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Purpose: The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for hepatocellular carcinoma (HCC) has been used since 2018. However, whether any significant difference in overall survival (OS) exists between patients with T1a and T1b HCC who undergo resection has been controversial. We aim to clarify this issue.Methods: We consecutively enrolled newly diagnosed HCC patients who underwent liver resection (LR) from 2010 to 2020 at our institution. OS was estimated using the Kaplan–Meier method and compared using log-rank tests. Prognostic factors for OS were identified by multivariate analysis.Results: This study enrolled 1250 newly diagnosed HCC patients who underwent LR. No significant differences in OS were identified between patients with T1a and T1b tumors among all patients (p=0.694), cirrhotic patients (p=0.753), non-cirrhotic patients (p=0.146), patients with alpha-fetoprotein (AFP) >20 ng/ml (p=0.562), patients with AFP ≤20 ng/ml (p=0.967), patients with Edmondson grade 1 or 2 (p=0.615), patients with Edmondson grade 3 or 4 (p=0.825), patients positive for hepatitis B surface antigen (HBsAg; p=0.308), in patients positive for anti–hepatitis C virus (HCV) antibody (p=0.781), or patients negative for both HBsAg and anti-HCV antibody (p=0.125). Using T1a as the reference, multivariate analysis showed that T1b is not a significant predictive factor for OS (hazard ratio [HR]: 1.338; 95% confidence interval [CI]:0.737–2.431; p=0.339).Conclusion: No significant difference in OS was observed between patients who underwent LR to treat T1a and T1b HCC tumors.

Purpose: Tumor necrosis is a significant risk factor affecting patients’ prognosis after liver resection (LR) for hepatocellular carcinoma (HCC). Only one previous study has used a model incorporating tumor necrosis to predict tumor recurrence after LR in patients with a solitary HCC of ≤ 3.0 cm. We aimed to develop a model with tumor necrosis as a variable to predict early tumor recurrence in HCC patients undergoing LR. Methods: Patients who underwent LR between 2010 and 2018 for newly diagnosed HCC but did not receive neoadjuvant therapy were enrolled in this retrospective study. Six predictive factors based on pathological features—tumor size > 5 cm, multiple tumors, high-grade tumor differentiation, tumor necrosis, microvascular invasion, and cirrhosis—were chosen a priori based on clinical relevance to construct a multivariate logistic regression model. The variables were always retained in the model. The impact of each variable on early tumor recurrence within one year of LR was estimated and visualized using a nomogram. The nomogram’s performance was evaluated using calibration plots with bootstrapping. Results: Early tumor recurrence was observed in 161 (21.3 %) patients. The concordance index of the proposed nomogram was 0.722. The calibration plots showed good agreement between nomogram predictions and actual observations of early recurrence. Conclusion: We developed a nomogram incorporating tumor necrosis to predict early recurrence of HCC after LR. Its predictive accuracy is satisfactory.

Serum Wisteria floribunda agglutinin-positive Mac-2 binding protein (WFA(+)-M2BP) is a novel marker for evaluating fibrosis and predicting the development of hepatocellular carcinoma (HCC). However, the role of WFA(+)-M2BP in the prognosis of HCC patients after curative surgery remains unknown. In this study, we aimed to evaluate the prognostic role of serum WFA(+)-M2BP in HCC patients after curative resection and liver transplantation. We enrolled 460 HCC patients (357 resection and 103 transplantation) to analyze the risk factors for HCC recurrence and patient’s survival. We employed time-to-event models using univariate and multivariable Cox proportional hazards regression analyses and calculated the hazard ratios (HRs) and adjusted HRs with their corresponding 95% confidence intervals (CIs). The levels of WFA(+)-M2BP were 0.19-14.51 COI (median 1.08) in patients of hepatectomy and 0.47-19.90 COI (median 6.0) in transplant patients. The levels of WFA(+)-M2BP in liver transplant patients is much higher than that of hepatectomy patients. Overall, liver fibrotic stage was positively correlated to WFA(+)-M2BP levels (P

Introduction: Pancreatoblastoma (PB) is a rare pancreatic neoplasm that occurs most in pediatric patients. Here, we report a rare case of adult PB with liver metastasis and review the literature in order to assist clinicians in the management of the disease. Case Presentation: A 27-year-old female patient suffered from postprandial fullness, anorexia, and weight loss in the past 3 months. An abdominal ultrasound and contrast-enhanced computed tomography scans confirmed right abdominal mass with compression of major liver vessels, as well as the P-duct and biliary ducts and causing mild dilatation. Pancreatoduodenectomy was performed and pathologic findings showed typical squamoid corpuscles, which confirmed the diagnosis of PB. The patient was alive and disease-free for 1 year and 10 months until a new metastatic lesion was found. Radiofrequency ablation was arranged as a curative treatment, and no viable tumor or sign of recurrence was found until this paper was submitted. Based on a review of previous case reports, we found adult PB patients with only liver metastasis presented with a smaller tumor size (P = 0.031), more frequent pancreatic head origin (P = 0.043), and decreased 1-year mortality (P = 0.009) compared with patients with other distal metastases. Therefore, we assumed that PB with liver metastasis might present favorable outcome by complete surgical resection or other curative treatment. Conclusion: PB patients with liver metastasis are more likely to show a pancreatic head origin, smaller tumor size, and more favorable outcomes compared with other sites of metastasis. PB should be treated aggressively with surgical resection or other curative treatment as opposed to chemotherapy alone.

Background Diabetes is a risk factor of fibrosis progression in chronic hepatitis C (CHC). However, only one longitudinal study exploring whether diabetes is associated with progression from non-cirrhotic liver to cirrhosis in CHC patients has been conducted. Aims We investigated whether diabetes is associated with progression from non-cirrhotic liver to cirrhosis in non-genotype 3 CHC patients. Methods A cohort consisting of 976 non-genotype 3 patients histologically proven to have CHC was studied. After excluding patients with biopsy-proven or ultrasound-identified cirrhosis, there were 684 patients without cirrhosis. All 684 patients underwent hepatocellular carcinoma surveillance using ultrasound every 6 months, with a median duration of follow-up evaluation of 102.4 months. During the follow-up period, 60 patients developed cirrhosis according to ultrasound findings. Results For the subgroup of 684 patients without cirrhosis, Kaplan–Meier survival analyses showed no significantly different cumulative incidences of cirrhosis (log-rank test; P = 0.71) among the patients with diabetes as compared to those without. However, after making adjustments for age, gender, fibrosis, steatosis, sustained virological response status, and obesity using Cox’s proportional hazard model, diabetes was found to be an independent predictor for cirrhosis (HR = 1.9; 95% CI = 1.05–3.43, P = 0.03). Conclusions Diabetes is associated with progression from non-cirrhotic liver to cirrhosis in non-genotype 3 CHC patients.

