Fatal Hepatitis C after Chemotherapy in a Patient with Malignant Lymphoma: Possible Reactivation of Seronegative Occult Hepatitis C Virus Infection Due to Chemotherapy.

A 79-year-old man with lymphoma who tested negative for anti-hepatitis C virus (HCV) antibody received rituximab-containing chemotherapy. Liver dysfunction of unknown cause had persisted since the second cycle of chemotherapy. Ten months after treatment, he rapidly developed massive ascites and atrophy of the liver, and we detected HCV RNA in his serum using real time polymerase chain reaction. Furthermore, medical interviews showed that the patient had no episodes for acute HCV infection, but he did have a history of unspecified liver dysfunction. These findings support the possibility of the reactivation of seronegative occult HCV infection due to chemotherapy in a cancer patient.

The prognostic role of lactate dehydrogenase serum levels in patients with hepatocellular carcinoma who are treated with sorafenib: the influence of liver fibrosis.

BACKGROUND: Serum lactate dehydrogenase (LDH) levels could be a prognostic factor for sorafenib-treated patients with several types of solid tumor because it reflects hypoxic circumstances in aggressive tumors. For hepatocellular carcinoma (HCC), however, the prognostic role of LDH has been controversial. Liver fibrosis can potentially cause hypoxia in the liver, which has not been previously studied in the patients with advanced HCC. Thus, we aimed to analyze the prognostic role of LDH based on the degree of fibrosis. METHODS: Eighty-nine consecutive patients with HCC (Child-Pugh class A) who were treated using sorafenib were enrolled into this study. Pretreatment characteristics and changes in hepatic functional tests based on early response to sorafenib and serum LDH levels were analyzed. The degree of fibrosis was estimated using the aspartate aminotransferase (AST) to platelet ratio index (APRI), and the tumor response was evaluated after 3 months of sorafenib treatment. RESULTS: Overall, five patients discontinued sorafenib within 4 weeks. For the other 84 patients, those with progressive disease (PD) had significantly high pretreatment LDH levels, which correlated with the APRI score but not with the tumor stage. Multivariate logistic analysis revealed that older age and lower pretreatment LDH levels were independent prognostic factors for a better response to sorafenib. In patients who discontinued sorafenib early, three experienced acute liver failure accompanied with an increase in serum LDH. CONCLUSIONS: We demonstrated that baseline serum LDH levels in HCC patients were affected by liver fibrosis but not by the tumor stage, and these LDH levels could be a marker for early response to sorafenib. A marked increase in serum LDH levels during sorafenib administration might also indicate subsequent acute liver failure. Close observation of serum LDH levels before and during sorafenib treatment could be useful in managing treatment of patients receiving this therapy.

Composite small cell and mucinous carcinoma originating from the intrahepatic bile duct: report of a case.

The biliary tract is a very rare site for the occurrence of extrapulmonary small cell carcinoma. A 68-year-old Japanese female was being followed up for autoimmune hepatitis, and was referred to our hospital because segmental intrahepatic bile duct dilation was found on routine imaging studies, suggesting intrahepatic cholangiocarcinoma. She underwent left lobectomy of the liver and concomitant resection of the caudate lobe. Microscopic examination of the explanted liver showed a primary composite tumor comprising small cell and mucinous carcinomas that originated in the intrahepatic bile duct. Further immunohistochemical studies, including cytokeratin-19 and chromogranin-A staining, showed the two cellular components of the tumor to have similar characteristics. The amphicrine properties indicated that the tumor had a monoclonal origin but with biphenotypic differentiation, which was responsible for the histogenesis of this tumor.

[Estimation of indication for living donor liver transplantation in patients with HCV and/or HBV infection].

We evaluated 78 patients with chronic viral hepatitis for liver transplantation. 51 patients met our original criteria for liver transplantation, and 35 patients of them suffered from hepatocellular carcinoma (HCC). Patients with HCC were significantly older and showed higher prothrombin activity than those without HCC. Eighteen of 35 patients with HCC did not meet the Milan criteria, and they showed lower levels of total bilirubin, Child-Pugh score, and MELD score than those who met the criteria. Theses results indicate that acceptability for transplantation should be evaluated soon after the patients have become candidates for liver transplantation. In Japan, decompensated liver cirrhosis is a necessary condition for the application of public health insurance against liver transplantarion and, in cases with HCC, it is necessary to meet the Milan criteria. Application to liver transplantation should also be considered based on HCC stage such as the UNOS scoring system.

