Surgery versus radiofrequency ablation in patients with Child- Pugh class-A/single small (≤3 cm) hepatocellular carcinoma

Background/Aims@#We compared the post-treatment overall survival (OS) and recurrence-free survival (RFS) between patients with Child-Turcotte-Pugh (CTP) class-A and single small (≤3 cm) hepatocellular carcinoma (HCC) treated by surgical resection (SR) and radiofrequency ablation (RFA). @*Methods@#We retrospectively analyzed 391 HCC patients with CTP class-A who underwent SR (n=232) or RFA (n=159) as first-line therapy for single small (≤3 cm) HCC. Survival was compared according to the tumor size (≤2 cm/2–3 cm) and the presence of cirrhosis. Inverse probability of treatment weighting (IPW) method was used to estimate the average causal effect of treatment. @*Results@#The median follow-up period was 64.8 months (interquartile range, 0.1–162.6). After IPW, the estimated OS was similar in the SR and RFA groups (P=0.215), and even in patients with HCC of ≤2 cm (P=0.816) and without cirrhosis (P=0.195). The estimated RFS was better in the SR group than in the RFA groups (P=0.005), also in patients without cirrhosis (P<0.001), but not in those with HCC of ≤2 cm (P=0.234). The weighted Cox proportional hazards model with IPW provided adjusted hazard ratios (95% confidence interval) for OS, and the RFS after RFA versus SR were 0.698 (0.396–1.232) (P=0.215) and 1.698 (1.777–2.448) (P=0.005), respectively. @*Conclusions@#SR was similar for OS compared to RFA, but was better for RFS in patients with CTP class-A and single small (≤3 cm) HCC. The RFS was determined by the presence or absence of cirrhosis. Hence, SR rather than RFA should be considered in patients without cirrhosis to prolong the RFS, although there is no OS difference.

The best predictive model for hepatocellular carcinoma in patients with chronic hepatitis B infection

Chronic hepatitis B (CHB) seriously threatens human health. About 820,000 deaths annually are due to related complications such as hepatitis B and hepatocellular carcinoma (HCC). Recently, the use of oral antiviral agents has significantly improved the prognosis of patients with CHB infection and reduced the risk of HCC. However, hepatitis B virus still remains a major factor in the development of HCC, raising many concerns. Therefore, numerous studies have been conducted to assess the risk of HCC in patients with CHB infection and many models have been proposed to predict the risk of developing HCC. However, as each study has different models for predicting HCC development that can be applied depending on the use of antiviral agents or the type of antiviral agents, it is necessary to properly understand characteristics of each model when using it for the evaluation of HCC in patients with CHB infection. In addition, because different variables such as host factor, viral activity, and cirrhosis are used to evaluate the risk of HCC development, it is necessary to assess the risk by carefully verifying which variables are used. Recently, studies have also evaluated the risk of HCC using risk prediction models through transient elastography and artificial intelligence (AI) system. These HCC risk predication models are also noteworthy. In this review, we aimed to compare HCC risk prediction models in patients with CHB infection reported to date to confirm variables used and specificity between each model to determine an appropriate HCC risk prediction method.

Incidence and Clinical Features of Hepatitis C Virus-associated Hepatocellular Carcinoma Patients without Liver Cirrhosis in Hepatitis B Virus-endemic Area

Background@#/objective: Hepatitis C virus (HCV)-associated hepatocellular carcinoma (HCC) is rarely observed in patients without liver cirrhosis (LC). We evaluated the incidence and clinical feature of HCV-associated HCC patients with or without LC. @*Methods@#The medical records of 1,516 patients diagnosed as having primary HCC at our hospital between January 2005 and December 2017 were retrospectively reviewed. Of these, 154 (10.2%) HCV-associated HCC patients were analyzed. LC was diagnosed histologically or clinically. @*Results@#Seventeen (11.0%) of the 154 patients had non-cirrhotic HCC, and all were of Child-Turcotte-Pugh (CTP) class A, Among the 17 patients, 88.2% were male, all had nodular type HCC, and only 2 (11.8%) were under HCC surveillance. Median overall survival (OS) of HCV-associated HCC patients with and without LC was 15 months and 37 months, respectively. Cumulative OS rates were not different between non-cirrhotic patients and cirrhotic patients with CTP class A (P=0.229). Cumulative OS rates were significantly higher in non-cirrhotic patients than in cirrhotic patients of CTP class B (P<0.001) or C (P<0.001). Multivariate analyses showed serum AST (hazard ratio [HR] 1.01, P=0.003) and AFP levels (HR 1.01, P=0.016), antiviral therapy (HR 0.25, P=0.022), and LC of CTP class B (HR, 5.24, P=0.006) or C (HR 21.79, P<0.001) were significantly associated with prognosis in HCV-associated HCC patients. @*Conclusions@#HCC in a non-cirrhotic liver was found in 11% of HCV-associated HCC patients. OSs of HCV-associated HCC patients were better in those of CTP A, regardless of LC than in those with LC of CTP class B or C.

