Pancreatic Metastases from Renal Cell Carcinoma Showing Atypical Imaging Findings.

A 59-year-old man receiving sunitinib chemotherapy for postoperative recurrence of renal cell carcinoma (RCC) metastases was found to have multiple metastases on contrast-enhanced computed tomography (CECT). CECT revealed a typical hyperdense enhanced nodule in the arterial phase of the stomach and head and tail of the pancreas. However, in the uncinate process of the pancreas, CECT revealed an atypical image and a hypodense enhanced nodule in each phase. Both lesions were finally pathologically diagnosed as clear cell carcinoma. Treatment-modified pancreatic metastases from RCC may present with nonspecific images; therefore, caution is required when deciding on treatment strategies.

The Usefulness and Reliability of Coagrasper for Artery Bleeding during Endoscopic Necrosectomy.

Although endoscopic necrosectomy (EN) is a less invasive therapy for walled-off necrosis (WON), arterial bleeding can occur during EN. A 60-year-old man with infected WON underwent the EN procedure. During EN, the artery in the WON cavity was injured. As the artery was directly visible, we grasped it using a Coagrasper and coagulated the bleeding point. However, the bleeding was aggravated after coagulation owing to an extension of the vessel damage. The entire vessel was grasped, and complete hemostasis was achieved. The Coagrasper is useful for managing arterial bleeding; however, it should be employed only on the basis of its characteristics and in suitable scenarios.

Comparison of 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma using endoscopic ultrasound fine-needle aspiration.

Background/Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) using a 19-gauge needle is an efficient sampling method for the diagnosis of lymphadenopathy. This study compared 19-gauge conventional and Franseen needles for the diagnosis of lymphadenopathy and classification of malignant lymphoma (ML). Methods: Patient characteristics, number of needle passes, puncture route, sensitivity, specificity, and accuracy of cytology/histology for lymphadenopathy were analyzed in patients diagnosed with lymphadenopathy by EUS-FNA using conventional or Franseen needles. Results: Between 2012 and 2022, 146 patients met the inclusion criteria (conventional [n=70] and Franseen [n=76]). The median number of needle passes was significantly lower in the conventional group than in the Franseen group (3 [1-6] vs. 4 [1-6], p=0.023). There were no significant differences in cytological/histological diagnoses between the two groups. For ML, the immunohistochemical evaluation rate, sensitivity of flow cytometry, and cytogenetic assessment were not significantly different in either group. Bleeding adverse events (AEs) were observed in three patients in the Franseen group. Conclusions: Both the 19-gauge conventional and Franseen needles showed high accuracy in lymphadenopathy and ML classification. Considering sufficient tissue collection and the avoidance of AEs, the use of 19-gauge conventional needles seems to be a good option for the diagnosis of lymphadenopathy.

Evaluation of the Cell Block Method Using Overnight-Stored Bile for Malignant Biliary Stricture Diagnosis.

The specimen collection and subsequent pathological diagnosis of malignant biliary stricture (MBS) are difficult. This study aimed to determine whether the cell block (CB) method using overnight-stored bile is useful in the diagnosis of MBS. This trial was a single-arm prospective study involving a total of 59 patients with suspected MBS. The primary endpoint was cancer detectability and accuracy using the CB method, and a comparison with the detectability and accuracy achieved with bile cytology was made. The immunohistochemical sensitivity for maspin and p53 was also investigated in the CB and surgical specimens. We were able to collect bile from all 59 patients, and 45 of these patients were clinically diagnosed with MBS. The cancer detectability using the CB method (62.2%) was significantly higher than that using cytology (37.8%) (p = 0.0344). When CB was combined with biopsy, the rates of cancer detectability (75.6%) and accuracy (81.4%) increased. In eight patients who received surgical therapy, maspin- and p53-immunohistochemistry was applied to the surgical and CB specimens, and cancer cells in both specimens showed positive cytoplasmic and nuclear staining for maspin and nuclear staining for p53. The CB method is, thus, useful for detecting malignancy (UMIN000034707).

Impact of serum chemerin levels on liver functional reserves and platelet counts in patients with hepatocellular carcinoma.

Obesity-related metabolic abnormalities, including adipokine imbalance and chronic inflammation, are involved in liver carcinogenesis. Chemerin, a novel adipokine, plays a critical role in adipogenesis, energy metabolism, and inflammation. We evaluated the impact of serum chemerin levels on liver functional reserves in hepatocellular carcinoma (HCC) patients and on the recurrence and prognosis of HCC. This study included 44 patients with any stage of HCC who underwent curative treatment at Gifu Municipal Hospital (Gifu, Japan) between 2006 and 2007. Recurrence-free survival and overall survival were estimated using the Kaplan-Meier method. Serum albumin levels (Pearson's correlation coefficient; r = 0.3110, p = 0.0399), platelet counts (r = 0.4159, p = 0.0050), and prothrombin times (r = 0.3775, p = 0.0115) were significantly correlated with serum chemerin levels in patients with HCC, and they were inversely correlated with Child-Pugh scores (r = -0.3732, p = 0.0126), serum alanine aminotransferase levels (r = -0.3864, p = 0.0105), and total bilirubin levels (r = -0.4023, p = 0.0068). Among these variables, a multiple comparison test identified that platelet counts and total bilirubin levels were associated with serum chemerin levels (p < 0.0083). No significant correlation was found between serum chemerin levels and recurrence-free survival (p = 0.3691) or overall survival (p = 0.7916). In HCC patients, serum chemerin concentrations were correlated with liver functional reserves and platelet counts, but not with recurrence or prognosis.

