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Hepatic haemangiomas are the most common benign hepatic tumour; they are usually solitary, less than 5 cm in size, and clinically silent. Giant cavernous haemangiomas are a minor subset of hepatic haemangiomas, often symptomatic due to a mass lesion, complications or compression of adjacent structures. Few of these are pedunculated—often difficult to diagnose because of their exophytic development and greater tendency towards complications through the twisting of their peduncle. We report the case of a 55-year-old woman with a giant pedunculated hepatic cavernous haemangioma causing abdominal pain, with epigastralgia mimicking a gastric stromal tumour. We discuss the diagnostic workup, focusing on the useful of computed tomography and magnetic resonance imaging findings and giving a brief report of the therapeutic management and literature review.

The aim of this study was to investigate the prognostic value of neutrophil-to-lymphocyte ratio (NLR) and its relationship with several metabolic parameters obtained through PET in intrahepatic cholangiocarcinoma (ICC) submitted to radioembolization with Y-microspheres (Y-radioembolization).Records of 20 subjects affected by ICC and submitted to Y-radioembolization were retrospectively evaluated. In all cases, pretreatment NLR was carried out and fluorine-18-fluorodeoxyglucose (F-FDG) PET/CT was acquired with the calculation of the following metabolic parameters: maximum and mean standardized uptake value (SUVmax and SUVmean), metabolic total volume and total lesion glycolysis. After Y-radioembolization, all patients underwent regular imaging and laboratory follow-up.All patients presented F-FDG-avid hepatic tumors at pretreatment PET/CT examination. NLR significantly correlated with SUVmax (r = 0.64; P = 0.002) and SUVmean (r = 0.67; P = 0.001). After treatment with Y-microspheres, the mean OS resulted 12.5 ± 1.5 months. When the average pretreatment NLR value (i.e. 2.7) was used as a cutoff for patients' stratification, subjects with low NLR (2.7) had a significantly longer OS than those with high NLR (2.7). At Cox regression analysis including bilirubin, age, the presence of extrahepatic disease, hepatitis C virus/hepatitis B virus status and PET-derived parameters, only NLR resulted to be a significant predictor of OS (P = 0.01; hazard ratio = 13.1, 95% confidence interval = 1.6-102.7).NLR is correlated with SUVmax-mean values in ICC and resulted to be an easy available predictor of survival in patients submitted to treatment with Y-microspheres.

Background. Chronic liver diseases (CHDs) are an important public health issue. The presence of significant fibrosis is a hallmark for liver disease staging and prognosis. Aims. To develop a non-invasive score that can discriminate between patients with or without fibrosis in the aim to avoid liver biopsy.Methods. Forty patients with CHDs who received liver biopsy to stage fibrosis and 12 normal subjects performed also share wave elastography (SWE) and ELF-test. We chose two different outcome for histological fibrosis (F0-F1 vs F2-F4) and (F0-F2 vs F3-F4). ELF-test and SWE were independent predictors, categorized using ROC analysis. Two scores called SCORE1 and SCORE2 were devised.Results. The discriminatory values for SCORE1 were SWE>5.62 kPa and ELF-test >9.33 and for SCORE2 were SWE>7.04 kPa and ELF-test 9.33. SCORE1 specificity was 91.7% (CI 77.5-98.2%), significatively greater than obtained using SWE 63.9% (CI 46.2-79.2%; p=0.0013) or ELF-test 83.3% (CI 67.2-93.6%; p=0.1760) separately. SCORE2 specificity was 95.2% (CI 83.8-99.4%). This value was not-significatively greater than obtained using SWE or ELF-test 81.0% (CI 65.9-91.4%; p=0.0921) separately. Conclusion. SWE and ELF-test can be performed for non-invasive staging of liver fibrosis. Their use grouped in a single score increase the specificity for the prediction of histological fibrosis stage.