Incidence and Clinical Features of Hepatitis C Virus-associated Hepatocellular Carcinoma Patients without Liver Cirrhosis in Hepatitis B Virus-endemic Area

Background@#/objective: Hepatitis C virus (HCV)-associated hepatocellular carcinoma (HCC) is rarely observed in patients without liver cirrhosis (LC). We evaluated the incidence and clinical feature of HCV-associated HCC patients with or without LC. @*Methods@#The medical records of 1,516 patients diagnosed as having primary HCC at our hospital between January 2005 and December 2017 were retrospectively reviewed. Of these, 154 (10.2%) HCV-associated HCC patients were analyzed. LC was diagnosed histologically or clinically. @*Results@#Seventeen (11.0%) of the 154 patients had non-cirrhotic HCC, and all were of Child-Turcotte-Pugh (CTP) class A, Among the 17 patients, 88.2% were male, all had nodular type HCC, and only 2 (11.8%) were under HCC surveillance. Median overall survival (OS) of HCV-associated HCC patients with and without LC was 15 months and 37 months, respectively. Cumulative OS rates were not different between non-cirrhotic patients and cirrhotic patients with CTP class A (P=0.229). Cumulative OS rates were significantly higher in non-cirrhotic patients than in cirrhotic patients of CTP class B (P<0.001) or C (P<0.001). Multivariate analyses showed serum AST (hazard ratio [HR] 1.01, P=0.003) and AFP levels (HR 1.01, P=0.016), antiviral therapy (HR 0.25, P=0.022), and LC of CTP class B (HR, 5.24, P=0.006) or C (HR 21.79, P<0.001) were significantly associated with prognosis in HCV-associated HCC patients. @*Conclusions@#HCC in a non-cirrhotic liver was found in 11% of HCV-associated HCC patients. OSs of HCV-associated HCC patients were better in those of CTP A, regardless of LC than in those with LC of CTP class B or C.

Diagnostic Assessment of Nonalcoholic Fatty Liver Disease / 대한내과학회지

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease worldwide, and is characterized by fat accumulation at levels exceeding 5% in hepatocytes due to insulin resistance. The disease spectrum ranges from simple nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH)/NASH-related fibrosis or cirrhosis defined by histological findings. Unlike simple NAFL, NASH/NASH-related fibrosis or cirrhosis increases the risk of liver-related morbidity or mortality. Therefore, accurate diagnosis of NASH/NASH-related fibrosis or cirrhosis is needed for management of patients with these diseases. Currently, liver biopsy is the only way to confirm the presence of NASH in an individual with features of NAFLD, but this has some limitations, including sample error, interpretation error, and the invasiveness of the procedure. Therefore, there have been a number of attempts to develop noninvasive methods for differential diagnosis of NASH/NASH-related fibrosis or cirrhosis easily and quickly. Here, we review the assessments for diagnosing NAFLD and the methods for differential diagnosis of NASH/NASH-related fibrosis or cirrhosis.