Fertile females with nonalcoholic fatty liver disease (NAFLD) have higher levels of ALT than postmenopausal females: implications for the influence of fertility on NAFLD.

BACKGROUND/AIMS: Insulin resistance recently has been reported to play a major role in nonalcoholic fatty liver disease (NAFLD). We evaluated the influence of fertility on fatty liver injury in fertile and postmenopausal women with insulin resistance. METHODOLOGY: We investigated 152 patients with noninsulin-dependent diabetes mellitus without insulin treatment; 46 males, 52 fertile women and 54 postmenopausal women. All had liver damage and/or steatosis recognized by ultrasonography. We measured the fasting serum levels of C-peptide and insulin, as markers of insulin resistance, and the serum levels of ALT. The severity of liver steatosis was judged by ultrasonography. RESULTS: Fertile females had significantly higher levels of ALT and demonstrated a more significant correlation between serum levels of ALT and C-peptide or insulin than did the postmenopausal females or males. Fertile females with moderate to severe steatosis had significantly higher levels of ALT than those with mild or no steatosis, although such a significant difference was not found in postmenopausal females or males. CONCLUSIONS: We demonstrate that fertility is an important factor in fatty liver damage of NAFLD with insulin resistance, suggesting that estrogen may exacerbate nonalcoholic steatohepatitis.

Decreased portal flow volume increases the area of necrosis caused by radio frequency ablation in pigs.

BACKGROUND/AIMS: Although radio frequency ablation (RFA) has been widely accepted as an effective treatment for hepatocellular carcinoma (HCC), severe complications are not uncommon. Major complications seem to occur as a result of over-ablation beyond the intended area. As most patients with HCC have underlying cirrhosis, we speculated that decreased portal flow might cause the necrosis associated with RFA. To confirm this hypothesis, we examined the area of necrosis resulting from RFA under varying conditions of portal flow in a porcine model. METHODS: RFA was performed using ultrasonographic guidance in anesthetized pigs. During the RFA procedure, portal flow was regulated by a balloon catheter, which was set in a portal trunk. The necrosis area was measured after sacrifice and was compared with the hyperechoic area that appeared during ablation. In another session, RFA was performed close to the hepatic vein and endothelial damage was examined. RESULTS: The necrosis area caused by RFA was significantly larger when the portal flow volume was decreased by 50% or more. The hyperechoic lesion was always larger than the area of pathological necrosis regardless of portal flow volume. Under conditions of decreased portal flow, the vessel endothelium near the ablated area was more readily damaged. CONCLUSION: Decreased portal flow volume resulted in enlargement of the area of necrosis caused by RFA. Our results indicate that over-ablation could easily occur in patients with advanced cirrhosis, and that this could lead to major complications. Ultrasonographic guidance may be helpful for avoiding over-ablation.

Comparison of tissue pressure and ablation time between the LeVeen and cool-tip needle methods.

BACKGROUND: Radio frequency ablation (RFA) has been accepted clinically as a useful local treatment for hepatocellular carcinoma (HCC). However, intrahepatic recurrence after RFA has been reported which might be attributable to increase in intra-tumor pressure during RFA. To reduce the pressure and ablation time, we developed a novel method of RFA, a multi-step method in which a LeVeen needle, an expansion-type electrode, is incrementally and stepwise expanded. We compared the maximal pressure during ablation and the total ablation time among the multi-step method, single-step method (a standard single-step full expansion with a LeVeen needle), and the method with a cool-tip electrode. Finally, we performed a preliminary comparison of the ablation times for these methods in HCC cases. RESULTS: A block of pig liver sealed in a rigid plastic case was used as a model of an HCC tumor with a capsule. The multi-step method with the LeVeen electrode resulted in the lowest pressure as compared with the single-step or cool-tip methods. There was no significant difference in the ablation time between the multi-step and cool-tip ablation methods, although the single-step methods had longer ablation times than the other ablation procedures. In HCC cases, the multi-step method had a significantly shorter ablation time than the single-step or cool-tip methods. CONCLUSION: We demonstrated that the multi-step method was useful to reduce the ablation time and to suppress the increase in pressure. The multi-step method using a LeVeen needle may be a clinically applicable procedure for RFA.