The presence of significant fibrosis is an indicator for liver disease staging and prognosis. The aim of the study was to determine reproducibility of real-time shear wave elastography using a hepatic biopsy as the reference standard to identify patients with chronic liver disease. Forty patients with chronic liver disease and 12 normal subjects received shear wave elastography performed by skilled operators. Interoperator reproducibility was studied in 29 patients. Fibrosis was evaluated using the Metavir score. The median and range shear wave elastography values in chronic liver disease subjects were 6.15 kPa and 3.14-16.7 kPa and were 4.49 kPa and 2.92-7.32 kPa in normal subjects, respectively. With respect to fibrosis detected by liver biopsy, shear wave elastography did not change significantly between F0 and F1 (p = 0.334), F1 and F2 (p = 0.611), or F3 and F4 (0.327); a significant difference was observed between the F0-F2 and F3-F4 groups (p = 0.002). SWE also correlated with inflammatory activity (Rs = 0.443, p = 0.0023) and ALT levels (Rs = 0.287, p = 0.0804). Age, sex and body mass index did not affect shear wave elastography measurements. Using receiver operator characteristic curves, two threshold values for shear wave elastography were identified: 5.62 kPa for patients with fibrosis (≥F2; sensitivity 80%, specificity 69.4%, and accuracy 77%) and 7.04 kPa for patients with severe fibrosis (≥F3; sensitivity 88.9%, specificity 81%, and accuracy 89%). Overall interobserver agreement was excellent and was analysed using an interclass correlation coefficient (0.94; CI 0.87-0.97).This study shows that shear wave elastography executed by skilled operators can be performed on almost all chronic liver disease patients with high reproducibility. It is not influenced by age, sex or body mass index, identifies severely fibrotic patients and is also related to inflammatory activity.

Malignant Hepatic Epithelioid hemangioendothelioma (HEHE) is an uncommon vascular tumor of intermediate malignant potential. HEHE is a rare tumor and it is difficult to diagnose for surgeons, hepatologists, radiologists and pathologists. So, misdiagnosis with a delay of the treatment is not uncommon. We describe a case of a young woman with a diagnosis of HEHE made 6 years after the first evidence of liver mass with a very long term follow-up after surgical treatment. She had two diagnoses of Hepatocellurar carcinoma (HCC) and a diagnosis of Cholangiocarcinoma after three different fine needle biopsies. After clinical observation, a new laparoscopic core biopsy was performed. In a first time approach, considering clinical and radiological patterns, a diagnosis of Budd-Chiari Syndrome was finally made. For that the patient underwent an orthotopicliver transplantation (OLTx). The surgical sample histological analysis allowed a definitive diagnosis of HEHE. At last, at follow up 7 years after three OLTx the patient is still alive and in good health with no evidence of recurrence.

Background & Aims Patients with chronic hepatitis C virus (HCV) infection are frequently treated with a combination of pegylated interferon (peginterferon) and ribavirin. This study compared the efficacy and safety of peginterferon alfa-2a and peginterferon alfa-2b, each in combination with ribavirin. Methods A total of 320 consecutive, treatment-naive, HCV RNA–positive patients with chronic hepatitis were randomly assigned to once-weekly peginterferon alfa-2a (180 μg, group A) or peginterferon alfa-2b (1.5 μg/kg, group B) plus ribavirin 1000 mg/day (body weight Results More patients in group A than group B achieved an SVR (110/160 [68.8%] vs 87/160 [54.4%]; P = .008). Higher SVR rates were obtained in group A than group B among patients with genotype 1/4 (51/93 [54.8%] vs 37/93 [39.8%]; P = .04), with genotype 2/3 (59/67 [88.1%] vs 50/67 [74.6%]; P = .046), without cirrhosis (96/127 [75.6%] vs 75/134 [55.9%]; P = .005), and with baseline levels HCV RNA >500,000 IU/mL (58/84 [69%] vs 43/93 [46.2%]; P = .002). SVR rates in groups A and B were not statistically different among patients with baseline HCV RNA ≤500,000 IU/mL (52/76 [68.4%] vs 44/67 [65.7%]; P = .727) or in patients with cirrhosis (14/33 [42.4%] vs 12/26 [46.1%]; P = .774). Conclusions In patients with chronic HCV infection, peginterferon alfa-2a plus ribavirin produced a significantly higher SVR rate than peginterferon alfa-2b plus ribavirin.

Visceral involvement in absence of lymphadenopathy is a rare manifestation in cat scratch disease; hepatic granulomas are rare, representing 0.3% of systemic manifestations of cat scratch disease, and gallbladder extension is a singular case. The present article refers to 2 rare cases of visceral cat scratch disease in immunocompetent adults with hepatic granulomatous inflammation, caused by Bartonella henselae infection, with gallbladder involvement in 1 case and no lymphadenopathy. Histological features demonstrated the presence of inflammatory necrotizing granulomatous nonneoplastic process. Molecular studies (polymerase chain reaction) were performed to confirm the infectious etiology.