Acute-on-chronic liver failure as a major predictive factor for mortality in patients with variceal bleeding

Background/Aims@#This study examined the risk factors associated with mortality in cirrhotic patients hospitalized with variceal bleeding, and evaluated the effects of acute-on-chronic liver failure (ACLF) on the prognosis of these patients. @*Methods@#This study was retrospectively conducted on patients registered in the Korean acute-on-chronic liver failure study cohort, and on 474 consecutive cirrhotic patients hospitalized with variceal bleeding from January 2013 to December 2013 at 21 university hospitals. ACLF was defined as described by the European Association for the Study of Liver-Chronic Liver Failure Consortium. @*Results@#Among a total of 474 patients, 61 patients were diagnosed with ACLF. The cumulative overall survival (OS) rate was lower in the patients with ACLF than in those without (P<0.001), and patients with higher ACLF grades had a lower OS rate (P<0.001). The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score was identified as a significant prognostic factor in patients hospitalized with variceal bleeding (hazard ratio [HR], 1.40; 95% confidence interval [CI], 1.30–1.50; P<0.001), even in ACLF patients with variceal bleeding (HR, 1.32; 95% CI, 1.19–1.46, P<0.001). Concerning the prediction of the mortality risk at 28- and 90-day using CLIF-SOFA scores, c-statistics were 0.895 (95% CI, 0.829–0.962) and 0.897 (95% CI, 0.842–0.951), respectively, and the optimal cut-off values were 6.5 and 6.5, respectively. @*Conclusions@#In cirrhotic patients hospitalized with variceal bleeding, the prognosis was poor when accompanied by ACLF, especially depending upon CLIF-SOFA score. CLIF-SOFA model well predicted the 28-day or 90-day mortality for cirrhotic patients who experienced variceal bleeding.

Durability of Sustained Virologic Response and Improvement of Fibrosis Markers after Daclatasvir and Asunaprevir Treatment in Genotype 1b Hepatitis C Virus-Infected Patients: a Real Life and Multicenter Study

BACKGROUND: The long-term data with direct acting antiviral agents were rare. This study investigated the durability of a sustained virologic response (SVR) and the improvement of fibrosis after daclatasvir and asunaprevir (DCV/ASV) treatment in genotype 1b (GT1b) hepatitis C virus (HCV)-infected patients. METHODS: A total of 288 HCV GT1b patients without baseline non-structural 5A (NS5A) resistance-associated substitution (RAS) treated with DCV/ASV were enrolled. Virologic response was measured at 12 weeks and 1 year after treatment completion. In cirrhotic patients, liver function, aspartate transaminase to platelet ratio index (APRI), FIB-4 index, fibrosis index (FI), and liver stiffness measurement (LSM) at baseline and 1 year after treatment completion were evaluated. RESULTS: SVR12 was obtained in 278 patients (96.5%). Six patients who checked NS5A RAS after treatment failure were RAS positive. Only one patient showed no durability of SVR. In cirrhotic patients who achieved SVR12 (n = 59), the changes of albumin (3.8 [2.2–4.7] to 4.3 [2.4–4.9] g/dL; P < 0.001), platelet count (99 [40–329] to 118 [40–399] × 103/mm3; P < 0.001), APRI (1.8 [0.1–14.8] to 0.6 [0.1–4.8]; P < 0.001), FIB-4 index (5.45 [0.6–32.8] to 3.3 [0.4–12.2]; P < 0.001), FI (5.5 [0.6–32.8] to 3.3 [0.4–12.2]; P < 0.001), and LSM (17.2 [5.3–48.0] to 11.2 [3.7–28.1] kPa; P = 0.001) between baseline and 1 year after treatment completion were observed. CONCLUSION: DCV/ASV treatment for HCV GT1b infected patients without RAS achieved high SVR rates and showed durable SVR. Cirrhotic patients who achieved SVR12 showed the improvement of liver function and fibrosis markers.

Post-Hepatitic Aplastic Anemia Associated with Hepatitis A Virus

Hepatitis-associated aplastic anemia is a rare disease, but can be fatal if it is diagnosed late or untreated. Despite the previous case report of severe aplastic anemia following hepatitis, hepatitis A virus (HAV)-associated aplastic anemia is very rare, and a case with bone marrow transplantation (BMT) has not been reported in the literature. Here, we report the case of a 13-year-old boy, who developed severe aplastic anemia after full recovery of acute HAV infection, and eventually received BMT for aplastic anemia following HAV infection. It is a very rare case and the first case that recovered after BMT. The aim of this case report is to highlight the potential of progression to aplastic anemia after acute HAV infection and the importance of suspicion when pancytopenia is developed.

