A peculiar anomaly of the main biliary duct: choledochal cystic dilatation

The Authors report a case of choledochal cystic dilatation and examine this particular anomaly of the main biliary duct analysing the complex classification. After a brief review of the embryology of the hepato-pancreatic ring, etiopathogenetic theories, clinic characteristics, as well as diagnostic and therapeutic possibilities for this affection are taken into account. It is concluded that the best therapeutic choice should be always based on an accurate evaluation of the anatomo-pathological conditions in each single case.     

Traumatic biliary stricture successfully treated by percutaneous transhepatic bile duct dilatation: a case report

A 24 year-old woman complained of obstructive jaundice 24 days after blunt abdominal trauma due to a traffic accident. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a stricture, 15 mm in length, at the common bile duct associated with upper bile duct dilatation. Jaundice was reduced by percutaneous transhepatic cholangio-drainage (PTCD). A 7 Fr-sized PTCD tube was exchanged for a larger-sized catheter for percutaneous transhepatic cholangioscopy expecting gradual dilatation of the stricture. Following the confirmation of satisfactory dilatation of the stricture, the catheter was removed. There was no recurrence of jaundice 16 months later in a follow-up study.     

Differentiation of hypervascular hepatic pseudolesions from hepatocellular carcinoma: value of single-level dynamic CT during hepatic arteriography

The relative relationships among anatomic features visualized on planar radiographic images change due to rotations of the patient out of the imaging plane. These changes can be predicted a priori from a three-dimensional radiographic model of the patient. In this study we assess the feasibility of using that information together with a planar image feature alignment tool to account for out-of-plane rotations in the evaluation of subsequent clinical patient images. A series of digitally reconstructed radiographs (DRRs) with known patient rotations was generated from a computed tomography scan of an anthropomorphic head phantom. Fixed anatomic features were extracted, as seen in the DRRs of rotated anatomy and entered into a database. Alignment of features from test radiographs with those from an entry in this database yielded an estimate of rotation out of plane (database entry that resulted in the best fit via planar transformation) along with the planar components of setup errors in the rotated plane. Tests using DRRs and films show that it is possible to select anatomic features in AP skull radiographs with position and orientation sensitive to out-of-plane rotation.     

The diagnostic value of dilatation and curettage in endometrial carcinoma

Exfoliation syndrome is more frequently in the older age and represents a risk factor for cataract surgery. This paper presents the results of a clinical trial made on 436 patients with troubles of transparency of the lens who were investigate in our clinic during January 1995-January 1997, and in whom, clinic and paraclinic exams have not revealed any associated ocular disease. In 14% of these patients who presented troubles of transparency of the lens were found uni- or bilateral exfoliation. The authors present the treatment applied both in patients in clinical follow-up (50% of patients with exfoliation syndrome develop secondary glaucoma) and patients who underwent surgical treatment. The patients with exfoliation syndrome and cataract have had a high risk to develop intra- and postoperative complications. The surgical treatment suggested by authors is extracapsular cataract extraction, either or without lens implantation and peripheral iridectomy which represents a compulsory step.     

Cystic dilatation of the biliary tract]

Cystic dilatation of the biliary tract is a rare disorder, more common in children, with a high morbidity and mortality rate. Death may follow one of the possible complications (recurrent cholangitis, biliary cirrhosis, cholangiocarcinoma). The Authors report the case of an asymptomatic adult woman. According to CT scan and ERCP the lesion found was classified as type IVb of Todani's classification. The cyst was removed and a Roux en-Y reconstruction was performed. This procedure is currently associated to a low mortality rate and the best long term results.     

Cystic dilatation of the common bile duct

The Authors report a case of cystic dilatation of the common bile duct and a review of the Literature. The lesion is a congenital malformation of infancy or childhood, being rare in adult life. The main symptoms are biliary colic with jaundice and fever. Modern techniques such as abdominal ultrasonography, CT, ERCP, PTC generally provide to achieve preoperative diagnosis. When radical surgery is possible the complete excision of the cyst is the management of choice. The case reported is classified as type 1 of Todani's classification. Surgical management consisted in a complete excision of the cyst. Bile flow was re-established by hepaticojejunostomy.     

Long-term survival of a patient with bile duct carcinoma by endoscopic biliary drainage

An 80-yr-old female presented with obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed a carcinoma in the middle extrahepatic bile duct, and a biliary endoprosthesis was inserted. Exfoliative cytology of the bile and forceps biopsy of the tumor revealed a papillary adenocarcinoma. Surgical resection could not be done because of her cardiovascular complications, and neither chemotherapy nor radiotherapy was administered. Stents were exchanged and cleaned 21 times because of occlusion and cholangitis. Subsequent serial cholangiogram showed a slow growth of the papillary tumor, but local invasion to the adjacent organs or distant metastasis was not observed. The patient survived for 7 yr and 6 months after insertion of the biliary endoprosthesis.     

