Colonic intussusception caused by anisakiasis: a case report and review of the literature.

A 67-year-old woman presented with periumbilical pain. Contrast-enhanced computed tomography findings indicated intussusception of the ascending colon without ischemia or necrosis, and we performed successful colonoscopy to treat the condition. Furthermore, an edematous area caused by anisakis was detected in the ascending colon and the anisakis was removed. The patient noted that she had eaten raw fish one day before the symptoms developed. Although colonic intussusception caused by anisakiasis is extremely rare, colonoscopy should be performed in colonic intussusception patients suspected of having anisakiasis in order to avoid invasive resection.

Huge pancreatic acinar cell carcinoma with high levels of AFP and fucosylated AFP (AFP-L3).

A 25-year-old Japanese woman with a large abdominal tumor (10 cm in diameter) and high level of serum alpha-fetoprotein (AFP, 1,222.4 ng/mL) was introduced and admitted to our hospital in January 2011. Pre-operative imaging modalities could not identify the tumor origin. There was no chronic hepatic viral disease, however, the elevated level of fucosylated AFP (87.8%) and connection with the left hepatic lobe led us to diagnose the tumor as a hepatocellular carcinoma. Surgical resection was performed in February. Histological findings revealed a pancreatic acinar cell carcinoma (ACC). Herein, we provide details of this difficulty to diagnose a case of ACC.

An adult patient with acute infection with hepatitis B virus genotype C that progressed to chronic infection.

In 2008, a 28-year-old woman consulted our hospital due to general fatigue. Her ALT level was within normal range but she was positive for hepatitis B surface antigen (HBsAg). Her ALT level was nearly within normal range thereafter and she was consistently positive for HBeAg. Later, it was proven that she was negative for HBsAg in 1999. She had been a sex worker in 2007-2008. Complete genome sequencing revealed that her HBV was genotype C. The present case may indicate that it is possible for acute infection with HBV genotype C to progress to chronic infection in adults.

Recent trends of Japanese hepatocellular carcinoma due to HCV in aging society.

BACKGROUND/AIMS: The mean age of hepatocellular carcinoma (HCC) patients has increased (=65 years old). We want to identify the recent trend of the clinical features of HCC patients due to hepatitis C virus (HCV) (HCV-HCC). METHODOLOGY: From 2000 to 2009, 855 naive HCC patients were admitted. HCV-HCC patients were divided into two groups, first period group (2000-04, n=270) and second period group (2005-09, n=343) and the clinical features of HCV-HCC were investigated. RESULTS: There was no difference in gender, TNM stage and percentages of HCV-HCC between the periods. On the other hand, the ratio of HCV-HCC patients with worse liver function (Child-Pugh B or C), elderly (=75 years old) and the population of patients treated with low invasive radiofrequency ablation were increased (30.0% to 42.0%, 17.2% to 35.8% and 25.1% to 36.2%, respectively; p<0.01). The 1y-, 3y- and 5y-survival rate of HCV-HCC did not show differences (82.1%, 60.5% and 44.7% vs. 81.8%, 56.9% and 37.7%, respectively; p=0.219). CONCLUSIONS: The ratio of aged HCV-HCC as well as HCV-HCC patients with worse liver function was increased. The less invasive treatment for HCC in these patients and the quick anti-viral treatment for HCV patients should be considered to avoid occurrence of HCC in Japan.

Hepatic resection assisted by ablative therapy for advanced hepatocellular carcinoma.

BACKGROUND/AIMS: We attempted combinations of resection and ablative therapies (ethanol injection (EI) or radiofrequency therapy (RFA)) in hepatocellular carcinoma (HCC) patients. METHODOLOGY: Thirty-one patients with naive HCC treated from January 2000 to June 2010 were enrolled. All were tumor node metastasis stage III and the number of tumors was countable (< or = 5). Twelve were treated with resection assisted with an ablative therapy (combination group) and 19 with resection only (resection group). Clinical backgrounds and prognosis were investigated. RESULTS: The total scores for up-to-seven criteria were larger in the combination group than in the resection group (p=0.01), while other clinical background findings were not significantly different between the groups. In the combination group, 10 cases underwent resection combined with RFA and 2 with EI. The 1- and 3-year survival rates were not significantly different between the groups (combination group, 88.2% and 88.2%, respectively; resection group, 90.9% and 80.8%, respectively). There were no severe complications. CONCLUSION: Our results indicate that combination therapy is a therapeutic option for cases with countable HCCs who are difficult to treat by resection only.