An adult case with Hunter's syndrome presenting prominent hepatic failure: light and electron microscopic features of the liver.

We describe a 40-year-old male patient with Hunter's syndrome. His main manifestations were ascites and esophageal varices due to cirrhotic liver. We obtained hepatic biopsy samples and examined them. Ultrastructurally, the features of the hepatocytes and Kupffer cells were the same as those reported in young patients. The passage of 40 years led to gradual progression to fibrosis, and ultimately liver cirrhosis. Namely, with a longer survival time, the complications of liver cirrhosis become more remarkable. Hepatic fibrosis in Hunter's syndrome is slowly progressive and patients who are expected to have a longer life span should be continuously monitored for hepatic complications.

Arterial steroid injection therapy can inhibit the progression of severe acute hepatic failure toward fulminant liver failure.

AIM: To utilize transcatheter arterial steroid injection therapy (TASIT) via the hepatic artery to reduce hepatic macrophage activity in patients with severe acute hepatic failure. METHODS: Thirty-four patients with severe acute hepatic failure were admitted to our hospital between June 2002 to June 2006 providing for the possibility of liver transplantation (LT). Seventeen patients were treated using traditional liver supportive procedures, and the other 17 patients additionally underwent TASIT with 1000 mg methylprednisolone per day for 3 continuous days. RESULTS: Of the 17 patients who received TASIT, 13 were cured without any complications, 2 died, and 2 underwent LT. Of the 17 patients who did not receive TASIT, 4 were self-limiting, 7 died, and 6 underwent LT. Univariate logistic analysis revealed that ascites, serum albumin, prothrombin time, platelet count, and TASIT were significant variables for predicating the prognosis. Multivariate logistic regression analysis using stepwise variable selection showed that prothrombin time, platelet count, and TASIT were independent predictive factors. CONCLUSION: TASIT might effectively prevent the progression of severe acute hepatic failure to a fatal stage of fulminant liver failure.

Evaluation of liver parenchymal pressure and portal endothelium damage during radio frequency ablation in an in vivo porcine model.

BACKGROUND/AIMS: We previously developed a multi-step, incremental expansion method (multi-step method) for radio frequency ablation (RFA) in vitro, which prevented increases in pressure and reduced the ablation time as compared with other methods. In this study, we evaluated liver parenchymal pressure and portal endothelium damage during RFA with different devices and protocols in an in vivo porcine model. METHOD: Nine healthy female pigs were anaesthetized. RFA was performed with two different devices and protocols; one involved the use of a LeVeen needle with a single-step full expansion method or a multi-step method, and the other used a cool-tip needle with 40 or 60 W power. We measured the pressure in the liver parenchyma and the gallbladder during RFA. We also evaluated portal endothelium damage by NADH staining. RESULTS: The multi-step method with the LeVeen electrode resulted in the lowest parenchymal and intra-gallbladder pressures (multi-step method

Local recurrence is an important prognostic factor of hepatocellular carcinoma.

AIM: To clarify the importance of complete treatment by PEIT. METHODS: A total of 140 previously untreated cases of HCC were enrolled in this study from 1988 to 2002. The inclusion criteria were: a solitary tumor less than 4 cm in diameter or multiple tumors, fewer than four in number and less than 3 cm in diameter, without extrahepatic metastasis or vessel invasion. As general principles for the treatment of HCC, the patients underwent transcatheter arterial chemoembolization (TACE) prior to PEIT. After the initial treatment of the patients, ultrasonography and computed tomography were performed, and measurement of serum levels of alpha-fetoprotein (AFP) was determined. When tumor recurrences were detected, PEIT and/or TACE were repeated whenever the hepatic functional reserve of the patient permitted. We then analyzed the variables that could influence prognosis, including tumor size and number, the serum levels of AFP, the parameters of hepatic function (albumin, bilirubin, ALT, hepaplastin test, platelet number, and indocyanine green retention at 15 min (ICG-R15)), combined therapy with TACE, distant recurrence, and local recurrence. RESULTS: Univariate analysis identified the ICG test, serum levels of AFP and albumin, tumor size and number, and local recurrence, but not distant recurrence, as significant prognostic variables. In multivariate analysis using those five parameters, the ICG test, tumor size, tumor number, and local recurrence were identified as significant prognostic factors. In both univariate and multivariate analyses, the relative risk for the ICG test was the highest, followed by local recurrence. CONCLUSION: We found that local recurrence is an independent prognostic factor of HCC, indicating that achieving complete treatment for HCC on first treatment is important for improving the prognosis of patients with HCC.

