Positive immunostaining of Sal-like protein 4 is associated with poor patient survival outcome in the large and undifferentiated Korean hepatocellular carcinoma

PURPOSE: Previous studies have shown the role of Sal-like protein 4 (SALL4) as a biomarker in hepatocellular carcinoma (HCC), and some studies have shown the relationship between SALL4 and prognosis. Given the debates in study groups differences in terms of etiologic causes between Western and Asian HCC and detection methods, we attempted to verify the features of SALL4 immunoreactivity and its clinical correlation in Korean HCC patients. METHODS: Immunohistochemical staining of SALL4 of tissue microarrays (TMAs) consisting of 213 surgically resected HCC patients' tissue were scored in a semiquantitative scoring system with immunoreactive score and the results analyzed with clinical outcome, in addition to general demographics and clinical characteristics. RESULTS: SALL4 immunoreactivity was expressed in 50 cases. Relevance between SALL4 and α-FP correlated significantly (P = 0.002). Also, the SALL4-positive patients had considerably higher tumor grade (P < 0.001). The survival analysis showed negative correlation with SALL4 immunoreactivity in all HCC patient groups, but SALL4 immunoreactivity in T3 and T4 HCC correlated with poor prognosis. CONCLUSION: Here, we found that positive immunostaining of SALL4 is correlated with poor patient survival outcome in large and undifferentiated Korean HCC. SALL4 expression showed close relationship with clinical outcomes of HCCs in Korean patients.

Positive immunostaining of Sal-like protein 4 is associated with poor patient survival outcome in the large and undifferentiated Korean hepatocellular carcinoma

PURPOSE: Previous studies have shown the role of Sal-like protein 4 (SALL4) as a biomarker in hepatocellular carcinoma (HCC), and some studies have shown the relationship between SALL4 and prognosis. Given the debates in study groups differences in terms of etiologic causes between Western and Asian HCC and detection methods, we attempted to verify the features of SALL4 immunoreactivity and its clinical correlation in Korean HCC patients. METHODS: Immunohistochemical staining of SALL4 of tissue microarrays (TMAs) consisting of 213 surgically resected HCC patients' tissue were scored in a semiquantitative scoring system with immunoreactive score and the results analyzed with clinical outcome, in addition to general demographics and clinical characteristics. RESULTS: SALL4 immunoreactivity was expressed in 50 cases. Relevance between SALL4 and α-FP correlated significantly (P = 0.002). Also, the SALL4-positive patients had considerably higher tumor grade (P < 0.001). The survival analysis showed negative correlation with SALL4 immunoreactivity in all HCC patient groups, but SALL4 immunoreactivity in T3 and T4 HCC correlated with poor prognosis. CONCLUSION: Here, we found that positive immunostaining of SALL4 is correlated with poor patient survival outcome in large and undifferentiated Korean HCC. SALL4 expression showed close relationship with clinical outcomes of HCCs in Korean patients.

Role of Experimental Research as a Surgeon / 한양의대학술지

No abstract available.

Bladder Reconstruction Using Bovine Pericardium in a Case of Enterovesical Fistula

The use of graft materials in bladder mucosa has been examined in animal models, but debate exists over which materials are effective. Intestine has been used as a substitute in augmentation cystoplasty for patients with neuropathic bladder, but serious adverse effects of the operation have occurred in some instances. We report a case of a successful repair of an enterovesical fistula by use of bovine pericardium. The patient has remained well for 2.5 years. We suggest that bovine pericardium may be a suitable option as a bladder substitute.

Hepatoid adenocarcinoma of the gallbladder with production of alpha-fetoprotein / 대한외과학회지

Hepatoid adenocarcinoma (HAC) is a tumor with aberrant hepatocellular differentiation that occurs in extrahepatic organs. HAC of the gallbladder is rare, and cases of alpha-fetoprotein production are extremely rare. A 61-year-old man was diagnosed with gallbladder adenocarcinoma after laparoscopic cholecystectomy. A radical operation including resection of liver bed and lymph node dissection was performed, and no tumor cell was found. However, at postoperative 19 months, he showed lymphadenopathy of the portocaval area and tumor thrombi in the right portal vein with high levels of serum alpha-fetoprotein. After right hemihepatectomy and portahepatis lymph node dissection was performed, he was diagnosed with metastatic HAC. On reviewing the gallbladder specimen, the tumor finally demonstrated HAC as the primary origin. Despite adjuvant therapy, the patient died from multiple liver metastasis 26 months after cholecystectomy. Although HAC of the gallbladder is a very rare malignancy, awareness of its existence is critical to avoid misdiagnosis.