The value of emergency CT studies in spontaneous rupture of hepatocellular carcinoma. Analysis for tumor protrusion and hemorrhagic ascites

CT characteristics of spontaneous rupture of HCC (n = 13) were reviewed retrospectively, and the value of emergency CT studies in this disease was evaluated. Especially, tumor protrusion ratio (TPR) and ascitic CT numbers were measured to for comparison with the data for unruptured HCCs and ordinary (e.g. non hemorrhagic) ascites (n = 13). As a result, except for diffuse type HCCs, the TPR was significantly higher than for the unruptured HCCs. Nine cases had intraperitoneal HDAs, and the laterality of the HDAs corresponded with that of the ruptured tumors in 8 cases. Also, the ascitic CT numbers apart from the HDA were still higher than the ordinary ascites. Therefore, a high TPR, HDAs adjacent to the tumor, and elevated ascitic CT numbers are important CT manifestations indicating HCC rupture. Diffuse HCCs, however, require careful clinical evaluation.     

Early advanced hepatocellular carcinoma: evaluation of CT and MR appearance with pathologic correlation

PURPOSE: To determine the computed tomographic (CT) and magnetic resonance (MR) imaging appearances of early advanced hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Twenty-seven surgically resected cases of early advanced HCC were studied with CT, CT during arterial portography, CT arteriography, and MR imaging. RESULTS: The sensitivity of standard CT (unenhanced, early, and late CT combined) for the detection of early advanced HCC was 81%, while that of standard MR imaging (T1- and T2-weighted MR imaging combined) was 83%. A nodule-in-nodule appearance was identified in approximately one-third to one-half of cases. Signal behavior of early and advanced components of early advanced HCC followed the expected behaviors of isolated early HCC and isolated advanced HCC, respectively. Tumor size was accurately estimated with standard CT and standard MR imaging. CONCLUSION: More research must be performed to ascertain whether any relationship exists between the different types of HCC and the clinical outcome.     

MRI and CT of metastatic hepatocellular carcinoma causing spinal cord compression

We report the imaging features in five patients with metastatic hepatocellular carcinoma causing spinal cord compression, three of which were biopsy proven and two were in patients with known diagnosis of hepatocellular carcinoma. The radiographic, magnetic resonance imaging (MRI) and computed tomography (CT) features are highlighted. Although the occurrence of metastatic disease in hepatocellular carcinoma is exceedingly rare, it may be increasingly encountered as survival of patients is improved with advancing methods of therapy, both surgical and palliative. It often accompanies local recurrence, and invariably signals a grave prognosis with extremely short life expectancy. Unusually, two of the five patients in this series presented initially with skeletal metastases which led to the diagnosis of hepatocellular carcinoma.     

Sinusoidal capillarization of human hepatocellular carcinoma: possible promotion by fibroblast growth factor

Expression of acidic and basic fibroblast growth factors (aFGF and bFGF) and von Willebrand factor (vWF) was immunohistochemically investigated in 55 nodules of human hepatocellular carcinoma (HCC), 15 nodules of adenomatous hyperplasia (AH) of the liver and 10 cirrhotic livers (LC). AH, a putative preneoplastic lesion in the cirrhotic liver, was subdivided into ordinary and atypical types: the former was characterized by little cellular and structural atypia and the latter had some atypia equivocal as to benignity and malignancy. The positive rates of FGF (aFGF and/or bFGF) were as follows: 0% in LC, 20% in AH (ordinary and atypical) and 42% in HCC, whereas the positivity of vWF was 10% in LC, 20% in ordinary AH, 30% in atypical AH and 40% in HCC. There was no correlation between the expression of FGF or vWF and the size of HCC. No correlation was also found between the positivity of FGF and that of vWF in HCC and atypical AH. While vWF was not constantly expressed in the vicinity of FGF-positive HCC cells, capillarized sinusoids were significantly more numerous in FGF-positive cases than in FGF-negative cases (p < 0.01). These data indicate that FGF may be pathogenetically linked to the multistep development of HCC in relation to sinusoidal capillarization.     