Liver transplantation is one of the main therapeutic options for hepatocellular carcinoma (HCC) occurring in cirrhotic patients; an accurate diagnosis and staging of this cancer is crucial to selecting the candidates for this treatment. Although the best diagnostic strategy is debated, the guidelines proposed by the European Association for the Study of the Liver (EASL) are used by many centers. We report 2 cases of cirrhotic patients with hepatic splenosis, a rare condition that may be misinterpreted as HCC. In conclusion, the application of the EASL guidelines in the first case would have led to an incorrect staging of the cancer and in the second case would have led to a false diagnosis of HCC. (Liver Transpl 2004;10:706–709.)

Для лечения пациентов с хроническим вирусным гепатитом С (ВГС) обычно применяется комбинация пегилированного интерферона (пегинтерферона) и рибавирина. В данном исследовании проводилось сравнение эффективности и безопасности пегинтерферона альфа-2а и пегинтерферона альфа-2Ь, каждый из которых принимался пациентами в сочетании с рибави-рином. Методы. В исследовании принимало участие 320 пациентов с хроническим вирусным гепатитом С, не получавших лекарственной терапии, у которых определялась РНК ВГС. Пациенты были рандомизированы в две терапевтические группы: группа А получала лечение пегинтерфероном альфа-2а по 180 мкг один раз в неделю в сочетании с рибавирином, а группа Б - пегинтерфероном альфа-2Ь в дозе 1,5 мкг/кг в сочетании с рибавирином. Доза рибавирина составляла 1000 (при массе тела пациента < 75 кг) или 1200 мг/сут (при массе тела пациента > 75 кг). Длительность терапии составляла 48 (для генотипа 1 или 4) и 24 недели (для генотипа 2 и 3). Первичной конечной точкой было наличие устойчивого вирусологического ответа (УВО) у всех пациентов, получавших лечение. Результаты. УВО был достигнут в большей степени у пациентов группы А, чем в группе Б( 110/160 [68,8 %] по сравнению с 87/160 [54,4 %], Р = 0,008). В группе А были получены более высокие уровни УВО, чем в группе Б: у пациентов с генотипом 1 и 4 они составляли соответственно 51/93 [54,8 %] по сравнению с 37/93 [39,8 %], Р = 0,04; а у пациентов с генотипом 2иЗ- 59/67 [88,1 %] против 50/67 [74,6 %], Р = 0,046; у пациентов без цирроза - 96/127 [75,6 %] по сравнению с 75/134 [55,9 %], Р = 0,005; и у пациентов с исходным уровнем РНК ВГС > 500 000 МЕ/мл 58/84 [69 %] против 43/93 [46,2 %], Р = 0,002. У пациентов с исходным уровнем РНК ВГС < 500 000 МЕ/мл, а также у пациентов с циррозом УВО в группах А и Б статистически не отличался (52/76 [68,4 %] по сравнению с 44/67 [65,7%],Р = 0, 727 и 14/33 [42,4 %] против 12/26 [46,1 %], Р = 0,774 соответственно). Выводы. У пациентов схроническим вирусным гепатитом С при применении комбинации пегинтерферона альфа-2а и рибавирина частота УВО была выше, нежели при использовании комбинации пегинтерферона альфа-2Ь и рибавирина., Background & Aims. Patients with chronic hepatitis С virus (HCV) infection are frequently treated with a combination of pegylated interferon (peginterferon) and ribavirin. This study compared the efficacy and safety of peginterferon alfa-2a and peginterferon alfa-2b, each in combination with ribavirin. Methods. A total of 320 consecutive, treatment-naive, HCV RNA-positive patients with chronic hepatitis were randomly assigned to once weekly peginterferon alfa-2a (180 |ig, group A) or peginterferon alfa-2b (1.5 ugAg, group B) plus ribavirin 1000 mg/day (body weight < 75 kg) or 1200 mg/day (body weight > 75 kg) for 48 weeks (genotype 1 or 4) or 24 weeks (genotype 2 or 3). The primary end point was sustained virological response (SVR) by intention-to-treat. Results. More patients in group A than group В achieved an SVR (110/160 [68.8 %] vs 87/160 [54.4 %]; P = 0.008). Higher SVR rates were obtained in group A than group В among patients with genotype 1/4 (51/93 [54.8 %] vs 37/93 [39.8 %]; P = 0.04), with genotype 2/3 (59/67 [88.1 %] vs 50/67 [74.6 %]; P = 0.046), without cirrhosis (96/127 [75.6 %] vs 75/134 [55.9 %]; P = 0.005), and with baseline levels HCV RNA > 500,000 IU/mL (58/84 [69 %] vs 43/93 [46.2 %]; P = 0.002). SVR rates in groups A and В were not statistically different among patients with baseline HCV RNA < 500,000 IU/mL (52/76 [68.4 %] vs 44/67 [65.7 %]; P = 0.727) or in patients with cirrhosis (14/33 [42.4 %] vs 12/26 [46.1 %]; P = 0.774). Conclusions. In patients with chronic HCV infection, peginterferon alfa-2a plus ribavirin produced a significantly higher SVR rate than peginterferon alfa-2b plus ribavirin.