Re-evaluation of antitumor effects of combination chemotherapy with interferon-alpha and 5-fluorouracil for advanced hepatocellular carcinoma.

AIM: To evaluate the efficacy of combination chemotherapy with interferon-alpha (IFNalpha) and 5-fluorouracil (5-FU) in patients with advanced hepatocellular carcinoma (HCC). METHODS: Twenty-eight HCC patients in advanced stage were enrolled in the study. They were treated with IFNalpha/5-FU combination chemotherapy. One cycle of therapy lasted for 4 wk. IFNalpha (3 x 10(6) units) was subcutaneously injected thrice weekly on days 1, 3, and 5 for 3 wk, and 5-FU (500 mg/d) was administered via the proper hepatic artery for 5 consecutive days per week for 3 wk. No drugs were administered during the 4(th) wk. The effect of combination chemotherapy was evaluated in each patient after every cycle based on the reduction of tumor volume. RESULTS: After the 1(st) cycle of therapy, 16 patients showed a partial response (PR, 57.1%) but none showed a complete response (CR, 0%). At the end of therapy, the number of patients who showed a CR, PR, or no response (NR) was 1, 10, and 17, respectively. The response rate for therapy (CR+PR) was 21.5%. Biochemical tests before therapy were compared between responsive (CR+PR) and non-responsive (NR) patients, but no significant differences were found for any of the parameters examined, indicating that no reasonable predictors could be identified in our analysis. CONCLUSION: Attempts should be made to discriminate between responders and non-responders by evaluating tumor size after the first cycle of IFNalpha/5-FU combination chemotherapy. For non-responders, therapy should not proceed to the next cycle, and instead, different combination of anticancer drugs should be explored.

Short-term intensive treatment for donors with hepatic steatosis in living-donor liver transplantation.

BACKGROUND: The use of steatotic livers is associated with increased primary nonfunction in liver transplantation. To reduce the risk of liver injury, we applied a short-term combination therapy of diet, exercise and drugs for 11 living-donor liver transplantation (LDLT) candidates with steatosis. METHODS: Subjects were treated with a protein-rich (1000 kcal/day) diet, exercise (600 kcal/day), and bezafibrate (400 mg/day) for 2-8 weeks. RESULTS: The treatment significantly improved macrovesicular steatosis (30+/-4% vs. 12+/-2% [mean +/- SEM], P = 0.0028). Body weight and BMI were significantly reduced (73.7 +/- 3.2 kg vs. 66.9 +/- 2.9 kg, P = 0.0033, 26.4 +/- 0.7 kg/m vs. 24.1 +/- 0.8 kg/m, P = 0.0033). The treatment completely normalized liver function tests and lipid metabolism. Seven treated liver grafts (left lobe) were transplanted to the recipients. We compared transplanted graft function and resected liver function of donors using parameters such as peak total bilirubin, prothrombin time at postoperative day 3, and peak alanine aminotransferase between treated liver (n = 7) and donor liver without hepatic steotosis (n = 37). The transplanted grafts showed good liver functions, and there was no difference between them with respect to functional parameters. The treated donors also showed good liver functions, and no significant differences in functional parameters. CONCLUSIONS: The results of this study indicate that our short-term treatment effectively reduced steatosis and contributed to safer LDLT. Our findings also suggest that even severely steatotic livers can be used for LDLT grafting subsequent to our short-term treatment regimen.

