Hepatic artery ligation for liver metastasis of a acinar cell carcinoma of the pancreas revealed by a nodular panniculitis

We report the case of a 67-year-old-man presenting with pancreatic acinar cell carcinoma revealed by dermatological manifestations of cytosteatonecrosis and treated by hepatic artery ligation. The pancreatic etiology of these lesions was suspected due to hyperlipasemia, and was confirmed by abdominal computerized tomography showing a pancreatic tumor and multiple liver nodules, and by histological examination of one of these lesions. Because of symptomatic treatment failure, rapid impairment of patient's general condition, and by analogy with the treatment of hepatic metastases of neuroendocrine tumors, hepatic artery ligation was performed. Lipasemia decreased markedly and symptoms disappeared for 45 days. Hepatic artery obstruction may be used for emergency treatment of secreting liver metastases.     

Driving cognitive and motor gains with rehabilitation after brain and spinal cord injury

Hepatic involvement in hereditary hemorrhagic telangiectasia (HHT) is rare. Among local pathologic alterations like fibrosis and cirrhosis, arteriovenous shunts lead to hypercirculatory heart failure and require efficient therapy. Present therapeutic strategies consist of percutaneous selective embolization or complete ligation of the hepatic artery. We describe a 53-year-old woman with HHT in whom percutaneous selective embolization of the left hepatic artery failed because of unfavorable anatomy. Instead of ligation a new method of adjustable banding of the hepatic artery was tested. After small-incision laparotomy an expander prosthesis was put on the proper hepatic artery. By filling the prosthesis via the implanted port system the hepatic perfusion could be reduced under control. This method led to effective reduction of the liver perfusion and heart time volume and to successful treatment of heart failure. The method described is an alternative treatment to ligation of the hepatic artery in cases in which percutaneous embolization failed or is not possible.     

First experience and technical aspects of isolated liver perfusion for extensive liver metastasis

BACKGROUND: New drugs and modalities for locoregional tumor treatment in recent years may offer new potential for isolated liver perfusion in patients with nonresectable liver tumors. The purpose of this study was to prove the feasibility of arterial isolated liver perfusion and to assess the tolerance of perfusion with high-dose tumor necrosis factor (TNF). METHODS: Twelve patients with extensive liver metastases previously treated unsuccessfully with systemic chemotherapy underwent isolated hyperthermic liver perfusion using a heart-lung machine. High doses of mitomycin were administered in the first six and a combination of TNF and melphalan in the last six patients. RESULTS: No operative death occurred and no direct postoperative liver failure was observed in any patient. In cases of variations of the arterial hepatic blood supply, the perfusion was done through the splenic artery or an angiography catheter. Histologic analysis of tumor biopsy specimens obtained on the first postoperative day revealed major tumor necrosis in 8 of 12 patients. CONCLUSIONS: Isolated arterial perfusion of the liver is a complex surgical procedure that is feasible in patients with anatomic variations of the hepatic artery. The remarkable histologic response to perfusion in several pretreated patients, especially after application of high-dose TNF and melphalan, suggests that this modality is very effective in tumor killing.     

Low-dose aspirin therapy is associated with few side effects but does not prevent hepatic artery thrombosis in liver transplant recipients

Hepatic artery thrombosis occurs in 4% to 10% of adult patients and in up to 26% of children undergoing liver transplantation. Aspirin has been used to prevent this complication but may increase procedure-related and gastrointestinal bleeding. The aim of this study was to assess the efficacy and safety of low-dose aspirin in the prophylaxis of hepatic artery thrombosis. The histories of 529 patients who survived liver transplantation between September 1988 and December 1993 were reviewed retrospectively. The routine clinical practice followed until 1992 was to initiate oral aspirin therapy on the first postoperative day (81 mg daily in adults and 40 mg daily in children) as prophylaxis for vascular thrombosis. This was done in 354 patients. Aspirin was not administered to the remaining 175 patients. Hepatic artery thrombosis occurred in 13 patients treated with aspirin (3.7%) and in 7 patients not treated with aspirin (4.0%) (P = .85). Recipient age of younger than 2 years and low donor liver weight were the only factors that predisposed the patients to hepatic artery thrombosis. A total of 1,651 percutaneous liver biopsies were performed in this series, with 1,111 performed in patients treated with aspirin. Significant bleeding after liver biopsy occurred in 12 patients treated with aspirin (1.1%) and in 3 patients not treated with aspirin (0.6%) (P = .29). Gastrointestinal bleeding occurred in 66 patients treated with aspirin (18.9%) and in 23 patients not treated with aspirin (12.8%) (P = .08). Low-dose aspirin therapy is not shown to be effective in preventing hepatic artery thrombosis after liver transplantation. Although aspirin does not produce a statistically significant increase in the risk of bleeding after liver biopsy, there is a trend toward an increased incidence of gastrointestinal bleeding.     