We report a case of hepatic angiomyolipoma associated to a small bowel schwannoma in a 40-years old woman. Both lesions were asyntomatic. Histologically, hepatic angiomyolipoma showed oncocytic features and scanty adipose tissue, the tumor cells expressed desmin, smooth muscle actin, S-100 protein and HMB45. The tumor cells of intramural small intestinal mass were positive for S-100 protein and GFAP and negative for CD117, CD34 and desmin. To the best of our knowledge, no case of hepatic angiomyolipoma has been previously reported in association with intestinal schwannoma.

Adenoid cystic carcinoma (ACC) is characterized by a particularly aggressive behavior even many years after resection of primary tumor. The evolution of metastasis dramatically affects the final outcome but resection should always be evaluated. Herein is described a case of aggressive ACC of the parotid gland in a 30-year-old female. She developed local recurrence and lung metastases; then, she also developed two liver metastasis 112 and 132 months after the resection of the primitive cancer of the parotid gland. Both lesions were successfully managed by a laparoscopic approach. Intra-abdominal adhesions after the first surgery were mild, allowing an easier access for the second laparoscopic liver resection. At 1 year follow-up, the patient is liver disease free with a stable lung disease. To our knowledge, this is the first report of a double laparoscopic liver resection for parotid gland’s ACC metachronous metastases. Patients with resected ACC need a strict and lifelong follow-up after the resection of the primitive cancer. Also for ACC, a laparoscopic approach to liver metastasis should always be considered as a viable alternative to open surgery. In our experience of over 90 cases, laparoscopic surgery causes less adhesions, allowing an easier approach for repeated resections.

Background/Aims HCV infection recurs almost in all HCV-positive patients receiving liver transplantation and carries a poor prognosis. Aim of this study was to analyze efficacy and effect on survival of antiviral therapy in this clinical setting. Methods Pegylated-interferon α-2b and ribavirin were administered at a dose of 1μg/kg of bwt weekly and 600–800mg/day. Planned duration of treatment was 24 or 48 weeks according to HCV genotype. Patients who failed to respond at week 24 were considered as non-responders. Results 61 patients were enrolled. According to intention-to-treat analysis, 44 (72%) patients were considered as treatment failure (31 non-responders, 4 relapsers, 9 dropout). Sustained virological response was achieved in 17 cases (28%). Genotype 2, higher doses of antivirals and absence of histological cirrhosis were predictors of sustained virological response. In the follow up, patients with sustained virological response had a significantly lower mortality compared to patients with treatment failure ( χ 2 =6.9; P Conclusions Response rate to antiviral therapy in HCV reinfection after liver transplantation is higher if a full dose of antiviral drugs is administered and if treatment starts before histological cirrhosis has developed. Sustained virological response improves patient survival.

A case of multicystic mesothelioma of the liver with secondary involvement of the pelvic peritoneum and the inguinal region is presented. The case is of interest because of its unusual location and peculiar biological behavior.

Clear cell "sugar" tumor is a rare benign tumor considered as a member of the family of perivascular epithelioid cell tumors. To the best of our knowledge, this is the first case of clear cell "sugar" tumor presented as a mass protruding from the urethra in a 15-year-old girl. Pathologic examination revealed a tumor composed of epithelioid cells with "water" clear cytoplasm that stained positively for melanocytic and smooth muscle-specific markers. Treatment of this tumor included a surgical excision and complete removal of the urethral mass, with examination of surgical margins. Three months after surgery, the patient remains clinically free of disease.