Large well-differentiated hepatocellular carcinoma (HCC) ≥ 3 cm (defined as atypical HCC) is uncommon. We evaluated the characteristics and outcomes of atypical HCC patients underwent liver resection (LR).This retrospective study enrolled patients who underwent LR for HCC from 2007 to 2017. Patient characteristics and overall survival (OS) were compared between patients with atypical HCC and patients with typical HCC (moderate-to-undifferentiated HCC ≥ 3 cm).Among 598 patients, 51 (8.5%) had atypical HCC. Patients with atypical HCC had higher rates of non-hepatitis B or C infections (p = 0.02) and American Joint Committee on Cancer T1 pathology (p 0.001), a lower rate of alpha-fetoprotein20 ng/ml (p 0.001) and a longer OS (p 0.001) than those with typical HCC. Multivariate analysis showed that atypical HCC was associated with OS (HR = 0.50, 95% CI = 0.27-0.91, p = 0.02).Patients with atypical HCC have a higher rate of non-hepatitis B or C infections and a lower rate of aggressive tumor biologic behavior. Atypical HCC is an independent predictor of OS.

Background Non-invasive techniques for liver fibrosis diagnosis are very important for clinician especially in high-risk patients for liver biopsy. We further explored the diagnostic accuracy of FibroScan, FIB-4 and aminotransferase-to-platelet ratio index (APRI) in identifying liver fibrosis and assess their predictive role for oesophageal varices in patients with hepatocellular carcinoma (HCC). Methods In total, 380 patients who underwent surgery for HCC were included based on retrospective study design. Liver fibrosis was pathologically diagnosed using the Ishak scoring system. Liver stiffness parameters were measured using FibroScan. APRI and FIB-4 were calculated. Among those, 121 patients who received oesophagogastroduodenoscopic examination underwent variceal evaluation. Results For liver cirrhosis diagnosis with FibroScan, the optimal cut-off values for the patients with HCC overall, left HCC and right HCC were 8.85, 11.75 and 8.70 kPa (the accuracy were 78.7%, 78.4% and 79.2%, respectively). They had high areas under the receiver operating characteristic curve of 0.84, 0.84 and 0.85. The combined FibroScan, APRI and FIB-4 had very high specificity (more than 92%) for cirrhosis diagnosis. The optimal cut-off liver stiffness values for the diagnosis of varices were all 11.2 kPa. For predicting varices, the optimal cut-off values of FIB-4 and APRI were 2.64 and 0.71, their accuracy were 64.3%-78.4%, 69.4% and 72.7%, respectively. Conclusions FibroScan, FIB-4 and APRI have moderate accuracy for liver fibrosis diagnosis and oesophageal varices prediction in patients with hepatoma. This is a study of these non-invasive techniques applied in specific hepatoma patients and with inevitable limitations and need future more studies for validation.

BACKGROUND AND OBJECTIVES A recent study proposed simple classifications of microscopic vascular invasion (MVI): microscopic portal vein invasion (MPVI) and microvessel invasion (MI). We aim to validate these classifications of MVI. METHODS This retrospective study consecutively enrolled 514 Barcelona Clinic Liver Cancer stage 0, A, and B naive hepatocellular carcinoma patients who underwent liver resection in our institution from 2011 to 2017. RESULTS Among these 514 patients, 240 patients were classified as having no MVI at all (designated as no vascular invasion, NVI), 157 patients were classified as having MI only, and 117 patients were classified as having MPVI. The 5-year overall survival (OS) rate in the MI-only group was 83.3%, which was not significantly different from that of the NVI group (87.2%), p = .20. Using NVI as a reference, multivariate analysis showed that MI-only is not an independent variable associated with OS. The 5-year OS in the MPVI group was 59.2%, which was significantly lower than those for MI-only (p

Hepatic steatosis (HS) can cause substantial problems for both donors and recipients in living donor liver transplantation. The controlled attenuation parameter (CAP) is a noninvasive method of measuring HS using a process based on transient elastography.To evaluate the accuracy of CAP in quantifying HS during living donor liver transplantation.A total of 54 liver donors who received CAP and intraoperative liver biopsy (LB) were enrolled in this study. The performance of CAP compared with LB for diagnosing HS was assessed using areas under receiver operating characteristic curves. HS was defined by the presence of steatosis in5% of hepatocytes.No HS was found in 47 donors, while the remaining 7 donors showed HS ranging from 10% to 30%. Using CAP, the area under receiver operating characteristic curve was 0.96 (95% CI, 0.91-1; P .001) for HS; the optimal cutoff value for HS was 257 dB/m (sensitivity: 100%, specificity: 89.4%, positive predictive value: 58.3%, negative predictive value: 100%). Among the 42 candidates with CAP 257 dB/m, none had HS, while of the 12 candidates with CAP ≥257 dB/m, 7 had HS. In a multivariate linear regression analyses, body mass index (β = 0.71, P .001) was found to be independently associated with CAP in those without HS.CAP might be a promising tool to exclude HS in East Asian living liver donors. Body mass index was found to be independently associated with CAP values in those without HS.

AIMS Cellular senescence plays a role in tumour suppression and in the pathogenesis of various non-neoplastic diseases, including primary biliary cholangitis and other adult cholangiopathies. Less is known about the role of cellular senescence in cholangiopathies in children. With that in mind, we examined the expression of senescence-associated cell cycle regulators in biliary atresia, the most common form of paediatric obliterative cholangiopathy. METHODS AND RESULTS The expression of senescence-associated cell cycle regulators (p16Ink4a and p21WAF1/Cip1 ) and a ductular reaction related marker (neural cell adhesion molecule: NCAM) was examined in bile ducts and bile ductules in liver samples taken from the patients with biliary atresia [n = 80; including 23 samples at the time of the Kasai procedure (KP) and 63 obtained from the explanted liver (LT) (six cases with samples at both surgical stages of disease)] and from appropriate controls (n = 17). The degree of ductular reaction and cholestasis was significantly more extensive in LT than KP (P < 0.01). The expression of p16INK4a and NCAM was significantly more extensive in bile ducts and bile ductules in ductular reaction in both KP and LT compared to controls and in LT compared to KP (P < 0.05). The expression of p21WAF1/Cip1 was significantly more extensive in bile ducts and bile ductules in KP compared to both LT and controls (P < 0.01). CONCLUSIONS Cellular senescence may play a role in the progression of bile duct loss in biliary atresia in a manner similar to that of adult cholangiopathies.