Focal nodular hyperplasia of the liver: a rational approach to treatment

Focal nodular hyperplasia of the liver in a 3 year old child has been successfully treated by ligation of the hepatic artery branches supplying the lesion. The prominence of the abnormal vasculature in the lesion and its possible aetiological involvement is stressed. Because of the risks of partial hepatectomy, hepatic artery ligation is suggested as the treatment of choice for focal nodular hyperplasia.     

Bromodeoxyuridine uptake by early liver metastases in rats: a comparison of the hepatic artery and portal vein infusion routes

Liver metastases generated by the intraportal inoculation of ascites hepatoma cells in Donryu rats were labeled with bromodeoxyuridine (BrdU) through the hepatic artery, or through the portal vein with or without ligation of the hepatic artery, 3, 6, or 9 days after tumor inoculation. The distribution of BrdU-labeled cells was evaluated in 174 metastases, 110-1640 microm in diameter, by immunohistochemical methods. When a dual blood supply from the portal vein and hepatic artery existed, the BrdU-labeled cells were diffusely found in the metastases regardless of their size and the route of BrdU infusion. When blood supply to metastases larger than 610 microm in diameter was from a single source, namely the portal vein, the BrdU-labeled cells were located within 90-290 microm from the margin of the metastases. These results indicate first, that drug uptake by the inner part of the early metastatic liver tumors is achieved through the hepatic artery, and second, that drug uptake by early liver metastases through the portal vein is limited to within the extent of portal diffusion regardless of the size of the metastases. Thus, we conclude that prophylactic treatment against liver metastases would be more effective when given via the hepatic artery route rather than via the portal vein route.     

Interventional radiology in the treatment of primary and metastatic liver cancer

The data available in the literature and the authors' own treatment outcomes in 600 patients with primary and metastatic carcinoma of the liver (in 1983-1996) were analyzed. Systemic or intravascular therapy as regional drug infusion, embolization, chemoembolization of the hepatic artery (CEHA) and portal vein (CEPV) was performed in unresectable cases. Whether pre- and postoperative chemoembolization was evaluated in resectable tumors. It is concluded that X-ray endovascular interventions play an important role in the treatment of malignant hepatic tumors. Transcatheter CEHA alone and in combination with CEPV is the most effective current treatments of unresectable carcinoma of the liver. In some patients, preoperative CEHA makes it possible to remove the tumor previously considered to be unresectable. Resection in combination with adjuvant CEHA and CEPV reduces the incidence of postoperative recurrences. The combined approach to treating malignant hepatic neoplasms expands the possibilities of delivering care to patients and improving late outcomes.     

A case of surgical resection for metachronous multiple liver metastases of chromophobe cell renal carcinoma

A 64-year-old female was hospitalized because of multiple liver metastasis, during the postoperative observation of chromophobe cell renal carcinoma. Injection of Epirubicin/Lipodol into the right hepatic artery followed by transcatheter arterial embolization was performed two times, and the metastatic foci responded favorably to this therapy. Since no new metastatic tumors were observed in the liver nor any other organs, a partial hepatectomy was thus performed. The liver tumor was pathologically diagnosed to be metastasis of the chromophobe cell renal carcinoma. The postoperative course has been uneventful and at present, 6 months after the operation, no further tumors have been observed.     