Acinar Cell Carcinoma of the Pancreas in Korea: Clinicopathologic Analysis of 27 Patients from Korean Literature and 2 Cases from Our Hospital / 대한소화기학회지

BACKGROUND/AIMS: Acinar cell carcinoma (ACC) of the pancreas is a rare malignancy. ACC has been considered a cancer with poor prognosis due to frequent metastasis, a high recurrence rate, and low resectability. The aim of this study was to examine the clinical, radiologic and pathologic features of ACC in Korean patients, and surgical outcome was also investigated. METHODS: We reviewed the clinical records of two patients with ACC who had undergone operation in January 1996 and December 2005 at Hanyang University Medical Center. Through searching of medical journal from 1983 to 2009, 27 patients reported on literatures as Korean ACC patients were reviewed together. The clinical, pathohistologic, and radiologic features, treatment, and prognosis were investigated for all 29 patients. RESULTS: ACC was more common in male, and age at diagnosis ranged from 25 to 68 years (median 54). Symptoms were, mostly abdominal pain and mass. Liver was most common organ of metastasis at diagnosis and recurrence after operation. The mean tumor size was 7.0 cm, and most common location was tail. Of the 29 patients, 22 underwent surgical resection. Excluding 7 cases of not-reported survival, the median survival with operation was 22.4 months compared to 1.5 months with non-operation. CONCLUSIONS: In Korea, the clinical features of ACC include young age, large size, tail location, and nonspecific tumor markers. Surgery should be actively performed in the treatment of ACC regardless of size.

Acinar Cell Carcinoma of the Pancreas: A Report of Two Cases with Long-term Follow-up and a Review of the Literature

Acinar cell carcinoma (ACC) of the pancreas is a rare malignancy making up approximately 1% of pancreatic non-endocrine malignant tumors. The common finding on computed tomography is a solitary, well-defined, heterogenous hypodense mass with enhancing capsule. ACC is a highly cellular tumor with minimal stroma and a lack of stromal desmoplasia. The accurate diagnosis of ACC cannot typically be done by histology alone but rather requires immunohistochemical staining or electron microscopy for the identification of pancreatic enzymes and zymogen granules. ACC has been considered a cancer with a poor prognosis due to frequent metastasis, a high recurrence rate, and low respectability. Surgical resection is the treatment of choice that can lead to long-term survival. ACC has a better prognosis than ductal carcinoma of the pancreas, but a worse prognosis compared to islet cell carcinoma. We report two cases of ACC with 5-year survival after surgical resection.

Left-sided Gallbladder with Intrahepatic Portal Vein Anomalies: A Single Center Experiences

PURPOSE: The goal of this article was to characterize and explain the etiology of a left-sided gallbladders with intrahepatic portal vein anomalies, and these cases of this unusual anatomy were all encountered at a single center. METHODS: We reviewed the movies recorded during surgery, the database information and the preoperative radiologic examinations of 1,141 patients who underwent cholecystectomies at our institution between August 2007 and July 2010 to assess the presence of left-sided gallbladder and its combined anomalies. RESULTS: Four of 1141 patients (0.35%) were diagnosed with left-sided gallbladder. In all the cases, the gallbladder was located on the left side of the falciform ligament, under the left lobe of the liver with typical abnormal intrahepatic portal venous branching. The right posterior portal vein came directly from the main portal vein, and the right anterior portal vein originated from the left portal vein, but the ligamentum teres joined to the left branch of the portal vein in the liver. CONCLUSION: Left-sided gallbladder with intrahepatic portal venous branching anomaly resulted from the defective development of the central portion of the liver rather than from abnormal regression of the left umbilical vein with persistence of the right umbilical vein.

Laparoscopic Surgery in the hepatopancreato biliary diseases / 한양의대학술지

"Big Incision, Big Surgeon !!" At the beginning of surgery, excellence was associated with big incisions and rapidity of the operation because of the anesthesia. But, nowadays there has been a big change after the development of laparoscopic surgery. It is not a discipline unto itself, but more a philosophy of surgery, a way of thinking. " Small Incision, Best Surgeon!!" So-called Minimally invasive surgery (MIS) is a means of performing major operations through small incisions, often using miniaturized, high-tech imaging systems, to minimize the trauma of surgical exposure. Laparoscopic cholecystectomy became the stepping stone of the present status of MIS and is opening the dawn of the least invasive and eventually to non-invasive surgery, for exemple, Natural Orifice Transluminal Endoscopic Surgery (NOTES). I review the history of laparoscopic cholecystectomy cholecystectomy and introduce what procedures the surgeons are performing in the field of hepatopancreato biliary diseases.