BACKGROUND Liver transplantation (LT) is the best radical treatment of hepatocellular carcinoma (HCC). Salvage liver transplantation (SalvLT) provides good outcomes for recurrent HCC cases after initial curative liver resection (LR). However, the salvage strategy is not feasible in all situations due to aggressive recurrences. Recently, sequential liver transplantation (SeqLT) was proposed for cases that show adverse pathological features after LR, thus LT is performed pre-emptively before recurrence. In this report, we compared the outcomes of SalvLT and SeqLT for surgical treatment of HCC. MATERIAL AND METHODS One hundred and ten cases underwent LR for HCC, then were subjected to either SalvLT (n=91) or SeqLT (n=19), from January 2001 to December 2015. For cases that underwent several LR before LT, we collected the data of the last LR before transplantation. A comparison was made according to pre- and post-transplant clinical and pathological variables. Survival analysis and comparison between both pathways are provided. RESULTS The median interval (months) between LR and LT for the SeqLT group and the SalvLT group were 9.6 and 22.2, respectively. (p=0.01). The LR histopathological features were similar in both groups. In the SalvLT group, the histopathological comparison between the criteria of last LR and the criteria of liver explants revealed that 14 cases advanced from stage I to stage II, one cases from stage I to stage IIIa, one case from stage I to stage IIIb, one case from stage I to stage IIIc, three cases from stage II to stage IIIb and one case from stage II to stage IIIc. The overall rate of pathological upstaging in the SalvLT group was 27%. The incidence of post-transplant HCC recurrence was 5% (1/19) and 11% (10/91) for the SeqLT and SalvLT groups, respectively (p=0.4). The incidence of post-LT in-hospital mortality was 0% among the SeqLT group and 2% (2/91) among the SalvLT group. The estimated rates of five-year overall survival and cancer specific survival for the SeqLT group versus the SalvLT group were (92.3% versus 87.6%; p=0.4) and (92.3% versus 91.9%; p=0.7), respectively. CONCLUSIONS The SeqLT approach might be associated with low incidence of cancer recurrence, better overall survival, and less operative mortality. Another possible benefit is the avoidance of aggressive non-transplantable HCC recurrences. More studies and/or randomization are required for highre evidence conclusions.

A recurrent YAP1-TFE3 gene fusion has been identified in WWTR1-CAMTA1-negative epithelioid hemangioendotheliomas arising in soft tissue, bone, and lung, but not in liver. We present the first case of TFE3-rearranged hepatic epithelioid hemangioendothelioma in a 39-year-old Taiwanese woman. Computed tomography scan revealed multifocal, ill-defined nodules involving both hepatic lobes. She then underwent deceased donor liver transplantation. Histologically, the tumors in the liver explant showed a biphasic growth pattern. One component was composed of dilated and well-formed blood vessels lined by epithelioid cells with abundant eosinophilic cytoplasm, mimicking an alveolar pattern, whereas the other component was composed of cords and single cells, featuring intracytoplasmic vacuoles, separated by a myxoid stroma. The tumor cells showed vesicular nuclei and small indistinct nucleoli with mild to moderate cytologic atypia. Most tumor cells showed factor VIII, CD34, CD31, and TFE3 positivity in immunohistochemical study. Fluorescence in situ hybridization analysis for the tumor cells exhibited TFE3 gene rearrangement. The patient is currently alive, and no post-operative tumor recurrence developed during a 13-year follow-up. Awareness of this rare vasoformative variant and identification of the gene rearrangement would be helpful on differential diagnosis with other high-grade carcinoma and angiosarcoma of liver.

Ultrasound is routinely used during the evaluation of liver cirrhosis. Inter-observer variability is considered a major drawback. This retrospective study investigated the accuracy of ultrasound in diagnosing compensated cirrhosis (i.e., modified Knodell F3, F4) in chronic hepatitis C (CHC) patients in real world clinical practice. Consecutive treatment-naive CHC patients who underwent liver biopsy (LB) prior to interferon therapy from 1997 to 2010 were enrolled. Ultrasound was performed by 30 hepatologists prior to LB. Ultrasound-identified cirrhosis was defined as small liver size, nodular liver surface and coarse liver parenchyma. LB was used as a reference, and the diagnostic accuracy of ultrasound was assessed and compared. Fibrosis was scored according to the modified Knodell classification. A cohort comprising 1738 patients, including 922 men and 816 women with a mean age of 52.5 years, was analyzed in the present study. The distribution of the patients’ modified Knodell scores was F0 = 336, F1 = 489, F2 = 165, F3 = 315, F4 = 433. Ultrasound-identified cirrhosis was noted in 283 patients. Using ultrasound-identified cirrhosis to predict compensated cirrhosis, the sensitivity was 34.0%, the specificity was 97.1%, the positive predictive value was 89.8%, the negative predictive value was 66.1%, the positive likelihood ratio was 11.6, and the negative likelihood ratio was 0.68. The area under the ROC curve (AUROC) was 0.66. Despite being affected by inter-observer variability, ultrasound is highly specific in diagnosing compensated cirrhosis in CHC patients in real world clinical practice. However, the sensitivity is low.

Tumor histology affects outcome after liver transplantation (LT) for hepatocellular carcinoma (HCC). This study explores the association between F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) and tumor histology in living donor liver transplantation (LDLT) recipients and their outcome.Two hundred fifty-eight patients with primary liver tumors who underwent FDG-PET before LDLT were enrolled in this retrospective study. Unfavorable tumor histology was defined as primary liver tumor other than a well- or moderately differentiated HCC. Thirteen patients had unfavorable tumor histology, including 2 poorly differentiated HCC, 2 sarcomatoid HCC, 5 combined hepatocellular cholangiocarcinoma, 3 intrahepatic cholangiocarcinoma, and 1 hilar cholangiocarcinoma.FDG-PET positivity was significantly associated with unfavorable tumor histology (P0.001). Both FDG-PET positivity and unfavorable tumor histology were significant independent predictors of tumor recurrence and overall survival. In a subgroup analysis of patients with FDG-PET-positive tumors, unfavorable tumor histology was a significant independent predictor of tumor recurrence and overall survival. High FDG uptake (tumor to non-tumor uptake ratio ≥ 2) was a significant predictor of unfavorable tumor histology. Patients with high FDG uptake and/or unfavorable tumors had significantly higher 3-year cumulative recurrence rate (70.8% versus 26.2%, P = 0.004) and worse 3-year overall survival (34.1% versus 70.8%, P = 0.012) compared to those with low FDG uptake favorable tumors.The expression of FDG-PET is highly associated with histology of explanted HCC and predicts the recurrence. FDG-PET-positive tumors with high FDG uptake may be considered contraindication for LDLT due to high recurrence rate except when pathology proves favorable histology.

Current guidelines recommend that patients with hepatitis B virus-hepatitis C virus (HBV-HCV) coinfection be treated with direct anti-viral agents (DAAs). Compared with DAAs, pegylated interferon (PEG-IFN) and ribavirin therapy has the advantages of treating both viruses while maintaining an acceptable HCV sustained virological response (SVR) rate (70–80%) in Asian cohorts. In this study, we aimed to develop a simple scoring system to predict hepatitis B surface antigen (HBsAg) seroclearance in these patients. We enrolled 201 patients with HCV-HBV coinfection after IFN and ribavirin therapy. The study population was randomly allocated into derivation and validation sets in a 1:1 ratio. In the derivation cohort, multivariate analysis by Cox regression analysis revealed that HBsAg seroclearance was associated with age > 60 years (HR: 5.55, 95% CI: 1.68–18.37, P = .005), male gender (HR: 3.88, 95% CI: 1.18–12.80, P = .03), and qHBsAg level ≤100 IU/ml (HR: 4.87, 95% CI: 1.20–19.74, P = .03). Regression coefficients were used to build up a risk score, and the accuracy of the risk score was evaluated by using the area under the receiver operating characteristic curve (AUROC). The patients were classified into either a low-risk group or high-risk group based on the risk scores. Twenty-three (23.0%) patients in the derivation cohort and 30 (29.7%) patients in the validation cohort showed HBsAg seroclearance with an AUROC of 71.8%, sensitivity of 65.22%, and specificity of 75.32%. In the validation cohort, the 5-year HBsAg seroclearance incidence rates were 23.4% in the low-risk category and 43.8% in the high-risk category (HR = 2.21; 95% CI, 1.04–4.68, P = .04) The risk scoring system could be used to predict HBsAg seroclearance for HCV-HBV coinfected patients treated with IFN and ribavirin.