Sex differences and lateral specialization of hemispheric functioning

Acute renal failure developed in nine of 78 patients who were subjected to hepatic artery ligation for nonresectable and extensive malignant tumor of the liver. Of those nine, six had hepatomas, one cholangiocarcinoma, one metastatic islet-cell carcinoma and one metastatic melanoma. Preoperative renal function as reflected in blood-urea-nitrogen and serum creatinine values was within normal limits. There were marked elevations of serum glutamic-oxalacetic transaminase and lactic dehydrogenase levels after hepatic artery ligation, an indication of massive ischemic injury of the tumor and the liver. A diagnosis of acute renal failure was established within 14 to 70 hours after hepatic artery ligation. In five patients, oliguric renal failure developed, and in four, high urinary output renal failure. In only three patients did systemic hypotension and hypovolemia precede acute renal failure. Seven of the nine patients died. Postmortem examination was done in five patients, and in only two was there evidence of renal tubular necrosis. The factors contributing to acute renal failure appear to be extensive involvement of the liver by tumor, presence of ascites and jaundice, occlusion of the portal vein and hyperuricemia. The presence of any one of the foregoing contraindicates the procedure.     

Transcatheter liver lobar ablation: an experimental trial in an animal model

Complete embolization of tumor tissue together with surrounding liver sufficiently prevents collateral blood supply to the tumor, offering curative treatment for hepatic malignancies. The present experiment was designed to test the feasibility of hepatic lobar ablation by means of the transcatheter chemoembolization technique. Five groups of rats (n = 6) were treated with a mixture of iodized oil/ethanol in ratios of 5:1, 4:1, 3:1, 1:1, and 1:0, which was injected selectively into the right-lobe artery until saturation during open surgery. Another group (n = 6) was studied using in vivo microscopy to observe the distribution of the mixture in the liver and changes in hepatic microcirculation. Ethiodol/ethanol mixture entered the portal vein after injection into the hepatic artery creating dual, complete arterial and portal venous embolization. Lobar ablation effects were achieved in 2 weeks in the 5:1, 4:1, and 3:1 ratio groups, indicated by the lobe/liver weight measurements (p < 0.001 vs normal liver). Hepatic arterial administration of the Ethiodol/ethanol mixture creates dual hepatic arterial and portal venous embolization, achieving a lobar ablation effect.     

Long-term survival in a case of multiple liver metastasis from postoperative gastric cancer effectively treated by hepatic intraarterial infusion chemotherapy using MMC and pirarubicin

We experienced a case of multiple liver metastasis from postoperative gastric cancer who showed long-term survival with hepatic arterial infusion chemotherapy (HAI) of MMC and pirarubicin. A catheter was inserted into the hepatic artery, and 4 mg of MMC and 20 mg of pirarubicin were administered through an implantable port catheter every two to four weeks. The total dose of MMC and pirarubicin by the time of this report was 164 mg and 820 mg, respectively. The follow-up CT scan 2 months after the beginning of HAI showed a decrement of the liver tumors. The decrease rate at 12 and 17 months was 50% and 70%, respectively, which was diagnosed as partial response (PR). The therapeutic effect at 49 months is still PR without any sign of tumor enlargement of extra hepatic lesion.     

Hepatic actinomycosis infiltrating the diaphragm and right lung

Hepatic actinomycosis is a rare infectious disease caused by an anaerobic gram-positive bacterium of the genus Actinomyces. Herein, we describe an unusual case of hepatic actinomycosis involving the diaphragm and right lung. A 41-yr-old man was admitted to Wakayama Medical School Hospital presenting with right back pain and cough. Computed tomography and magnetic resonance image revealed a 5 x 10 cm tumor in the anterior superior segment of the liver, which extended to the diaphragm and right lung. Angiography demonstrated a hypervascular tumor and the enlarged right inferior phrenic artery feeding around the tumor. The patient underwent a hepatectomy with partial resections of the diaphragm and the right middle pulmonary lobe. Microscopically, the specimen showed sulfur granules and was positive for Gram stain and Grocott stain and negative for Ziehl-Neelsen stain. These findings were consistent with actinomycosis of the liver. His postoperative course was uneventful and no recurrence was observed 1 yr postoperatively. Although there are at least 36 well-documented cases until 1993, no other report has been found infiltrating the diaphragm and lung.     