A Case of Ruptured Mycotic Hepatic Artery Aneurysm Successfully Treated Using Arterial Embolization / 영남의대학술지

Mycotic hepatic artery aneurysms (HAAs) have become very rare due to antibiotics. Untreated, they have a high possibility of rupture and mortality. In this paper, on the case of a 67-year-old male who had severe right-upperquadrant abdominal pain and a history of infective endocarditis is reported. The computed tomography (CT) and arterial angiography findings led to a diagnosis of a ruptured mycotic HAA. The CT showed an HAA and the formation of an intrahepatic hematoma caused by aneurysmal rupture. The arterial angiography showed a mycotic HAA that arose from the right posterior hepatic artery. Percutaneous transcatheter arterial embolization was used to successfully treat the HAA. Since then, the patient has been doing well, without symptoms.

Concurrent hepatic adenomatoid tumor and hepatic hemangioma: a case report

A 45-year-old male with alleged asymptomatic hepatic hemangioma of 4 years duration had right upper-quadrant pain and was referred to a tertiary hospital. Computed tomography and magnetic resonance imaging scans revealed a hypervascular mass of about 7 cm containing intratumoral multilobulated cysts. A preoperative liver biopsy was performed, but this failed to provide a definitive diagnosis. The patient underwent a partial hepatectomy of segments IV and VIII. The histologic findings revealed multifocal proliferation of flattened or cuboidal epithelioid cells and a highly vascular edematous stroma. Immunohistochemistry findings demonstrated that the epithelioid tumor cells were positive for cytokeratin (AE1/AE3), vimentin, calretinin, and cytokeratin 5/6, and were focally positive for CD10, and negative for WT1 and CD34, all of which support their mesothelial origin. Immunohistochemistry for a mesothelial marker should be performed for determining the presence of an adenomatoid tumor when benign epithelioid cells are seen.

A Case of Emphysematous Cholecystitis and Pneumobilia after Transarterial Chemoembolization for Hepatocellular Carcinoma / 대한내과학회지

Transarterial chemoembolization (TACE) is reportedly a useful palliative treatment in patients with unresectable or recurred hepatocellular carcinoma. Post-TACE complications are common; however, acute cholecystitis after TACE is rare. We herein report a case of a 73-year-old woman who presented with emphysematous cholecystitis and pneumobilia following TACE. Computed tomography performed for evaluation of her tumor status before TACE incidentally showed gallbladder and common bile duct stones. After TACE, she complained of severe epigastric pain with a positive Murphy's sign. Computed tomography showed emphysematous cholecystitis and pneumobilia. She was successfully treated with emergent biliary stone removal by endoscopic retrograde cholangiopancreatography.

A Case of Anaphylaxis to Oral Minocycline

Minocycline is a semisynthetic tetracycline derivative that is often used in the treatment of acne vulgaris. To date, there has been only one case report of anaphylaxis to minocycline. We report here a case of anaphylaxis to oral minocycline. A 56-yr-old woman visited our hospital after three episodes of recurrent anaphylaxis. We performed an oral challenge test, the standard method for diagnosing drug allergies, with minocycline, one of the drugs she had taken previously. She developed urticaria, angioedema, nausea, vomiting, hypotension, and dyspnea within 4 min and was treated with intramuscular epinephrine, intravenous antihistamine and systemic corticosteroid. However, she presented similar symptoms at 50 min and at 110 min. In prescribing oral minocycline, physicians should consider the possibility of serious adverse reactions, such as anaphylaxis.

Cholestyramine resin for erythropoietic protoporphyria with severe hepatic disease: a case report / 대한간학회지

Erythropoietic protoporphyria (EPP) is a rare disorder of heme biosynthesis caused by mutations in the gene encoding the enzyme ferrochelatase. In EPP, deficient ferrochelatase activity leads to the excessive production and biliary excretion of protoporphyrin (PP). The major clinical features of EPP are photosensitivity and hepatobiliary disease that may progress to severe liver disease, that are caused by the toxicity of PP. EPP-related liver disease has been treated medically or surgically including liver transplantation. We described a 20-year-old male with severe liver disease who was diagnosed with EPP based on clinical and laboratory findings. He was treated with cholestyramine resin. Six months after the treatment, he was doing well without any abdominal pain or photosensitivity.