Hepatocellular carcinoma (HCC) is increasingly managed by liver resection first then salvage liver transplantation in case of recurrence within accepted criteria. Many reports compared the safety of the salvage against the primary surgery in the setting of deceased donation but the difference in case of living donation is not sufficiently defined. Salvage living donor liver transplantation (SLDLT) is believed to be a more challenging surgery than primary living donor liver transplantation (PLDLT) due to operative field adhesions, in addition to the inherent difficulties particularly short vasculobiliary stumps. In this report, we compared both pathways from a surgical perspective in a homogenous LDLT-only cohort.Over 15 years, 448 LDLTs for HCC were performed in a single liver transplant institution in Taiwan, including PLDLT (n = 348) and SLDLT (n = 100). A retrospective comparative review of the surgical outcomes of both pathways using a propensity score matching model (1-1, 100 pairs) was performed with adjustment for age, Child score and MELD score. The surgical outcome and survival were compared across 2 time eras.The operative data showed that SLDLT surgery encountered more extensive adhesions (57% vs. 0%, p 0.001), longer operative duration (650 vs. 618 min, p=0.04), and was followed by more incidence of re-exploration (16% vs. 5%, p=0.01), than the PLDLT surgery. There was no significant difference regarding the incidence of in-hospital mortality, vascular and biliary complications, or overall survival (OS). The 1-year OS of SLDLT was inferior to PLDLT in the first 50 cases (90% vs. 98%, p=0.03), then the same OS was found in the 2nd 50 cases (96% vs. 96%, p=0.9).The SLDLT surgery is a demanding lengthy procedure with extensive adhesions and possibility of frequent re-explorations. Significant case load and high centre volume are important factors for safe practice of SLDLT and better cumulative OS.

Background & Aims Diabetes mellitus (DM) has been found to be strongly associated with an increased risk of hepatocellular carcinoma (HCC) among chronic hepatitis C (CHC) patients. Several studies have also found an association between metabolic steatosis and the risk of HCC in CHC patients, whether this latter association has been accounted for by the known relationship between DM and HCC is still unknown. Methods A cohort consisting of 976 non-genotype 3 patients histologically proven to have CHC and treated with interferon and ribavirin was studied. Cumulative incidence and HCC risk were analysed using the Kaplan-Meier method and Cox proportional hazard analysis. Results Hepatocellular carcinoma developed in 140 subjects over a median follow-up period of 97.3 months, while 699 patients achieved sustained virological response (SVR). According to multivariate analyses, age ≥ 60 years, advanced fibrosis and genotype 1 were identified as independent factors significantly associated with HCC development in SVR patients. Furthermore, using the absence of steatosis and absence of DM as references, the presence of steatosis without DM (HR = 2.09, 95% CI = 1.12-3.9, P = .021), the presence of DM without steatosis (HR = 2.78, 95% CI = 1.3-5.92, P = .008) and the combined presence of steatosis and DM (HR = 3.25, 95% CI = 1.44-7.33, P = .004) were identified as independent factors significantly associated with HCC development in the SVR patients. In contrast, steatosis alone, DM alone and the combined presence of steatosis and DM were not associated with HCC development in non-SVR patients. Conclusions Steatosis and DM may be associated with HCC development in non-genotype 3 CHC patients with SVR.

BACKGROUND Because the outcome of liver transplantation for cholangiocarcinoma is often poor, cholangiocarcinoma is a contraindication for liver transplantation in most centers. Combined hepatocellular carcinoma and cholangiocarcinoma is a rare type of primary hepatic malignancy containing features of hepatocellular carcinoma and cholangiocarcinoma. Diagnosing combined hepatocellular carcinoma and cholangiocarcinoma pre-operatively is difficult. Because of sparse research presentations worldwide, we report our experience with living donor liver transplantation for combined hepatocellular carcinoma and cholangiocarcinoma. MATERIAL AND METHODS A total of 710 patients underwent living donor liver transplantation at our institution from April 2006 to June 2014; 377 of them received transplantation because of hepatocellular carcinoma with University of California San Francisco (UCSF) staging criteria fulfilled pre-operatively. Eleven patients (2.92%) were diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma confirmed pathologically from explant livers; we reviewed these cases retrospectively. Long-term survival was compared between patients diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma and patients diagnosed with hepatocellular carcinoma. RESULTS The mean age of the patients in our series was 60.2 years, and the median follow-up period was 23.9 months. Four patients were diagnosed with a recurrence during the follow-up period, including one intra-hepatic and three extra-hepatic recurrences. Four patients died due to tumor recurrence. Except for patients with advanced-stage cancer, disease-free survival of patients with combined hepatocellular carcinoma and cholangiocarcinoma compared with that of patients with hepatocellular carcinoma was 80% versus 97.2% in 1 year, and 46.7% versus 92.5% in 3 years (p

Biliary atresia-induced cholestasis increases hepatic oxidative stress with eventual progression to cirrhosis and liver failure. Omega-3 fatty acids play a possible role in the regulation of oxidative stress and the improvement of cholestasis. The goal of the present study is to investigate the role of dietary supplementation of fish omega-3 fatty acids in the reduction of hepatocellular damage by using a rat common bile duct ligation model. Sprague–Dawley rats received either sham or bile duct ligation (BDL) and were divided into four study groups: Sham+saline (Sham+sal) group, Sham+Fish oil (Sham+FO) group, BDL+saline (BDL+sal) group, and BDL+Fish oil (BDL+FO) group. Rats from each group were assigned to receive, besides regular chow, once daily with either normal saline or fish omega-3 fatty acids (0.4 % of its own body weight) via gavage for 10 days. Samples of blood, liver tissue homogenates, and histological studies from different groups were analyzed at the end of the study. Rats from BDL+FO had significantly impaired liver function as compared to other study groups (p

The thymus gland possesses the ability to regrow in children leading to a newly developed anterior mediastinal mass. This condition may represent a rebound phenomenon during recovery from a stressful event such as post-chemotherapy and hence was described as RTH. RTH after LT has not been well documented. We are reporting an infant with BA who underwent LT and presented with a symptomless anterior mediastinal mass, detected on follow-up imaging 6 months thereafter. Surgical partial excision was performed to rule out other differential diagnoses of a solid mass in the anterior mediastinum of an infant particularly lymphoma-that may arise as post-transplant lymphoproliferative disorder-and teratoma, as well as the other aggressive lesions such as thymoma and thymic carcinoma. The final pathological analysis revealed true thymic hyperplasia, consistent with RTH. The diagnosis of RTH should be considered for a child presenting by anterior mediastinal mass after LT.