The contribution of deficient DNA repair to chromosomal radiosensitivity of CHO cells after G2 irradiation

Neuroendocrine tumors, particularly those of gastrointestinal tract origin, have a predisposition for metastasizing to the liver. In such patients, the clinical course is often dominated by the hepatic disease, either because of hormone secretion or because of tumor bulk. Because the liver has a dual vascular supply and hepatic metastases derive the majority of blood from the hepatic artery, the regional delivery of chemotherapy can offer pharmacokinetic advantages over systemic administration. The hepatic artery is also a nonsurgical avenue for inducing selective metastasis ischemia by the embolization of tumor vessels. The combination of these two therapies, or chemoembolization, may provide additive benefits. Such an approach has been demonstrated to reduce tumor bulk, reduce hormone levels, and palliate the symptoms of many patients with liver-dominant neuroendocrine metastases. Embolization or chemoembolization is an appropriate modality for some patients with neuroendocrine tumors.     

Serum calcium, magnesium and inorganic phosphorous levels during various phases of menstrual cycle

BACKGROUND/AIM: Hepatic tumors with elements of both hepatocellular and cholangiocellular carcinoma are occasionally encountered; however, the independent and simultaneous occurrence of different epithelial malignant tumors in different lobes is rare. This is a case report of resected double cancer in different lobes of the liver. MATERIALS AND METHODS: A 73 year old Japanese man, with hepatic mass and a history of peritonitis and hepatitis, underwent laparotomy and hepatic resection of the posterior inferior and the left lateral segment, and cholecystectomy for cholecystlithiasis with left-sided gallbladder at our hospital in 1991. RESULTS: The tumor, located in the posterior inferior segment, a yellow-white, round, highly circumscribed mass with a thick capsule, was about 9.0 by 8.0 cm in size. The other tumor located in the left lateral segment, grayish-white on the cut section, was approximately 5.0 by 4.0 cm. CONCLUSION: In our case, it is unlikely the tumor in the right lobe metastasized to the left lobe and transformed into a different type. The two tumors showed clearly different microscopic features. Improved imaging will increase the frequency and number of double cancer diagnosis. This additional data may shed light on the pathogenesis and etiology of double cancer.     

Decreased interleukin-7 and transforming growth factor-beta1 levels in blister fluids as compared to the respective serum levels in patients with bullous pemphigoid. Opposite behavior of TNF-alpha, interleukin-4 and interleukin-10

Prognosis of hepatocellular carcinoma (HCC) patients with tumor thrombi (TT) in the trunk of the portal vein (PV) has been extremely poor. There have been few reports of long-term survivors with such an advanced condition. In this article, the case of a 62-year-old woman of HCC, who survived for 6 years and 9 months after an operation, with TT in the trunk of the PV is described. The patient not only had a primary tumor of 4 cm in diameter with TT but also multiple intrahepatic metastases in the bilateral lobe of the liver. A palliative lateral segmentectomy with tumor thrombectomy through the incised left first branch of the PV was performed. Moreover, an intraoperative ethanol injection for residual intrahepatic metastatic tumors was performed subsequently. Hepatic arterial infusion of anti-cancer drug with Lipiodol, intraportal continuous infusion of 5-FU and percutaneous ethanol injection therapy were performed suitably during the follow-up periods. The patient survived for 6 years and 9 months after operation and died of hepatic insufficiency with cancer. In this case a patient who suffered from HCC with TT in the trunk of the PV was successfully treated by multimodality procedures including hepatic resection with tumor thrombectomy.     

An improved technique for bloodless hepatic resection on in situ cold perfused liver

An improved technique for bloodless hepatic resection using in situ isolation and asanguinous hypothermic perfusion was described to deal with huge liver tumors involved in the liver hilum, the main hepatic veins and retrohepatic inferior vena cava. The original Fortner's technique was modified, including the choice of incision; semi-isolated perfusion of the liver portion preserved through the single portal vein; suprahepatic outlet of the perfusate and the shortening of the period of hepatic ischemia by reperfusion of hepatic artery prior to the repair or reconstruction of the portal vein. The initial successful experience of the technique applied to 2 pediatric cases with giant liver tumors was reported, and the indications, intraoperative and early postoperative courses were discussed.     