The prognostic significance of macroscopic growth pattern of hepatocellular carcinoma

AIM: To investigate the prevalence and amount of polyploidy in fine needle aspiration specimens of the liver, urinary cytospin preparations, and cytospin preparations from pleural and peritoneal fluid. METHODS: Cells from 44 liver smears, 48 urine specimens, and 46 pleural and peritoneal aspirations were examined. After Feulgen restaining the DNA content of 100 randomly selected nuclei was determined using a TAS-plus image analysis system, combined with an automated microscope. RESULTS: Polyploidy was observed up to 16c in the liver, and up to 8c in urothelium and mesothelium. Sixty eight per cent of the liver aspirates contained polyploid nuclei. The rate in urothelium was 20.8% and in mesothelium 6.5%. CONCLUSIONS: Polyploidy in the liver may be interpreted as being associated with tissue differentiation, but the findings in urothelium and mesothelium remain of unknown importance.     

Detection of hepatocellular carcinoma in patients with cirrhosis: MR imaging versus angiographically assisted helical CT

OBJECTIVE: The purpose of our study was to compare the combination of conventional spin-echo, phase-shift gradient-recalled echo (GRE), and triple-phasic dynamic GRE MR imaging with the combination of helical CT hepatic arteriography (CTA) and CT performed during arterial portography (CTAP) in the preoperative detection of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Thirty-seven patients with cirrhosis underwent MR imaging and angiographically assisted CT imaging. Paired T1- and T2-weighted spin-echo images, paired in-phase and out-of-phase GRE images, triple-phasic dynamic GRE images, the combined MR images, and the paired CTA and CTAP images were retrospectively and independently reviewed by three radiologists. Image review was done on a segment-by-segment basis. Of the 280 liver segments, 58 segments contained 79 HCCs that were 0.5-8.0 cm (mean, 2.0 cm) in diameter. The diagnostic value of each pair of images was rated by means of receiver operating characteristic curve analysis. RESULTS: The diagnostic accuracy of combined CTA and CTAP (mean area under the receiver operating characteristic curve [Az] = 0.94) was significantly better than that of spin-echo (Az = 0.86, p < .0001), phase-shift GRE (Az = 0.83, p < .0001), dynamic GRE (Az = 0.85, p < .0001), and all combined (Az = 0.91, p < .001) MR imaging. The relative sensitivity of combined CTA and CTAP (89%) was also significantly (p < .0005) better than that of the combined MR imaging (75%). CONCLUSION: Angiographically assisted helical CT imaging was superior to MR imaging combined with conventional spin-echo, phase-shift GRE, and triple-phasic dynamic GRE techniques in the detection of HCC in patients with cirrhosis. The noninvasive dedicated combined MR imaging could not obviate invasive angiographically assisted CT imaging. Combined CTA and CTAP is recommended, especially in the preoperative examination of patients with HCC.     

Big insulin-like growth factor II-producing hepatocellular carcinoma associated with hypoglycemia

A 76-year-old female with a hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) was hospitalized because of fasting hypoglycemia. Her sera contained a low concentration of immunoreactive insulin and insulin-like growth factor (IGF)-I, while the IGF-II level was normal. However, most of the IGF-II consisted of the high molecular weight form (big IGF-II). The tumor tissue contained fetal type of IGF-II mRNA (6.0 kb). Furthermore, we found that one of the four patients examined with HCV-related HCC had big IGF-II in serum. This indicates that non-islet cell tumor hypoglycemia (NICTH) in HCV-related HCC might be accompanied by production of big IGF-II by the tumor.     

Detection of hypervascular hepatocellular carcinoma by using spiral volumetric CT: comparison of US and MR imaging

BACKGROUND: Most hepatocellular carcinomas (HCCs) are hypervascular and arise in the liver with chronicity. Spiral volumetric CT (SVCT) is a new rapid-scan technique that offers whole-liver scanning during the arterial-dominant phase. The main aim of the present study is to evaluate the detectability of hypervascular HCC with SVCT as compared with ultrasonography (US) and magnetic resonance (MR) imaging. METHODS: Forty-three hypervascular HCCs in 512 patients with chronic liver disease were examined with US, precontrast SVCT, postcontrast SVCT during the arterial-dominant phase (CT-ADP) and during the equivalent-phase (CT-EP) noncontrast MR imaging and angiography including SVCT during arteriography and arterial portography. Angiographic and follow-up findings were used as the gold standard if the lesion was not confirmed histologically. RESULTS: The sensitivity was 61% with precontrast CT, 84% with CT-ADP, 58% with CT-EP, 70% with US, 72% with MR, and 95% with the combination of these five modalities. Five HCCs (12%) were detected with only CT-ADP. The vascularity of HCC was correctly evaluated as hypervascular in 38 nodules (88%) with the combination of precontrast CT and CT-ADP. CONCLUSIONS: We suggest that the combination of precontrast SVCT and CT-ADP is an essential modality to screen for HCC in patients with chronic liver disease. CT-EP did not contribute to the detection of hypervascular HCC.