Mitochondria are known to be involved in cholestatic liver injury, but the damage and biogenesis of mitochondria in response to the early stage of cholestasis is unknown. A rat model of cholestasis was established by bile duct ligation (BDL), with simultaneous creation of the sham group receiving laparotomy without BDL. A significant decrease of liver peroxisome proliferators-activated receptor gamma coactivator-1alpha, mitochondrial transcriptional factor A (Tfam) and glutathione peroxidase (GPx) mRNA and Tfam protein from 6 to 72 h after BDL was found, which was associated with significant decrease of the glutathione, GPx and catalase activity at 72 h. At 72 h after BDL, mitochondrial DNA copy number reached the lowest level, while caspase 9 and 3 activity, but not caspase 8, Bax, Bcl(2), Fas L and Fas-Fas L complex, were upregulated significantly in the liver homogenates of BDL rats. The apoptotic liver cells appeared in large amounts in the rat liver by 72 h after BDL. Our results indicate that transcriptional regulation of the mitochondrial biogenesis is impaired within a few hours after complete bile duct obstruction, resulting in later mitochondrial dysfunction and consequent cholestatic liver injury via the intrinsic apoptosis pathway.

Background: Steatosis is recognized as a predictor of the severity as well as the progression of fibrosis in chronic hepatitis C. The mechanisms that cause increased hepatocellular injury associated with steatosis remain largely unknown. Methods: We studied the correlation of hepatic expression of death receptors: Fas and tumour necrosis factor-α receptor 1 (TNF-R1), and downstream caspase (caspase-3) with hepatic steatosis by immunohistochemical study in chronic hepatitis C and determined the role of nuclear factor-κB (NF-κB). Results: Ninety patients (49 males and 41 females, mean age of 50.5 ± 10.4 years, genotype 1 or 2) with chronic hepatitis C virus infection were recruited. The factors associated with steatosis grade were body mass index (P=0.004) and fibrosis stage (P=0.034). Moderate/severe steatosis was an independent variable associated with advanced fibrosis stage by stepwise logistic regression analysis. The expression of immunoreactivity for Fas, TNF-R1 and active caspases-3 in liver tissues was significantly correlated with the steatosis grade (P

Hepatocarcinogenesis is a multistep process that evolves from cirrhosis or dysplastic nodule (DN), and eventually leads to overt hepatocellular carcinoma (HCC). Differentiation between early HCC and DN is an important issue in the clinical setting. This study aims to investigate the potential of circulating microRNA (miRNA) levels in the diagnosis of early HCC. RNA was extracted from sera of 30 chronic hepatitis B patients with pathologically proven DN and 120 age- and sex-matched patients with early HCC. Paired samples were collected from ten patients with DN who developed overt HCC in the follow-up. A panel of ten cancer-associated miRNAs was analyzed by quantitative real-time reverse-transcription polymerase chain reaction. Serum levels of miR-16, miR-122, miR-221, let-7b and miR-15b were significantly lower in patients with DN than in the HCC group. When DN progressed to overt HCC, serum miR-122, miR-let-7b and miR-15b levels increased significantly (p = 0.046, 0.043 and 0.044, respectively). As a single marker, α-fetoprotein (AFP) and miR-122 as well as let-7b had the similar performance for differentiate HCC from DN. As limited to subjects with normal AFP, let-7b resulted in a sensitivity of 84.8% and a specificity of 50% in separating HCC and DN with a cutoff value of 3.5 (p = 0.001). In conclusion, miR-122 and let-7b, which are upregulated in the serum of early-HCC patients, can be useful markers for differentiating early HCC from DN in chronic hepatitis B patients.

Biliary atresia (BA) accounts for most cases of pathologic infantile jaundice, which may lead to cirrhosis and eventually necessitate liver transplantation (LT). A cardinal histologic feature of BA is ductular reaction (DR), reflecting activation of the regenerative compartment in liver. We examined the immunohistochemical attributes of the progenitor cell population and its immediate descendants in BA patients undergoing Kasai procedure (KP) or LT. The BA cases were divided into those undergoing KP (n = 24) and those undergoing LT (n = 64). Immunohistochemistry for CD56, CK7, and CK19 was performed. Patients with BA (both KP and LT groups) had more DR than controls (scores 2.4, 2.2, and 0.1, respectively; P < .001), but the degree of DR did not differ between BA patients undergoing KP compared to LT. There was significantly more CD56 staining in DR in LT (2.5) versus KP samples (1.3; P < .001), with a trend toward the same pattern in hepatocyte progenitor cells in these samples (0.6 versus 0.2; P = .05). In intermediate hepatocytes, CK7 staining was higher in LT versus KP samples (1.7 versus 0.3; P < .001). No differences in CK19 staining were noted in the cell types in different BA groups. Immunohistochemistry suggests that the regenerative compartment is expanded in patients undergoing LT for BA, compared to patients with an earlier stage of disease undergoing KP. These observations support the notion that there is more active regeneration in livers with advanced-stage BA and highlight the immunophenotypic heterogeneity of progenitor cells in different phases of the disease.

Background Primary hepatic sarcoma (PHS) is a rare primary liver malignancy. The histological types of PHS are diverse, and the clinical outcomes and management mainly depend on the histopathology. This study aims to evaluate the results of surgical intervention. Methods Between January 2003 and June 2009, 13 adult patients with pathologically proven PHS were identified by record review. The patients’ demographic profile, tumor characteristics, treatment modalities, and outcomes were reviewed and analyzed. The end of follow-up was December 2014. Results Nine (69%) underwent curative liver resection and two underwent liver transplantation; the others received non-operative treatments. The pathologic findings were six (46%) angiosarcomas, four (30.7%) undifferentiated sarcomas, one (7.6%) leiomyosarcoma, one (7.6%) malignant mesenchymoma, and one (7.6%) hepatic epithelioid hemangioendothelioma. The median follow-up was 31.4 (2.8 ~ 142.5) months. The 1-, 2-, and 5-year survival of surgical patients were 72.7%, 63.6%, and 36.4%, respectively. Importantly, the 1-, 2-, and 5-year survival rates of non-angiosarcoma patients were superior to those of angiosarcoma (85.7% vs. 33.3%, 71.4% vs. 16.7%, and 57.1% vs. 0%, respectively, P = 0.023). Conclusions Surgical intervention provides the possibility of long-term survival from PHS. Angiosarcoma is associated with a more dismal outcome than non-angiosarcoma.