Biliary Cystadenoma and Cystadenocarcinoma of the Liver

PURPOSE: Cystic neoplasms in the liver are rarely seen tumors. Biliary cystadenoma and cystadenocarcinoma constitute less than 5% of intrahepatic cysts originating from the bile duct. The clinicopathologic and radiologic findings are important to arrive at the proper diagnosis and treatment of intrahepatic biliary cystadenoma and cystadenocarcinoma. The aims of this study were to characterize the clinical and pathologic aspects of these lesions, and also to discuss the treatment and prognosis of biliary cystadenoma and cystadenocarcinoma. METHODS: We reviewed the clinical records of six patients who had intrahepatic biliary cystadenoma and cystadenocarcinoma and who had undergone operations from January, 1986 to June, 2002 at Hanyang University Hospital. RESULTS: Primary biliary cystadenoma and cystadenocarcinoma of the intrahepatic biliary systems are rarely seen tumors. Biliary cystadenoma mainly affected women, and this was a different gender preponderance than was seen for biliary cystadenocarcinoma. We found no signs or symptoms that were specific for either of these tumors, and the diagnoses were usually made by abdominal CT and abdominal ultrasonography. These tumors were usually large, multilocular and cystic in appearance. The pathologic findings revealed multiple cystic masses lined with cuboidal to columnar epithelium. The nature of the cystic fluid was usually the mucous type. Of the 6 patients in whom the lesions were completely excised, 4 of the patients are alive. The other 2 patients died of old age and distant metastasis, respectively. CONCLUSION: Surgical resection of the tumor, including a margin of surrounding normal liver parenchyma, was the only curative method. If the tumor is confined in the liver, complete surgical excision yields an excellent prognosis. Complete resection of a biliary cystadenoma and radical resection of a biliary cystadenocarcinoma seem to offer these patients a chance for long-term survival.

In Vivo Differentiation of Mouse Embryonic Stem Cell into Hepatocytes

PURPOSE: Embryonic stem (ES) cells have been regarded as a powerful resource in cell replacement therapy. In recent reports, mouse ES cells have been successfully applied to the treatment of spinal cord injuries, hereditary myelin disorders of the central nervous system and diabetes mellitus. Various liver diseases are another group that could benefit from the availability of stem cell therapy; however, no previous demonstration has been made that shows the differentiation of ES cells into hepatocytes. METHODS: To investigate the in vivo differentiation potential of mouse ES cells, we injected ES cells into the splenic cortex of immuno-suppressed nude mice. RESULTS: In a histological analysis of the teratomas derived from injected ES cells some areas were shown, due to their morphology, to contain typical hepatocytes. The hepatic nature of these cells was further confirmed by immunohistochemical assays using the antibody against alpha-fetoprotein and hepatocyte-specific antibodies. In addition, periodic acid-Shiff staining revealed a small portion of hepatic area in the ES-derived teratoma produced glycogen, implying these cells are functional hepatocytes. CONCLUSION: Our case demonstrated for the first time that mouse ES cells can differentiate in vivo into a mixed population of hepatocytes with different maturation stati, which could potentially extend the usage of ES cells in cell replacement therapy for various liver diseases.

Carcinoid Tumor of the Common Bile Duct and Gallbladder

Carcinoid tumors are derived from Kultschitzky cells, and often found in the appendix, ileum, rectum and bronchus, but those of the biliary tract are rare. Here, the case of a 59-year-old man, unexpectedly found to have a carcinoid tumor obstructing the common bile duct, is reported. A gallbladder carcinoid tumor was also found incidentally during a planned subtotal gastrectomy operation. The literature on carcinoid tumors of the extrahepatic bile duct and gall bladder is also reviewed.

Delayed Superficial Transposition of Cephalic Vein for Salvage of Brachiocephalic FIstula

The small diameter and sclerosis of the veins are the main causes of failure of autogenous arterio-venous fistula(AVF) for hemodialysis. In addition, the deep location of veins prevents adequate access postoperatively, as exemplified by the frequent requirement of transposition of basilic veins either primarily or delayed. As for the cephalic veins, superficial transposition was not emphasized. We report a case of brachiocephalic AVF which required delayed superficial transposition for access. We emphasize that the depth of veins should be considered for adequate creation of AVF.

