

AIM

Our aim was to determine interobserver agreement in the application of the Sydney system to assess reversibility of gastritis after Helicobacter pylori eradication.

METHODS AND RESULTS

Forty-three patients with a Helicobacter pylori-positive duodenal ulcer disease were included in the study. All patients included had successful H. pylori eradication after different antimicrobial drug combinations. Biopsy samples were collected from antrum and body, according to the Sydney recommendations, before antimicrobial therapy, 2 months after and at yearly intervals during 2-4 years of follow up. Three pathologists, who were blind to clinical data, evaluated histological changes in 221 antral and 219 body specimens stained with haematoxylin and eosin and with Warthin Starry. The percentage of pairwise agreement, kappa and weighted kappa statistic were used. Agreement in recognizing the presence of H. pylori colonization of the gastric mucosa, activity of inflammation and intestinal metaplasia was over 90%. Agreement in recognizing chronic inflammation in the body and atrophy in the antrum was between 78 and 89% respectively. The kappa values were excellent (more than 0.75) for the grade of H. pylori in the body, good (between 0.50 and 0.75) for the grade of H. pylori in the antrum, grade of inflammatory activity and intestinal metaplasia in the antrum and moderate to good (0.38-0.53) for the grade of chronic inflammation. Kappa values were poor to good (from 0.17 to 0.57) only in evaluation of the grade of atrophy.

CONCLUSION

Interobserver agreement in the application of the Sydney system to reversibility of gastritis after H. pylori was good. More strict criteria should be used for atrophy and to differentiate normal and mild chronic inflammation.

Treatment options in Western hepatocellular carcinoma: a prospective study of 224 patients

BACKGROUND/AIMS

Though hepatocellular carcinoma (HCC) is one of the most frequent malignant tumors in the world, the optimal therapeutic strategy is still poorly defined. This is mainly due to geographic differences in HCC which may affect the validity of treatment regimens in differents areas of the world. The aim of the present study was to analyze the natural course of the disease as well as to assess the efficacy of different therapeutical schemes in HCC observed in Ljubljana (Slovenia) and Trieste (Italy), two cities in Western Europe situated close to each other.

METHODS

During the period from January 1988 to December 1993, 224 consecutive patients (132 in Trieste and 92 in Ljubljana) with HCC were enrolled in the study. Patients were treated with the following 3 schemes: surgery 39 (17.4%), transcatheter chemoembolization (TACE) 116 (51.8%), and no treatment 69 (30.8%). The tumor was classified by Okuda staging and the liver disease by Child-Pugh score. Patients were followed up for 12-60 months, with an average of 40 months. The response rate to TACE and recurrence following surgery were evaluated. Comparative analysis of survival between different treatment groups was performed.

RESULTS

The natural course of the disease, and other characteristics of the HCC, showed a typical Western type of tumor. Liver disease was scored as Child A in 58%, Child B in 30% and Child C in 12%, and the tumor was staged as Okuda I in 52%, Okuda II in 37% and Okuda III in 11%, respectively. Treatment with TACE was followed by an objective response in 27%, with a median survival of 31 months. Surgery was followed by a recurrence rate of 77% within 19.5 months and median survival of 49 months. The overall median survival of nontreated patients was 8 months. Survival in each group of patients differed significantly between all three consecutive stages of Okuda (p<0.001). In contrast, the differences in survival were significant only between Child A and B (p<0.02). The differences between Child B and C were not significant.

CONCLUSIONS

This study emphasizes the importance of staging in the choice of treatment modality and diffusion of HCC in affecting an overall response to treatment and survival. Surgery is highly effective in monofocal HCC of Okuda I and II without cirrhosis. TACE is effective in Okuda I and II and Child A cirrhosis only. The treatment of HCC in Child B cirrhosis needs further studies. In Child C and/or Okuda stage III of HCC, any treatment except pure symptomatic relief is detrimental and should not be used.

Hepatobiliary cystadenoma can protrude and grow into the bile ducts

BACKGROUND/AIMS

To evaluate the phenomenon and the potential reasons for protrusion and growth of hepatobiliary cystadenoma into the extrahepatic bile ducts in our patients, accomplished by a review of the data regarding hepatobiliary cystadenomas published elsewhere.

METHODOLOGY

In a retrospective open study conducted over the last eight years, five patients with hepatobiliary cystadenoma and one patient with hepatobiliary cystadenocarcinoma were operated on. All the patients were females aged between 25 to 61 years. Diagnostic procedures, laboratory, operative and histopathological findings and treatment were evaluated.

RESULTS

Most of our patients were found to have hepatobiliary cystadenoma located in the left surgical liver. In three out of five patients with HBC mesenchymal stroma was histologically detected. In two of the three, protrusion and growth into the extrahepatic bile ducts was found.