Despite the proximity of the vertebral bodies and discs to the vascular structures of the retroperitoneum, the association of spinal osteomyelitis and aortic infection is a rare1, easily overlooked, but potentially lethal condition that requires prompt diagnosis and aggressive surgical therapy. The pathogens responsible for concurrent vertebral and aortic lesions include Salmonella species as well as other gram-negative bacilli, mycobacteria, gram-positive cocci, and fungi1-3. A delay in the start of appropriate antimicrobial therapy for infections involving these anatomic sites could result in bone and joint destruction and possibly death. We report the case of an elderly immunocompromised patient who had a mycotic aneurysm caused by Salmonella species. After aneurysmectomy, he experienced persistent back pain and progressive loss of lower-extremity neurological function. Further work up disclosed tuberculous lumbar spondylitis and an epidural abscess in the vicinity of the resected aneurysm. The case of this patient emphasizes the possibility of coexistent infection in vulnerable patients. The pitfalls in diagnosis and management are discussed, to enable clinicians to avoid potentially catastrophic complications. The patient was informed that data concerning the case would be submitted for publication. A seventy-nine-year-old man presented to our emergency service because of fever and chills that he had had for eight days. The history included the use of analgesics and a steroid (20 mg/day of prednisolone) for one year for the treatment of chronic low back pain. On arrival, the patient was febrile (38.4°C), with a blood pressure of 150/90 mm Hg. Physical examination revealed a cushingoid habitus (moon face, truncal obesity, and paper-thin skin), a pulsatile abdominal mass, and low back pain limiting his spinal flexibility. Plain radiographs of the lumbar spine showed multiple traction spurs along the anterior edges of the vertebrae and decreased disc height at L3-L4 without overt evidence …

Background/AimsSteatosis is recognized as a cofactor influencing the presence and progression of fibrosis in chronic hepatitis C. It has been reported that antiviral therapy may reduce the progression of fibrosis and leads to regression in chronic hepatitis C patients achieving a sustained virological response (SVR). Whether steatosis might affect the long-term histological outcome of antiviral therapy remains unclear.MethodsOne-hundred and sixty-one consecutive patients (genotype 1, n=76; genotype 2, n=73) receiving interferon-α2b and ribavirin were analysed. Ninety patients had paired biopsies with a mean interval of 29.1 ±7.1 months.ResultsVariables associated with baseline steatosis were higher body mass index (≥25, P=0.002) and higher fibrosis stage (≥2, P=0.019). Neither the presence nor the severity of steatosis was associated with SVR. Evaluation of paired biopsies showed no different distribution of steatosis evolution between patients with and without SVR ( P=0.374). Among patients achieving a SVR, there was a significant difference in fibrosis changes between those with grade 0 or 1 steatosis and with grade 2 or 3 steatosis at post-treatment biopsy (-0.6 ±1.2 vs 0.3 ±1.3, P=0.041), whereas changes in histological activity index did not differ (-3.7 ±2.6 vs -4.0 ±2.9, P=0.740). Stepwise logistic regression analysis showed that SVR (odds ratio [OR]: 16.33, P=0.004) and grade 0 or 1 post-treatment steatosis (OR: 12.82, P=0.018) were independently associated with fibrosis regression.ConclusionsIn patients with chronic hepatitis C, steatosis not only correlates with advanced fibrosis at baseline but also affects fibrosis regression after antiviral therapy.

Juvenile xanthogranuloma (JXG) is a self-limited cutaneous lesion that most often occurs in infancy. Approximately 10% to 30% of JXGs occur in adult patients, where most cases present as cutaneous papulonodular lesions, with only rare cases involving extracutaneous sites. Intramuscular JXG is extremely rare and has received little attention. On review of the literature, all of the 6 previously reported intramuscular JXGs were noted in the pediatric population. The authors hereby describe a case of adult intramuscular JXG that occurred in a woman who initially had a dermal JXG in the nasal skin at the age of 48 years and then developed a slow-growing painless intramuscular JXG in the right forearm 4 years later. Both the dermal and intramuscular lesions revealed similar histologic features and consisted of diffuse infiltrates of histiocytes with eosinophilic and foamy cytoplasm, lymphocytes, eosinophils, and Touton giant cells in varying proportions. However, central fibrosis and a focal storiform arrangement of spindled fibroblast-like cells in the intramuscular lesion resulted in a histologic pattern reminiscent of a fibrous histiocytoma. Immunohistochemically, the intramuscular JXG was positive for CD68, factor XIIIa, CD31, and vimentin. This case underscores the fact that intramuscular JXG can also involve adult patients and its morphologic variation is more likely to be time dependent rather than site specific or age related.

Ground-glass hepatocytes are seen in chronic hepatitis B virus (HBV) infection and are known to harbor pre-S mutants, which are implicated in the pathogenesis of hepatocellular carcinoma (HCC). However, the association between ground-glass hepatocytes and HCC has yet to be clearly elucidated. The aim in the present study was to investigate the association of ground-glass hepatocytes with (1) the histologic characteristics of HBV-related HCC and (2) the grade of inflammation, stage of fibrosis, serologic markers of HBV infection, HBV viral load, and α-fetoprotein levels. We evaluated 45 hepatectomy specimens from chronic HBV-infected patients: 25 with HCC and 20 without. In comparison with those without HCC, cases with HCC had a significantly higher prevalence of type II ground-glass hepatocytes (84% versus 55%, P = .0488), demonstrating a geographically clustered pattern (84% versus 45%, P = .0102) and exceeding type I in the individual samples (84% versus 35%, P = .0005). Type II ground-glass hepatocytes also had a statistically significant association with higher stages of fibrosis, being present in 21 cases (66%) with Ishak fibrosis stages 3 to 6 as compared with only 4 cases (31%) without type II ground-glass hepatocytes (P = .0176). In conclusion, type II ground-glass hepatocytes are more likely to be present in cases of HCC, growing in a clustered pattern, and are also associated with advanced fibrosis in chronic HBV infection. Our data suggest that a growth advantage or clonal proliferation of hepatocytes with mutant hepatitis B surface antigen may play a role in the pathogenesis of HBV-related HCC with clinical relevance.