A Clinical Review for Resected Intrahepatic Cholangiocarcinoma / 한국간담췌외과학회지

BACKGROUND/AIMS: An intrahepatic cholangiocarcinoma, which has been defined as a primary adenocarcinoma from the intrahepatic bile duct to the second-order branch of the main hepatic duct, has a poor prognosis due to late diagnosis and low resectability. The purpose of this study is to define the prognostic factors that affected the survival of patients. METHODS: To evaluate the clinical manifestation and pathologic characteristics and the value of surgical management in relation to survival, we retrospectively reviewed the clinical records of 37 patients with an intrahepatic cholangiocarcinoma who had been underwent hepatic resection at the department of surgery, Hanyang University Hospital from April 1986 to April 2001. Cumulative survival rate and clinicopa-thologic factors that may influence the prognosis were analyzed statistically. Statistical significance was calculated by the Kaplan-Meier and compared by log rank test with statistical significance defined as p<0.05. RESULTS: The median survival time of the patients was 24.6 months (mean, 23.97 months), with 2 and 3-year survival rates of 33.3% and 27.3%, respectively. Univariate analysis showed that TMN stage and gross type correlated significantly with prognosis. Age, sex, tumor marker, Clonorchis Sinensis, intrahepatic duct stone and cell differentiation were not significantly correlated with prognosis. CONCLUSION: In case of the intrahepatic cholangiocarcinoma, without surgical treatment, survival time is not longer than mean 6 months from the first diagnosis. According to this study, we strongly recommend to early diagnosis and proper hepatic resection with lymph node dissection, be recommended to raise the long-term survival rate and improve the quality of life.

Relationship between COX-2 Expression and Clinicopathologic Data of GB Cancer / 한국간담췌외과학회지

BACKGROUND/AIMS: Gallbladder carcinoma has been associated with a dismal overall prognosis. Tumorigenesis of gallbladder carcinoma is complex and not completely understood. An association of gallbladder carcinoma with cholelithiasis or an anom alous arrangement of the panceraticobiliary duct suggests that long-term inflammation may modulate tumorigenesis and progression of carcinoma. COX-2 is a rate limiting enzyme of PG synthesis and related to chronic inflammation. Several report suggested the close relationship between and COX-2 and GB cancer. METHODS: We reviewed the clinical records of sixty-two patients with GB cancer who had undergone operation from January, 1990 to December, 1999 at Hanyang University Hospital. COX-2 expression of GB cancer were evaluated with im\munohistochemical staining and expression intensity was graded on a scale of 0-2 RESULTS: There were 62 patients, whose mean age was 52.5 years. The ages ranged from 28 years to 84 years. There were 27 male patients and 35 female patients. Generally, COX-2 expression was found in chronic inflammatory area and its level increased in dysplastic area and mucosal tumor. stromal tumor showed relatively weaker COX-2 expression level. COX-2 expression is related to depth of tumor invasion, lymph node metastasis, stage (TNM, Nevin) in a negative way. CONCLUSION: Early stage of GB cancer shows relatively increased level of COX-2. Its increased level means COX-2 can modulate early stage of GB cancer carcinogenesis. COX- 2 inhibitor, cancer chemopreventive agent in colon cancer, can be regarded as same one in GB cancer.

Clinicopathologic Characteristics of Hepatocellular Carcinoma with Extrahepatic Malignancy

PURPOSE: Multiple primary cancers are not a rare disease. The clinicopathologic characteristics of a hepatocellular carcinoma with extrahepatic malignancies, have not been identified. To address these points, the clinical data of patients with a hepatocellular carcinoma, with extrahepatic malignancies, treated with surgical resections at our hospital, were retrospectively reviewed. METHODS: We reviewed the clinical records of ten hepatocellular carcinoma patients, with extrahepatic malignancies, who had undergone an operation between January, 1986 and December, 2002 at the Hanyang University Hospital. RESULTS: 10 patients were comprised of 9 males and 1 female, with a mean age of 58.6 years, ranging from 34 to 75. There were 9 stomach cancers and 1 rectal cancer extrahepatic malignancies associated with the hepatocellular carcinomas. Four of these were synchronous type and six were metachronous type. The treatments used for the HCCs were: 1 extended right lobectomy, 6 right lobectomies, 1 each of a TAE with RFTA, a segmentectomy with RFTA, and a segmentectomy. The operations for the extrahepatic malignancies included 1 low anterior resection, for the rectal cancer and 9 subtotal gastrectomies, for the stomach cancers. During the mean follow up time of 66.1 months, five patients survived and five died. CONCLUSION: Patients who have a hepatocellular carcinoma, associated with extrahepatic malignancies, have been treated with aggressive operations and combination therapies. Stomach cancer is the most common extrahepatic malignancy associated with a hepatocellular carcinoma.