Evaluation of fatty acid metabolism-related gene expression in nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is one of the most frequent causes of abnormal liver dysfunction, and its prevalence has markedly increased; however, the mechanisms involved in the pathogenesis of NAFLD have not been thoroughly investigated in humans. In this study, we evaluated the expression of fatty acid metabolism-related genes in NAFLD. Real-time RT-PCR was performed using liver biopsy samples from 12 NAFLD patients. The target genes studied were: acetyl-CoA carboxylase (ACC) 1, ACC2, and fatty acid synthase (FAS) for the evaluation of de novo fatty acid synthesis; carnitine palmitoyltransferase 1a (CPT1a), long-chain acyl-CoA dehydrogenase (LCAD), and long-chain L-3-hydroxyacyl-coenzyme A dehydrogenase alpha (HADHalpha) for beta-oxidation in the mitochondria; peroxisome proliferator-activated receptor- (PPAR-) alpha and cytochrome P450 2E1 (CYP2E1) for oxidation in peroxisomes and microsomes (endoplasmic reticulum) respectively; and diacylglycerol O-acyltransferase 1 (DGAT1), PPAR-gamma, and hormone sensitive lipase (HSL) for triglyceride synthesis and catalysis. In NAFLD, expression of ACC1 and ACC2, but not FAS was increased, indicating that de novo fatty acid synthesis is enhanced in NAFLD. In contrast, expression of CTP1a, a rate-limiting enzyme, was remarkably decreased, indicating that beta-oxidation in the mitochondria was decreased, although the expression of LCAD and HADHalpha was increased. Expression of PPAR-alpha was increased, whereas that of CYP2E1 was reduced. The expression of DGAT1, PPAR-gamma, and HSL was enhanced. These data suggest that in NAFLD, increased de novo synthesis and decreased beta-oxidation in the mitochondria lead to accumulation of fatty acids in hepatocytes, although the extent of oxidation in peroxisomes and microsomes remains unclear.

[A case of idiopathic portal hypertension complicated with sepsis caused by Aeromonas hydrophila].

A 53 year old man with idiopathic portal hypertension (IPH) was admitted because of high fever and diarrhea. Nineteen years before admission, he had received splenic hilar renal shunt operation with proximal flush ligation of splenic vein due to gastric varices. Three months before admission, he had been admitted to our hospital for evaluation of liver dysfunction. Liver biopsy examination had revealed peri-portal fibrosis consistent with IPH. Aeromonas hydrophila was isolated from blood. Although he was treated with antibiotics plus dopamine, glucose-insulin therapy, and mechanical ventilation, he had severe septic shock, and died 29 days after admission. We have to take notice of A. hydrophila infection in cases of portosystemic shunt because they fall in severe septic shock.

Remote delivery and expression of soluble type II TGF-beta receptor in muscle prevents hepatic fibrosis in rats.

Transforming growth factor-beta (TGF-beta) has been implicated in the process of hepatic fibrosis, and stimulates production of extracellular matrix in hepatic stellate cells, which play a major role in the process. It has been recently reported that blockage of TGF-beta signaling prevents hepatic fibrosis. We evaluated a strategy for anti-TGF-beta gene therapy for hepatic fibrosis by transfecting plasmids expressing an entire extracellular domain of human TGF-beta type II [soluble type II TGF-beta receptor (sTGF-betaIIR)] into skeletal muscle in a rat experimental model of dimethylnitrosamine- (DMN-) induced fibrosis. sTGF-betaIIR treatment decreased significantly the occurrence of DMN-induced hepatic fibrosis, evaluated by computed image analysis and by measurement of hydroxyproline content of the liver, and reduced the expression of collagen and alpha-smooth muscle actin. The treatment also caused a significant decrease in hepatic levels of interleukin- (IL-) 12 (Th1 cytokine) and an increase in those of IL-10 (Th2 cytokine), indicating a change in the Th1/Th2 cytokine balance in the liver. In conclusion, blockade of TGF-beta after intramuscular transfer of the soluble type II TGF-beta receptor gene suppressed hepatic fibrosis, suggesting that this strategy may be useful for gene therapy of hepatic fibrosis.

Lemierre's syndrome: Porphyromonas asaccharolytica as a putative pathogen.

A case of Lemierre's syndrome is reported in which metastatic abscesses resulted from septic thrombophlebitis of the internal jugular vein secondary to bacterial pharyngitis. A 32-year-old male suffering from a painful left-sided neck mass, sore throat, and fever was admitted to our hospital. Computed tomography revealed thrombosis of the left internal jugular vein, septic pulmonary emboli, and a liver abscess. Blood culture showed Porphyromonas asaccharolytica. Although empyema occurred transiently during the treatment, the patient recovered following prolonged antimicrobial therapy. Although Fusobacterium species are a well-known cause of Lemierre's syndrome, cases in whom Porphyromonas species was isolated have scarcely been reported. Moreover, case reports from Japan have been few.