Hemobilia caused by a giant benign hemangioma of the liver: report of a case

We report herein the extremely unusual case of a 39-year-old woman in whom a giant cavernous hemangioma caused hemobilia. Cavernous hemangioma is the most common benign neoplasm of the liver and rarely causes any clinical symptoms or signs, while hemobilia usually occurs secondary to accidental operative or iatrogenic trauma, vascular disease, inflammatory disorders, gallstones, or tumors of the liver. Although invasive or malignant hepatic tumors often result in a communication between the biliary tract and the blood vessels, only one case of hemobilia caused by a benign cavernous hemangioma has ever been reported, but with no details about the patient. Our patient presented to a local hospital with severe melena as the initial main symptom, where ligation of the right hepatic artery was performed. This failed to relieve her symptoms, and she was subsequently referred to our department where a right hepatectomy was performed. Histopathological examination revealed no malignancy combined with the tumor; however, the hemangioma was exposed to the bile duct in segment VIII, which was presumably the cause of the hemobilia. This patient remains in good health almost 6 years after her operation. To the best of our knowledge this is the first case report of hemobilia caused by a cavernous hemangioma, and is accompanied by a detailed analysis.     

Reversal of pretreatment hypotension and control of hemorrhage in trauma patients by a simple device

The injection of a suspension of Walker 256 carcinoma cells into the carotid artery of rats produced a model of hematogenously spread cerebral metastases. Most animals died from massive extracerebral tumors of the head and jaw; brain tumors were present in only one-quarter. External carotid artery ligation prior to tumor inoculation did not increase the incidence of fatal brain tumor. When cyclophosphamide, 15 mg/kg, was injected as a single dose on the fourteenth day after tumor inoculation, most of the extracerebral tumor disappeared. Fifty percent of the animals so treated were cured of tumor, but 90% of the remainder died of large intracerebral tumors. Severe cytopathic changes resulting from cyclophosphamide were present in extracerebral or choroid plexus tumors but were mild or nonexistent in intracerebral tumors. These selective effects of cyclophosphamide suggest that water-soluble agents are less effective against tumor in the brain than against extracerebral tumors despite the fact that metastatic tumor breaks down the blood-brain barrier.     

Child, adolescent and general psychiatry

The incidence and characteristics of hepatic tumors -primitive or secondary- were analyzed in a series of 596 patients with cirrhosis and on whom an autopsy was carried out. A hepatic tumor was discovered in 43.6%: 96.5% with histological findings of malignant disease and only 3.4% with benign disease. The tumors discovered showed the following in order of frequency: hepatocellular carcinoma (90.3%), hepatic metastases (4.2%), cholangiocarcinoma (2.3%), adenoma (1.5%), hemangioma (1.2%) and hamartoma (0.8%). Therefore, 10% of the neoplasms located in the cirrhotic liver were different from the hepatocellular carcinoma. In 2% of the subjects with hepatic tumors, two histologically different lesions were found to co-exist in the liver, and in every case it was found to be a hepatocellular carcinoma related to another tumor, which further complicated the diagnosis. The most frequent type of hepatocellular carcinoma was multinodular, although diffuse tumors most frequently developed metastases. When the hepatocellular carcinoma was uninodular and small, distal spread was exceptional. Metastatic infiltration of the liver by neoplasms of different origin, characteristically infrequent in cirrhosis, was always accompanied by spread to other organs and did not appear as a single nodule in any case. We conclude that the correct diagnosis of tumor-related lesions located, in a cirrhotic liver is occasionally difficult during life, especially when the neoplasms are different from the hepatocellular carcinoma.     

Gastric tubes in children with caustic esophageal injury: a 32-year review

By means of ischemic coagulation of the hepatic artery and portal vein in a microwave coagulation experiment of in vivo swine [correction of bovine] liver, we confirmed approximate doubling of the coagulation diameter compared to the usual coagulation. Based on this fact, for treatment of patients with metastatic liver tumor, we developed an ischemic percutaneous microwave tumor coagulation method using IVR method and applied it in one case, and performed laparotomy microwave tumor coagulation in three cases. We performed the ischemic percutaneous microwave tumor coagulation method on one of the cases. Coagulation was performed for one minute at a dose of 100 W for treatment of metastatic liver tumor of 2 cm in diameter via laparotomy. The postoperative CT showed an extensive coagulation larger than 3 cm. A 2 cm liver tumor was coagulated under balloon ischemia of the hepatic vein and hepatic artery for 13 minutes at a dose of 60 W. The maximum coagulation diameter was 5 cm. Extensive coagulation was possible with percutaneous microwave tumor coagulation through ischemia.