Sigmoid colon metastasis from hepatocellular carcinoma / 대한간학회지

Hepatocellular carcinoma (HCC) is a major health problem worldwide, and it has a poor prognosis. Extrahepatic metastasis from HCC is not unusual, with direct invasion representing the main spreading mode. Sites that are frequently involved are the lung, bone, and lymph nodes. There are few reports of HCC invading the distant gastrointestinal tract, especially hematogenously. Herein we report a case of sigmoid colon metastasis from HCC. The patient was diagnosed with HCC and treated with transcatheter arterial chemoembolization (TACE). Eighteen months after TACE the patient presented with abdominal pain on the left lower quadrant, and a CT scan showed an enhanced mass on the sigmoid colon. Immunohistochemical staining revealed that a tumor cell was positive for polyclonal carcinoembryonic antigen and weakly positive for hepatocyte antigen, supporting the diagnosis of HCC metastasis. The patient underwent anterior resection for the metastatic HCC.

Mutations within the interferon sensitivity determining region in Korean patients infected with hepatitis C virus genotype 1b / 대한간학회지

BACKGROUND/AIMS: The treatment response to interferon could differ with mutations in the interferon-sensitivity-determining region (ISDR) in patients infected with hepatitis C virus (HCV) genotype-1b (HCV-Ib). We examined the pattern of ISDR mutations and analyzed whether the number of amino acid substitutions influences the treatment response to peginterferon plus ribavirin in chronic hepatitis or cirrhotic patients infected with HCV-Ib. METHODS: The study population comprised 52 patients who visited Seoul Asan Medical Center and Seoul National University Bundang Hospital from January 2006 to December 2008 and who received peginterferon alpha-2a (n=37) or -2b (n=15) plus ribavirin, and whose serum was stored. We analyzed the early virologic response, end-of-treatment response, and sustained virologic response (SVR), and examined the ISDR using direct sequencing. RESULTS: The proportions of patients with ISDR mutation types of wild (0 mutations), intermediate (1-3 mutations), and mutant (> or =4 mutations) were 50.0%, 42.3%, and 7.7%, respectively, and the corresponding SVR rates were 63%, 50%, and 67% (p>0.05). The SVR rates were 59.4% and 50.0% in patients with or =2 mutations, respectively (p>0.05). On univariate analysis, age was the only predictive factor for SVR (p=0.016). The pretreatment HCV RNA titer tended to be lower in those with SVR, but without statistical significance (p=0.069). CONCLUSIONS: The frequency of ISDR mutations was low in our cohort of Korean patients infected with HCV-Ib. Therefore, ISDR mutations might not contribute to the response to treatment with peginterferon plus ribavirin.

A Case of Acute Myopericarditis Associated with Mycoplasma pneumoniae Infection in a Korean Adult

We report on a 45-year-old man with a confirmed diagnosis of acute myopericarditis associated with Mycoplasma pneumoniae. He visited our emergency department due to high fever (39degrees C) via a primary clinic. We made a diagnosis of myopericarditis based on symptoms, cardiac enzymes, electrocardiography, and transthoracic echocardiography. Serology (particle agglutination) testing for M. pneumoniae IgG antibody was also performed. The IgG antibody titer was 1:80 on the second day of admission, and increased to 1:2,560 by the 12th day of admission. Therefore, we confirmed the diagnosis of acute myopericarditis associated with M. pneumoniae and subsequently treated him with azithromycin. The symptoms and laboratory findings improved, and he recovered uneventfully.

A Case of Acute Myopericarditis Associated with Mycoplasma pneumoniae Infection in a Korean Adult

We report on a 45-year-old man with a confirmed diagnosis of acute myopericarditis associated with Mycoplasma pneumoniae. He visited our emergency department due to high fever (39degrees C) via a primary clinic. We made a diagnosis of myopericarditis based on symptoms, cardiac enzymes, electrocardiography, and transthoracic echocardiography. Serology (particle agglutination) testing for M. pneumoniae IgG antibody was also performed. The IgG antibody titer was 1:80 on the second day of admission, and increased to 1:2,560 by the 12th day of admission. Therefore, we confirmed the diagnosis of acute myopericarditis associated with M. pneumoniae and subsequently treated him with azithromycin. The symptoms and laboratory findings improved, and he recovered uneventfully.

