Successful salvage of torsion testis by means of intraoperative indocyanine green fluorescence imaging.

BACKGROUND: Testicular torsion (TT) is common surgical emergency that requires early diagnosis and immediate intervention within 6 h since its onset to salvage the testis. However, the decision was made only by the surgeon's experience whether it has to be resected or not. Recently, indocyanine green (ICG) has become an excellent tool to identify biliary and vascular anatomy, and assess perfusion abnormalities in tissues. In this case report, we successfully salvaged the twisted testis, since the testicular blood perfusion was confirmed by means of intraoperative ICG (IICG) fluorescence imaging. CASE PRESENTATION: A 14-year-old healthy male patient presented due to acute left testicular pain. The patient was diagnosed with TT and had immediate surgery. Macroscopically, the testis had stagnant blood flow and appeared to be dark colored. After manual detorsion, the testis remained cyanotic and with macroscopically poor blood flow. ICG angiography was performed under near-infrared light by laparoscopic camera to assess the perfusion of the affected testicle. An excellent ICG signal appeared after 45 s in the testis, and decision was made to be preserved. Therefore, left orchidopexy was performed to complete the operation. The patient had a good postoperative course and was discharged the day after surgery. Six months later, the testis did not show any shrinkage, and both sides of the testis showed the same size without any consequences. CONCLUSION: The blood flow in the testis was visually confirmed during the IICG fluorescence method. ICG fluorescence imaging may become an effective alternative to evaluate whether a testis can be preserved following TT.

[A case of disseminated carcinomatosis of the bone marrow with disseminated intravascular coagulation caused by advanced colon cancer successfully treated with SOX/bevacizumab].

Our patient was a 58-year-old man who was diagnosed with a large bowel obstruction caused by ascending colon cancer, together with multiple liver metastases for which a right hemicolectomy was performed. After the operation, he developed disseminated intravascular coagulation(DIC)and severe anemia. Bone marrow biopsy findings led to a diagnosis of disseminated carcinomatosis of the bone marrow caused by colon cancer. We administered S-1+oxaliplatin(SOX) and bevacizumab( BV)chemotherapy, which improved the DIC. The patient was discharged from the hospital. After a total of six courses of chemotherapy, the carcinoma became resistant. We changed the drug regimen and his clinical condition improved. He survived for 292 days from the onset of disease.

[A case of bone metastases from hepatocellular carcinoma presenting with erythrocytosis after hepatectomy].

A 57-year-old man was admitted for careful examination of lower limb edema. Abdominal computed tomography(CT) showed hepatocellular carcinoma(HCC), 2 cm in diameter, arising in liver segment S6. Posterior segmentectomy was performed, and histological examination of the specimen revealed poorly differentiated HCC. Nine months after surgery, a metastatic tumor was detected in the left scapula, and the patient gradually began to show a high blood concentration of hemoglobin and erythropoietin(Epo). Sorafenib was started but was discontinued because of intractable diarrhea. The patient died of the metastatictumor 15 months after surgery. This is the first case report of a patient with metastaticHCC developing erythrocytosis associated with a high concentration of Epo.

Classification of ultrasonographic images of small hepatocellular carcinoma using galactose-based contrast agent: relation between image patterns and histologic features.

PURPOSE: The aim of this study was to establish the relation between observed ultrasonographic (US) images produced with a galactose-based contrast agent and histologic characteristics of small hepatocellular carcinomas (HCCs). MATERIALS AND METHODS: A total of 64 nodules in 64 patients, 22 well differentiated and 42 moderately differentiated with a histologically proven HCC, smaller than 3.0 cm in diameter and who had undergone hepatectomy were consecutively examined by contrast-enhanced US using a galactose-based contrast agent. Perfusion images were acquired by intermittent high-intensity, harmonic power Doppler sonography using a high pulse-repetition frequency and high-pass filter setting. Perfusion images of the arterial and late phases were classified into several patterns and compared with the histologic findings obtained from resected specimens. RESULTS: Most of the well- and moderately differentiated resected HCCs showed hyperechoic change during the arterial phase. However, 13 (59%) of the well-differentiated HCCs showed isoechoic change and 27 (64%) of the moderately differentiated HCCs showed hypoechoic change during the late phase. The difference is statistically significant (P < 0.0001). In a comparison of microscopic portal invasion (vp) of HCCs using enhanced US patterns, both vp(-) and vp(+) groups showed a high incidence of the hypervascular pattern during the arterial phase; in contrast, during the late phase 11 (73%) of 15 vp(+) nodules showed hypoechoic change with spotty signals. This difference is statistically significant (P < 0.0001) when compared with a high incidence (52%) of signal defect in the vp(-) group. The existence of well-differentiated components associated with the periphery of moderately differentiated HCCs also correlated closely with patterns during the late phase (P < 0.01). CONCLUSIONS: Late-phase contrast-enhanced US images of small HCCs with a galactose-based contrast agent are useful for predicting specific histologic characteristics.

Evaluation of portal vascular resistance using an intraoperative Doppler ultrasound.

BACKGROUND/AIMS: To evaluate portal vascular resistance using Doppler ultrasound intraoperatively. METHODOLOGY: We measured maximum flow velocities and pressures of umbilical portion of the left portal branch before and after clamping of the right main branch of the Glisson's sheath. We proposed a new index, simplified portal resistive index, that was the ratio of the difference of the portal venous pressure to the difference of maximum portal flow velocity. RESULTS: There were good correlations between portal vascular resistance and simplified portal resistive index. Simplified portal resistive index was found to become higher as fibrotic changes progressed, and there were significant differences between normal liver, chronic hepatitis, and liver cirrhosis. CONCLUSIONS: Simplified portal resistive index evaluated using intraoperative Doppler ultrasound is an easy and reliable index for assessing portal vascular resistance during liver surgery.

Frequent impairment of the spindle assembly checkpoint in hepatocellular carcinoma.

BACKGROUND: Chromosomal instability (CI) leading to aneuploidy is one form of genetic instability, a characteristic feature of various types of cancers. Recent work has suggested that CI can be induced by a spindle assembly checkpoint defect. The aim of the current study was to determine the frequency of a defect of the checkpoint in hepatocellular carcinoma (HCC) and to establish whether alterations of genes encoding the checkpoint were associated with CI in HCC. METHODS: Aneuploidy and the function of the spindle assembly checkpoint were examined using DNA flow cytometry and morphologic analysis with microtubule disrupting drugs. To explore the molecular basis, the authors examined the expression and alterations of the mitotic checkpoint gene, BUB1, using Northern hybridization and direct sequencing in 8 HCC cell lines and 50 HCC specimens. Furthermore, the authors examined the alterations of other mitotic checkpoint genes, BUBR1, BUB3, MAD2B, and CDC20, using direct sequencing in HCC cell lines with aneuploidy. RESULTS: An impaired spindle assembly checkpoint was found in five (62.5%) of the eight aneuploid cell lines. Transcriptional expressions of the BUB1 gene appeared in all cell lines. While some polymorphic base changes were noted in BUB1, BUBR1, and CDC20, no mutations responsible for impairment of the mitotic checkpoint were found in either the HCC cell lines or HCC specimens, which suggests that these genes did not seem to be involved in tumor development in HCC. CONCLUSIONS: The loss of spindle assembly checkpoint occurred with a high frequency in HCC with CI. However, other mechanisms might also contribute to CI in HCC.