A multi-step, incremental expansion method for radio frequency ablation: optimization of the procedure to prevent increases in intra-tumor pressure and to reduce the ablation time.

BACKGROUND/AIMS: Radio frequency ablation (RFA) has been accepted clinically as a useful local treatment for hepatocellular carcinoma (HCC). However, intra-hepatic recurrence after RFA has been reported. We initially hypothesized that recurrence was attributable to increases in intra-tumor pressure during RFA, and we subsequently measured the pressure and optimized the procedure. METHODS: A block of pig liver sealed in a rigid plastic case was used as a model of an HCC tumor with a capsule. We compared the pressure between a single-step full expansion of the needle (single-step method) and incremental, stepwise expansion (multi-step method), and evaluated the effect of varying the electrical power. Finally, we performed a preliminary comparison of the ablation times for these methods in HCC cases. RESULTS: The multi-step method resulted in a significantly lower pressure and shorter total ablation time than the single-step method. Furthermore, incremental expansion in 10 steps resulted in a lower pressure and shorter ablation time than four steps. Seventy W-ablation resulted in a lower pressure and shorter time than 30- or 50 W-ablation. In HCC cases, the multiple-step method had a significantly shorter ablation time than the single-step method. CONCLUSION: The multi-step method can be recommended to reduce the ablation time, and suppress the increase in pressure.

Effect of IL-4 and IL-13 on collagen production in cultured LI90 human hepatic stellate cells.

BACKGROUND: Recently, it has been reported that interleukin 4 (IL-4) and 13 (IL-13) directly activate fibroblasts and promote fibrosis. In the process of hepatic fibrosis, the effects of these cytokines on hepatic stellate cells (HSCs) are not well known. METHODS: We evaluated the effects of IL-4 and IL-13 on the collagen production and the proliferation of LI90, a hepatic stellate cell line. We also examined whether interferon (IFN) interferes with the expression of collagen, since IFN has been reported to clinically suppress hepatic fibrosis. RESULTS: The receptor complex for IL-4 and IL-13 was IL-4Ralpha/IL-13Ralpha1 on LI90 cells, and the phosphorylation of Stat6 was induced by IL-4 and IL-13. The treatment of LI90 cells with IL-4 or IL-13 increased the production of collagen I protein levels by nearly three times in comparison with untreated cells. Collagen mRNA levels were increased roughly 10-fold by IL-4 and 100-fold by IL-13. Interestingly, BrdU incorporation in LI90 cells was decreased by IL-4 or IL-13 treatment. Furthermore, induction of collagen I production by these cytokines was blocked by IFNalpha or IFNbeta treatment, although neither treatment alone suppressed collagen production. CONCLUSIONS: Our data suggested that IL-4 and IL-13 directly affected HSCs by increasing collagen production and suppressing cell proliferation. The anti-fibrogenetic effect of IFN may be due in part to the blockade of IL-4 and IL-13 stimulation of HSCs.

Scattered and rapid intrahepatic recurrences after radio frequency ablation for hepatocellular carcinoma.

AIM: To evaluate a series of patients with hepatocellular carcinoma (HCC) treated with several different protocols and devices. METHODS: We treated 138 patients [chronic hepatitis/liver cirrhosis (Child-Pugh A/B/C), 3/135 (107/25/3)] with two different devices and protocols: cool-tip needle [initial ablation at 60 W (standard method) (n=37) or at 40 W (modified method) (n=28)] or; ablation with a LeVeen needle using a standard single-step, full expansion (single-step) method (n=39) or a multi-step, incremental expansion (multi-step) method. RESULTS: Eleven patients experienced rapid and scattered recurrences 1 to 7 mo after the ablation. Nine patients were treated by the cool-tip original protocol (60 W) (9/37=24%) and the other two by the LeVeen single-step method (2/39=5%). The location of the recurrence was surrounding and limited to the site of ablation segment in three cases, and spread over one lobule or both lobules in the other eight cases. There was no recurrence in the patients treated with the modified cool-tip modified method (40 W) or the LeVeen multi-step method. CONCLUSION: There is a risk of rapid and scattered recurrence after RFA, especially when the standard cool-tip procedure is used. Because such recurrence would worsen the prognosis, we recommend that modified protocols for the cool-tip and LeVeen needle methods should be used in clinical practice.