Ultrasound (US) is recommended for hepatic steatosis screening. The purpose of this study was to determine the usefulness of US hepatic-renal echo-intensity (HR) difference in the quantitative assessment of hepatic steatosis. Consecutive patients undergoing liver biopsy were prospectively enrolled. Using US histogram technique, the mean gray level of hepatic parenchyma and right renal parenchyma at selected regions of interest were evaluated on the same day of biopsy. With steatosis assessed by histology as the reference, the diagnostic performances of HR difference in predicting the degree of steatosis was analyzed. The optimal cut-off level, diagnostic validity and post-test probability were assessed. A total of 175 patients were enrolled (M/F, 103/72; mean age, 48.6 ± 11.7). There were 64 (36.5 %), 42 (24 %), 29 (16.6 %), 12 (6.9 %) and 28 (16 %) patients with steatosis of

Studies have demonstrated poor survival outcomes for patients with resected combined hepatocellular carcinoma-cholangiocarcinoma tumours (CHCC-CC). Our objectives are to report on our institutional experience regarding the clinico-pathological and prognostic features of CHCC-CC and to compare our results with published series. The clinico-pathological features and outcomes of 11 patients with CHCC-CC who had a complete surgical resection for primary liver cancer were reviewed. There were 8 male and 3 female patients. The overall median age was 61 years. Active hepatitis B and hepatitis C infections were present in 6 (54%) and 2 (18%) patients, respectively. Alcoholism was present in one case. Cirrhosis was present in 8 (72%) cases. There were no causative factors identified in 2 patients with non-cirrhotic livers. The median AFP value was 30.56 ng/ml. A single mass located in the right lobe and a single mass located in the left lobe of the liver was noted in 6 (54%) and 4 (36%) patients, respectively. Bilobar involvement was observed in one case. Major and minor resections were performed in 2 (18%) and 9 (81%) cases, respectively. The median tumour size was 3 cm. Tumours measuring >5 cm were identified in only 2 (18%) cases. The majority of the cases were classified as stage I (54%) and stage II (36%). Four patients died 11–50 months after the surgery. Postoperative tumour recurrences were observed in 5 (45.45%) patients within 4 years of surgical resection. The overall 1- and 3-year survival rates in this series were 80% and 69.3%. Our series demonstrated cases of CHCC-CC with more favourable pathological traits and survival outcomes compared with similar studies.

Aims: To differentiate hepatoblastoma (HB) from hepatocellular carcinoma (HCC) by computerized image analysis. This is critical for treatment modalities and prognostic stratification but is usually difficult in small biopsy specimens. Methods and results: Computerized image-processing technology was used to calculate the nuclear–cytoplasmic ratio (N/C), cellularity (CEL) and other cellular and nuclear parameters in HB (n = 18) and paediatric HCC (pHCC, n = 11). The proliferation index (PI) and apoptotic index (AI) were also measured. Fetal type HB (FHB) compared with pHCC had more uniform nuclei (P ≤ 0.014), lower PI (P = 0.028) and AI (P = 0.009), whereas the embryonal type HB (EHB) had a higher N/C (P

Background Synovial sarcoma is a rare, aggressive high-grade neoplasm with poor prognosis. Synovial sarcoma is usually encountered in the lower extremities of young adults; only a few cases have been reported in the head and neck region. Methods We describe a case of a 44-year-old man seen with a 3-month history of progressive nasal obstruction. Nasoendoscopy revealed a pink polypoid mass filling in the entire right posterior nasal cavity. CT and MRI studies showed that a hyperintense mass on the right nasopharynx extending to the nasal cavity anteriorly and the oropharynx inferiorly. During the operation, the mass was noted as originating from the lower portion of anterior cushion of the right Eustachian tube. We endoscopically removed the tumor and part of the anterior cushion of the right Eustachian tube. Because of the large tumor size (7.0 × 3.5 cm), we took the tumor out transorally. Results The histopathology and genetic analysis confirmed the diagnosis of monophasic synovial sarcoma prominent myxoid pattern. The patient then underwent adjuvant irradiation to 64.8 Gy, and he was free of recurrence and distant metastasis in the 5-year follow-up. Conclusion To our knowledge, this is the first case report of synovial sarcoma of the Eustachian tube. Synovial sarcoma should be included in the differential diagnosis when managing the Eustachian tube region mass. Recommended treatment is surgery and postoperative adjuvant radiotherapy. © 2009 Wiley Periodicals, Inc. Head Neck, 2009

Background Pancreatic acini-like tissue is occasionally seen in the liver. It is uncertain whether its presence represents heterotopia or metaplasia. To gain further insight into this issue, we performed a pathologic and immunohistochemical study in liver explants to identify pancreatic acinar tissue. Design A total of 382 liver explants transplanted from 1995 to 2000 were examined. Formalin-fixed, paraffin-embedded tissues were stained with hematoxylin-eosin, and immunohistochemical analyses using antibodies against CK7, CK8, and CK19 (biliary type cytokeratins), CD56 (positive in reactive bile ductules), chromogranin A (positive in reactive bile ductules and human oval-like/hepatic progenitor cells), pancreatic amylase, and PDX-1 were performed. The immunohistochemical comparison group consisted of 3 gastric biopsies diagnosed as autoimmune gastritis with pancreatic metaplasia and 3 normal pancreatic tissues from pancreatectomy specimens. Results Sixteen (4.2%) of 382 liver explants contained pancreatic acini-like tissue. Fifteen of these were cirrhotic livers due to cryptogenic cirrhosis (n=1), primary biliary cirrhosis (n=3), primary sclerosing cholangitis (n=1), chronic hepatitis C-related cirrhosis (n=5), and cirrhosis with hepatitis C and hepatocellular carcinoma (n=5). There was 1 noncirrhotic explant, the result of isoniazid hepatotoxicity. The pancreatic acini-like tissue appeared as small clusters of compactly packed cells that either blended imperceptibly with or were in close proximity to adjacent bile ducts or ductules. The pancreatic acinar tissue was diffusely reactive for amylase, was occasionally positive for keratin 8 and chromogranin A, and was negative for CD56, keratin 7, and keratin 19. Biliary type epithelium (bile ducts and ductules) and the ductules within the acini was always diffusely positive for keratin 7, 8, and 19, occasionally reactive for CD56 and chromogranin A, and typically negative for amylase. Conclusions Our results collectively indicate that pancreatic acini-like tissue in liver represent aggregates of pancreatic acinar cells admixed with small intra-acinar terminal ductules. Given the close spatial relationship with reactive bile ductules and the apparent transition in immunophenotype from bile ductules to pancreatic acinar tissue, the latter is likely of metaplastic origin derived from a hepatic progenitor lineage.

Steatosis is recognized as a predictor of the severity as well as the progression of fibrosis in chronic hepatitis C. The mechanisms that cause increased hepatocellular injury associated with steatosis remain largely unknown.We studied the correlation of hepatic expression of death receptors: Fas and tumour necrosis factor-alpha receptor 1 (TNF-R1), and downstream caspase (caspase-3) with hepatic steatosis by immunohistochemical study in chronic hepatitis C and determined the role of nuclear factor-kappaB (NF-kappaB).Ninety patients (49 males and 41 females, mean age of 50.5 +/- 10.4 years, genotype 1 or 2) with chronic hepatitis C virus infection were recruited. The factors associated with steatosis grade were body mass index (P=0.004) and fibrosis stage (P=0.034). Moderate/severe steatosis was an independent variable associated with advanced fibrosis stage by stepwise logistic regression analysis. The expression of immunoreactivity for Fas, TNF-R1 and active caspases-3 in liver tissues was significantly correlated with the steatosis grade (P0.001, P0.001 and P0.001 respectively). The extent of active caspases-3 correlated significantly with the expression of Fas (r=0.659, P0.001) and TNF-R1 (r=0.617, P0.001). NF-kappaB p65 expression correlated significantly with the extent of Fas (r=0.405, P0.001), TNF-R1 (r=0.448, P=0.002) and active caspase-3 (r=0.313, P=0.003), and correlated with steatosis grade (P0.001) but not with inflammatory and fibrosis scores.Our observations suggest a mechanism whereby steatosis contributes to the progression of liver injury in chronic hepatitis C through upregulation of death receptors and activation of NF-kappaB.