Hepatocyte Transplantation Using Fibrin Gel / 대한이식학회지

PURPOSE: Whole liver transplantation, an effective therapy for many inherited and acquired hepatic disorders, has limitations including donor shortage and fatal surgical complications. Hepatocyte transplantation, which is simpler and less expensive than whole liver transplantation, allows the use of living related donors, permits the use of a single donor organ for multiple recipients, and makes possible the cryopreservation of hepatocytes for future use. However, choosing a proper scaffold for hepatocyte transplantation hampers wide use of hepatocyte transplantation. We performed hepatocyte transplantation using fibrin gel, as a cell transplantation scaffold and evaluated their effectiveness. METHODS: Female, five week old FVB mice, were prepared for donors, and two male, five week old nude mice, were used as recipients. Liver cells were isolated from FVB donors. The cell viability exceeded 95% as assessed by the trypan blue exclusion method. For three nude mice, 5x10(6) cells resuspended in 500microliter of fibrinogen were mixed with 500microliter thrombin, and were injected into the peritoneal cavity of each mouse. One nude mouse was transplanted with 5x10(6) cells resuspended in 500 microliter medium, which served as a negative control. Specimens were retrieved at one week, and histological and immunohistochemical analyses wereperformed. RESULTS: In the negative control, all transplanted hepatocytes disappeared at one week. In mice transplanted both fibrin gel and hepatocytes, conglomerates containing hepatocytes were observed on the intestinal mesentery. The hepatocytes were identified by H & E staining and immunohistochemistry using anti-hepatocyte antibody. Functional activity was evaluated with PAS staining. CONCLUSION: In this preliminary study, stable hepatocyte engraftment was achieved in hepatocyte transplantation with fibrin gel, but not in hepatocyte transplantation without scaffold. More studies on comparison between fibrin gel and injectable scaffolds would be necessary. Improvement on both initial vascularization and proliferation of transplanted hepatocytes is a target of our future work.

A Case of Klippel-Trenaunay-Weber Syndrome with Sigmoid Varices / 대한소화기내시경학회지

Colonic varix, which is a rare cause of lower gastrointestinal bleeding, can be developed by various diseases. Colonic variceal bleeding is more fatal than esophageal variceal bleeding. Klippel-Trenaunay-Weber syndrome is a rare congenital vascular malformation characterized by the clinical triad of bony or soft tissue hypertrophy, hemangioma and varicosities or vascular malformations. We report a 42-year-old female patient with fatal sigmoid variceal bleeding. She had dilated vessels over her body and face, and both superior and inferior vena cava were obstructed. She underwent an emergent operation due to uncontrolled massive bleeding from sigmoid varices. We report a case of Klippel-Trenaunay-Weber syndrome with literature review.

A Clinical Review of Initial 20 Cases of Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholaminesecreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.

A Clinical Review of Initial 20 Cases of Laparoscopic Adrenalectomy / 대한내분비외과학회지

PURPOSE: The laparoscopic adrenalectomy (LA) has become the preferred procedure for adrenal tumors due to many advantages; a more rapid and comfortable recovery, shortened hospitalization period, and fewer complications. This study reports on an initial 4 year period of experience with LA and describes various unusual findings encountered during the treatment. METHODS: From February 1997 to November 2000, a total of 20 LA were performed. Of the several LA techniques previously described we prefer the transabdominal approach in the lateral decubitus position utilizing 3 or 4 trocars, and this method was employed in all the cases presented here. RESULTS: All 20 patients had a unilateral tumor. The pathological findings consisted of 11 aldosteronomas, 6 Cushing adenomas, 2 pheochromocytomas and 1 cortical carcinoma. Of the 20 patients, 18 were successfully operated with the laparoscopic procedure and the remaining 2 cases were converted to open adrenalectomy. The reasons for conversion were sudden cardiac arrest of unknown origin in one and intraoperative bleeding due to periadrenal massive fat in the other. During LA, 2 patients with non-catecholaminesecreting cortical adenomas pathologies displayed abnormal EKG findings, which reverted to normal after the operation. The average complete LA operation times was 186 minutes in the first 9 cases and 132 minutes in the next 9 cases. The first oral intake was started within 24 hours in all cases. There were no postoperative complications, operative morbidity or mortality. The average hospital stay was 6.2 days in the first 9 cases and 4.2 days in the next 9 cases. CONCLUSION: LA is a relatively fast and safe method and has become is accepted as the preferred procedure for adrenal tumors but it requires good perioperative preparation. Surgeons and anesthesiologists need to be aware of the possible cardiovascular complications and of the problems inherent in the manipulation of the adrenal gland during LA.