Efficacy and safety of radiofrequency ablation for hepatocellular carcinoma in the caudate lobe of the liver.

AIM: Radiofrequency ablation (RFA) is a promising alternative to hepatic resection for the treatment of hepatocellular carcinoma (HCC) located in the caudate lobe. We evaluated the therapeutic efficacy and safety of RFA for HCC located in the caudate lobe compared with HCC located elsewhere in the liver. METHODS: Overall, 555 consecutive patients treated by RFA for a single HCC tumor of less than 3 cm diameter, were enrolled in this study, including 20 patients with HCC located in the caudate lobe. Among these 20 patients, HCC was located in the Spiegel lobe in eight patients, in the paracaval portion in another 10 and in the caudate process in two. We evaluated differences in the local recurrence rate and the incidence of complications associated with RFA between the caudate and the non-caudate groups. RESULTS: The 4-year cumulative local recurrence rate after RFA in the caudate group and the non-caudate group was 22.3% and 4.5%, respectively (P < 0.001). Multivariate analysis of factors affecting local recurrence demonstrated that tumor size and tumor location (caudate or non-caudate) were independent significant factors. No postoperative complications were observed in the caudate group, whereas 15 patients (2.8%) in the non-caudate group experienced complications related to RFA. CONCLUSION: We were able to safely treat HCC located in the caudate lobe by RFA. However, there was a high incidence of local recurrence, presumably because of the heat sink effect of the inferior vena cava and the restricted puncture approach. We should pursue a revised method to reduce local recurrence.

Advantage of IFN-beta/alpha2b same-day administration for ribavirin-intolerant patients with chronic hepatitis C.

AIM: Although interferon (IFN)/ribavirin is the mainstream combination treatment for chronic hepatitis C in patients with a high viral load, ribavirin is problematic for women of childbearing age and patients with anemia. Therefore we needed to establish a new regimen without ribavirin. METHODS: We devised a new regimen (same-day beta/alpha2b) to administer IFN-beta and alpha2b on the same-day, and compared it with IFN-alpha2b alone and IFN-alpha2b plus ribavirin. The cases were 36 patients (26.1%) in whom ribavirin could not be used (young women, anemia, etc.) among 138 patients who underwent IFN treatment after ribavirin release. RESULTS: The percentages of patients withdrawing due to side-effects were 6.8%, 18.8% and 17.0% in the treatment with same-day beta/alpha2b, IFN-alpha2b alone and IFN-alpha2b plus ribavirin groups, respectively. In genotype 1b, the sustained viral response (SVR) was 28.6% (4/14), 13.6% (3/22) and 25.0% (8/32) with a high viral load, and 91.7% (11/12), 27.3% (3/11) and 57.1% (4/7) with a low viral load for the respective groups. According to a study on viral half-life during the early phase of IFN therapy, there was no difference among the regimens of same-day IFN-beta/alpha2b, beta alone, alpha2b alone and twice-daily treatment with IFN-beta. Same-day beta/alpha2b treatment showed a significantly higher SVR rate in moving type patients with a genotype 1b/high viral load. CONCLUSIONS: Same-day beta/alpha2b treatment resulted in few cases where therapy was discontinued and showed a high SVR rate. This regimen is especially appropriate in cases where ribavirin has been deemed unsuitable.

Intraductal chilled saline perfusion to prevent bile duct injury during percutaneous radiofrequency ablation for hepatocellular carcinoma.

BACKGROUND AND AIM: Radiofrequency ablation (RFA) is a promising, minimally invasive treatment for hepatocellular carcinoma (HCC). However, thermal injury sometimes occurs in the bile duct, potentially leading to a critical situation. The aim of the present study was to investigate whether bile duct injury is reduced by an intraductal chilled saline perfusion (ICSP) through a nasobiliary tube during RFA for HCC. PATIENTS AND METHODS: The baseline incidence of bile duct injury at Gifu Municipal Hospital was 3.1% (13 patients) in 424 patients with HCC treated by percutaneous RFA. In all patients, the tumor was within 5 mm of the central bile duct on CT images. The incidence of bile duct injury was 46% among the 28 selected patients whose tumor was close to the central bile duct. To prevent complications in such high-risk patients, we placed a nasobiliary tube endoscopically before RFA, and performed ICSP during RFA. Forty consecutive patients with tumors close to the central bile duct were enrolled in this study. RESULTS: Of the 40 enrolled patients, only one had biliary injury, whereas the remaining 39 patients were able to avoid it. The incidence of biliary injury was significantly reduced in the ICSP group (1/40, 2.5%) compared to that in the control group (13/28, 46%) (P < 0.0001). Moreover, the liver function 6 months after RFA was also better preserved in the ICSP group according to Child-Pugh grading, thus resulting in a better clinical outcome. CONCLUSIONS: ICSP through a nasobiliary tube is a potential intervention method to prevent biliary injury by percutaneous RFA.

Pseudothrombosis with T2-weighted fast spin-echo MR images caused by static portal venous flow in severe cirrhosis.

Unenhanced T2-weighted fast spin-echo images obtained in a 65-year-old woman with severe cirrhosis showed an area of high signal intensity occupying the left second-order portal vein branch, suggesting portal vein thrombosis in cirrhosis. Doppler sonography, which revealed virtually no blood flow in the vessel, also supported the diagnosis. Gadolinium-enhanced MRI subsequently revealed the patency of the vessel. The extremely slow portal venous flow was considered to be the cause of false-positive findings with unenhanced MRI and sonography.