Aim: Animal models of fulminant hepatic failure (FHF) have been developed for characterization of disease progression and to evaluate the effectiveness of liverassist devices, some by treatment with hepatotoxic drugs, viral hepatitis or surgical procedures. We have developed a model in the rabbit by combining resection of the three anterior lobes with ligation of the pedicle of the right lateral lobes, resulting in liver necrosis; the remnant quadrate lobes are left intact. Materials and methods: Adult male New Zealand white rabbits (n=16) were used. Six animals were killed to measure the weight of the separate liver lobes. The others (n=10) underwent left neck central line placement to monitor continuous blood pressure and collect blood for laboratory analysis, and a burr hole on the right parietal bone to monitor the intracranial pressure (ICP). Blood laboratory analysis, clinical hepatic encephalopathy and ICP levels were measured in FHF animals (n=6). Animals (n=4) undergoing a sham operation served as controls. Results: All FHF animals died between 12 and 26h after liver surgery from FHF characterized by a progressive increase in liver enzymes, ammonia, total bilirubin, coagulopathy, hepatic encephalopathy and intracranial hypertension. Histological features of the ischaemic lobes showed coagulative necrosis of hepatocytes with absence of nuclei and collapse of cell plates. Brain histology revealed hypoxic cell damage. Conclusion: We have developed a simple, reproducible model of FHF in rabbits that has a number of features comparable with clinical FHF patients and is well suited for testing experimental bioartificial liver systems and investigating the pathogenesis of FHF.

Aim: To determine the incidence of needle tract seeding after fine needle aspiration (FNA) or percutaneous ethanol injection (PEI) and compare iatrogenic or spontaneous soft tissue metastasis (STM) by hepatocellular carcinoma (HCC) postradiotherapy (RT) in responses. Methods: From November 1997 to January 2006, those who presented with STM by HCC after our invasive procedures or developed spontaneously were enrolled into this retrospective study. Metastatic lesions could be divided into procedure related (PR), which were located at the liver span and were related to invasive procedures, and non-procedure related (NPR), which were in extrahepatic areas. STM was treated with an electron or photon beam. Results: A total of 39 HCC cases with developed STM were referred for RT, including 17 in the PR group and 22 in the NPR group. During the same period, a total of 18 227 person-times of FNA or PEI were performed on these HCC patients. The overall incidence of HCC with STM that was caused by invasive procedures was estimated at 0.13%. According to the Cox' regression model, the initial treatment modality influences the time duration after the initial diagnosis of HCC when STM has not occurred. None of these patients' soft tissue tumor increased in size during RT. The PR group had lower rates of bone metastasis (P=0.003) and coexisting extrahepatic metastasis (P=0.011) and a longer survival rate (P=0.003) than the NPR group. The estimated rates of 18-gauge and 22-gauge needle-induced HCC-related STM were 0.60% and 0.11%, respectively (P=0.064). Conclusion: The PR group bears a better prognosis than the NPR group post-RT.

Schwannoma of the tongue always presents as a painless mass on the lingual surface and exhibits no gender preference. A schwannoma on the base of tongue is usually larger at presentation than one on the tongue itself, since it is asymptomatic initially. Complete resection is achievable and recurrence is uncommon.To describe the patient demographics, presenting signs and symptoms, tumor location, imaging studies, management, and therapeutic outcomes of schwannoma of the tongue, an uncommon tumor of neuroectodermal origin that may arise from any myelinated nerve fiber.In this retrospective study, records of 10 patients who underwent surgical removal of schwannomas of the tongue or base of the tongue between January 1988 and June 2005 were reviewed and summarized.The records of five men and five women with ages ranging from 9 to 45 years (mean 27.4 years) were reviewed. The locations of the schwannomas were as follows: four on the lateral border of the tongue, two on the tongue tip, one on the ventral side of the tongue, and three on the base of the tongue. The major clinical sign was a painless mass on the lingual surface. For all patients, no tumor recurrence or complication was noted after tumor extirpation.

Juvenile xanthogranuloma (JXG) is a self-limited cutaneous lesion that most often occurs in infancy. Approximately 10% to 30% of JXGs occur in adult patients, where most cases present as cutaneous papulonodular lesions, with only rare cases involving extracutaneous sites. Intramuscular JXG is extremely rare and has received little attention. On review of the literature, all of the 6 previously reported intramuscular JXGs were noted in the pediatric population. The authors hereby describe a case of adult intramuscular JXG that occurred in a woman who initially had a dermal JXG in the nasal skin at the age of 48 years and then developed a slow-growing painless intramuscular JXG in the right forearm 4 years later. Both the dermal and intramuscular lesions revealed similar histologic features and consisted of diffuse infiltrates of histiocytes with eosinophilic and foamy cytoplasm, lymphocytes, eosinophils, and Touton giant cells in varying proportions. However, central fibrosis and a focal storiform arrangement of spindled fibroblast-like cells in the intramuscular lesion resulted in a histologic pattern reminiscent of a fibrous histiocytoma. Immunohistochemically, the intramuscular JXG was positive for CD68, factor XIIIa, CD31, and vimentin. This case underscores the fact that intramuscular JXG can also involve adult patients and its morphologic variation is more likely to be time dependent rather than site specific or age related.

Background. Sinonasal hemangiopericytoma-like tumor (SHPCL) is an uncommon vascular tumor that is sometimes difficult to diagnose. Method. We report five cases arising from the nasal cavity. The tumors were subdivided into two types, prototype and soft tissue type, by the difference in histologic features. Results. The prototype, made up of three tumors, is characterized by uniform, spindle-shaped myoid cells that have eosinophilic cytoplasm and uniform nuclei and lay down in an orderly fashion. The soft tissue type, made up of two tumors, is similar to the hemangiopericytoma of soft tissue. Immunohistochemically, the tumors were positive for vimentin (100%), smooth muscle actin (80%), muscle-specific actin (100%), fibroblast growth factor-2 (100%), and vascular endothelial growth factor (100%). All were negative for cytokeratin, desmin, CD34, and factor VIII–related antigen. These histopathologic features suggest myoid differentiation and angiogenic activity of the tumors. All the tumors were treated with wide surgical excision. Only one case of soft tissue–type tumor with active mitoses received additional postoperative radiotherapy. No recurrence was found during 13 to 120 months of follow-up. Conclusions. Our data suggest that SHPCL with convincing myoid differentiation may have a more favorable clinical course than its soft tissue counterpart. © 2004 Wiley Periodicals, Inc. Head Neck27: 124–129, 2004