A case of intramedullary nocardiosis in a patient after hematopoietic stem cell transplantation / 대한내과학회지

Nocardiosis is uncommon in healthy people but occurs as an opportunistic infection in patients after hematopoietic stem cell transplantation, solid organ transplantation, malignancy, or acquired immune deficiency syndrome. Involvement of Nocardia in the spinal cord is rare; to our knowledge, only six cases have been reported. We report here the case of a 54-year-old man with a spinal cord abscess and epidural and paraspinal abscesses in the thoracic and lumbar spinal cord, causing paraplegia, voiding and defecation difficulties, and combined lung involvement, which developed 5 months after allogeneic hematopoietic stem cell transplantation. Nocardia grew in a fungus culture obtained by percutaneous lung biospy and CT-guided aspiration of the spinal abscess. A double combination regimen of antibiotic therapy (imipenem/cilastatin sodium, amikacin) was given. His paraplegia and his voiding and defecation difficulties improved considerably. To our knowledge, this is the first reported case of spinal cord Nocardiosis observed after allogeneic hematopoietic stem cell transplantation.

A case of intramedullary nocardiosis in a patient after hematopoietic stem cell transplantation / 대한내과학회지

Nocardiosis is uncommon in healthy people but occurs as an opportunistic infection in patients after hematopoietic stem cell transplantation, solid organ transplantation, malignancy, or acquired immune deficiency syndrome. Involvement of Nocardia in the spinal cord is rare; to our knowledge, only six cases have been reported. We report here the case of a 54-year-old man with a spinal cord abscess and epidural and paraspinal abscesses in the thoracic and lumbar spinal cord, causing paraplegia, voiding and defecation difficulties, and combined lung involvement, which developed 5 months after allogeneic hematopoietic stem cell transplantation. Nocardia grew in a fungus culture obtained by percutaneous lung biospy and CT-guided aspiration of the spinal abscess. A double combination regimen of antibiotic therapy (imipenem/cilastatin sodium, amikacin) was given. His paraplegia and his voiding and defecation difficulties improved considerably. To our knowledge, this is the first reported case of spinal cord Nocardiosis observed after allogeneic hematopoietic stem cell transplantation.

A Case of Churg-Strauss Syndrome with Multiple Tracheobronchial Mucosal Lesions / 결핵및호흡기질환

Churg-Strauss syndrome is a rare form of systemic necrotizing vasculitis that occurs exclusively in patients with asthma, and is associated with blood and tissue eosinophilia. The classic pathology findings in the lung include a combination of eosinophilic pneumonia, granulomatous inflammation and necrotizing vasculitis. However, there are few reports of tracheobronchial mucosal lesions in Churg-Strauss syndrome. We report a case of Churg-Strauss syndrome with multiple tracheobronchial mucosal lesions in a 33-year-old man with a history of bronchial asthma and allergic rhinitis. He had been diagnosed with community acquired pneumonia at another hospital and was treated with antibiotics. However, the chest radiographic findings were aggravated and showed multifocal consolidations in the whole lung fields. He was transferred to the Asan Medical Center. Fiberoptic bronchoscopy revealed multiple nodular mucosal lesions of the trachea and bronchi. The histopathology of the mucosal lesions revealed necrotizing bronchial inflammation with eosinophilic infiltration. Video Assisted Thoracic Surgery was performed. The wedge resected lung tissue revealed chronic eosinophilic pneumonia that was consistent with Churg-Strauss syndrome. Methylprednisolone (1 mg/kg q 8 hr) was prescribed and his symptoms resolved gradually. The chest radiographic findings improved significantly, and a follow-up fiberoptic bronchoscopy performed eight days later showed that the tracheobronchial mucosal lesions had resolved. The patient was prescribed oral prednisolone for 20 months after discharge. Currently, the patient is not taking steroids and is being followed up.