CONCLUSION

Considering the pathogenesis, location and the morphology of HBC, the mesenchymal stroma may present the competent potential for intraductal progression of the tumor. Radical excision should be performed for successful treatment of hepatobiliary cystadenomas, because of the potential for reoccurrence.

Hepatoblastoma in fine needle aspirates

OBJECTIVE

To analyze cytomorphologic characteristics of hepatoblastoma (HB) and evaluate the feasibility of recognizing its histologic subtypes in smears.

STUDY DESIGN

Fine needle aspirates from 14 primary and 1 metastatic HB were reexamined. The diagnosis of HB was confirmed by tissue examination (10 cases) and by clinical and laboratory findings alone (5 cases).

RESULTS

In 12 samples, neoplastic cells resembled immature hepatocytes but were smaller and had a higher nuclear/cytoplasmic ratio. In nine of these smears the cells were rather uniform, while the other three presented with moderate pleomorphism. The cells were arranged in three-dimensional clusters, loose sheets, cords, rosettelike structures and occasional pseudopapillae and were dispersed.

CONCLUSION

With knowledge of the cellular features and architectural patterns of HB, a reliable diagnosis could be obtained in 12/15 cases without the use of special techniques. In the remaining three aspirates the tumor cell population partly or entirely differed from normal hepatocytes, requiring ancillary techniques for proper diagnosis. On reexamination of the 10 cases with tissue diagnoses, 4/6 mixed HBs could be correctly subtyped, whereas the distinction between embryonal and fetal cells in four cases of epithelial HB seemed questionable.

Spontaneous regression of hepatocellular carcinoma

Spontaneous regression of a histologically proven hepatocellular carcinoma was observed in a 62-yr-old male Slovenian patient with HBsAg-positive liver cirrhosis and a remarkable family history of hepatocellular carcinoma. After 3 months of persistent high fever, the patient's condition improved, and liver resection was performed. Histological examination of resected liver specimen revealed necrosis with pseudocapsular lining and no malignant cells. The patient is alive, without evidence of recurrence, 8 yr after the diagnosis was established.

Hepatobiliary cystadenomas and cystadenocarcinoma. Report of five cases

Clinicopathologic correlation of five cases of cystadenomas of the liver are reported. All patients were female and radical surgical procedure, total excision or resection was performed four times, and partial excision once. In all patients the postoperative course was uneventful and they are all alive and well. Examined by conventional histological and special immuno-histochemical stains the tumors fulfilled diagnostic criteria for these rare cystic growths. The cyst wall was composed of three, histologically distinct layers. From the viewpoint of histogenesis and differential diagnosis immunohistochemical properties were analysed. CEA and EMA were demonstrated in epithelial cells and Vimentin in stromal cells.

HLA-DR expression on CD8 lymphocytes from gastric mucosa in urease-positive and urease-negative gastritis

We isolated lymphocytes from chronically inflamed gastric mucosa. We analysed the expression of IL-2 receptors (CD25), transferin receptors (CD71) and HLA-DR molecules on T lymphocytes by flow cytometric analysis in 16 patients with urease-positive and in 7 patients with urease-negative chronic gastritis. In G0, G1 and G2 histological type (Sydney classification) of gastritis the number of lymphocytes obtained from the gastric mucosa biopsies was too low for the flow cytometric analysis. However, in G3 histological type of chronic gastritis we obtained enough cells for the flow cytometric analysis in 75%. We demonstrated a significant increase in HLA-DR expression on CD8 cells from patients with urease-positive gastritis compared to urease-negative gastritis. We also observed a statistically non-significant increase in HLA-DR expression on CD3 cells, and in CD71 expression on both CD3 and CD8 cells in urease-positive gastritis. However, no difference in CD25 expression was found between the two types of gastritis.

Mixed connective tissue disease associated with autoimmune hepatitis and thyroiditis

The case is reported of a 27 year old woman who had mixed connective tissue disease (MCTD) associated with chronic active hepatitis and thyroiditis. Although hepatomegaly is sometimes observed in MCTD, only four cases of MCTD and chronic active hepatitis have been described. It is thought that this is the first report of an association between MCTD, chronic active hepatitis and thyroiditis.

Histological diagnosis of different liver lesions using fine-needle aspiration biopsy

The aim of our study was to elucidate the applicability of FNA biopsies for histomorphological analysis. Ultrasonically-guided fine-needle biopsy proved to be a simple, safe and time-saving method of high diagnostic value in discovering and establishing liver lesions. FNA biopsies performed in 58 patients offered enough material for histomorphological analysis of primary liver tumors (8x), metastases (8x) and diffuse liver diseases (25x). Only 27% of the cases examined remained histomorphologically unclear. Furthermore, no complications were seen with this procedure.