Hepatocellular carcinoma in a case of Wilson's disease treated with radiofrequency ablation therapy.

A 37-year-old Japanese man was diagnosed with liver cirrhosis due to Wilson's disease in 2001 and treated with D-penicillamine. Thereafter, he was admitted to our hospital for further examination of a space occupying lesion in the liver. The patient was diagnosed with hepatocellular carcinoma (HCC) (7th segment, 2.5 cm in diameter) in May 2010 and treated with radiofrequency ablation therapy. Biopsy findings from a non-cancerous area revealed a fatty liver, though cirrhotic nodules were not found. Long-term treatment for Wilson's disease may improve hepatic fibrosis, and careful screening for HCC by abdominal imaging is needed in such cases.

Severe hypoglycemia associated with insulin-like growth factor II-producing liver metastasis from gastric carcinoma treated with overnight total parenteral nutrition via a central vein catheter reserve port.

Hypoglycemia caused by insulin-like growth factor II is difficult to control. A 77-year-old woman was diagnosed with gastric cancer and multiple liver metastases in September 2006 and underwent chemotherapy; however, at that time there were no symptoms of hypoglycemia. From January 2007 onwards, hypoglycemic comas and symptoms of hypoglycemia began to appear frequently. Her serum level of insulin was normal; thus, we suspected the presence of big insulin-like growth factor II was causing the hypoglycemia. This was proven by Western immunoblotting and we diagnosed non-islet cell tumor hypoglycemia associated with gastric cancer. Overnight nutrition provided via a central venous catheter port to prevent hypoglycemia allowed the patient to become ambulant and to remain free of hypoglycemic coma at follow-up until her death 7 months later.

Malignant pheochromocytoma with liver metastasis treated by transcatheter arterial chemo-embolization (TACE).

Multiple liver metastatic lesions were shown by computed tomography and scintigraphy with 123I- metaiodobenzylguanidine (MIBG) in a 76-year-old woman 2 years after resection of a pheochromocytoma of the right adrenal gland. Transcatheter arterial chemo-embolization (TACE) was performed for the liver metastasis, with blood pressure strictly controlled by administration of doxazosin and phentolamine for the prevention of hypertensive crisis after TACE. There were no severe adverse events associated with the treatment, and the number and size of the lesions were decreased. TACE with strict blood pressure control was an effective and safe therapy for multiple liver metastatic lesions related to malignant pheochromocytoma.

Clinical translation in the treatment of hepatocellular carcinoma following the introduction of contrast-enhanced ultrasonography with Sonazoid.

Some hepatocellular carcinoma (HCC) nodules are detectable with dynamic computed tomography, but not by conventional B-mode ultrasonography (US). Contrast-enhanced US (CEUS) with Sonazoid, a new injectable contrast agent, has been used in Japan since January 2007. The primary advantage of this agent is the ability to maintain observations continuously in the Kupffer phase. We assessed the clinical role of CEUS with Sonazoid for radiofrequency ablation (RFA). From January 2005 to December 2008, 1142 patients were treated with surgical resection, RFA, percutaneous ethanol injection or transcatheter arterial chemoembolization, following the exclusion of those patients treated with chemotherapy or supportive care. The patients included in the study were divided into the pre-CEUS (n=451, 2005 and 2006) and post-CEUS (n=691, 2007 and 2008) groups. Clinical background (e.g., etiology, Child-Pugh classification, tumor node metastasis stage, percentage of patients matched with Milan criteria and selected therapies) was compared between the two groups. In addition, naïve cases were compared between the groups. There were 130 naïve HCC cases in the pre-CEUS group and 171 in the post-CEUS group. Although there were no significant differences for clinical background, the percentage of RFA cases increased from 21 (n=95) to 32% (n=219) and from 32 (n=41) to 52% (n=89) for total and naïve subjects, respectively, after CEUS was introduced (P<0.01). In naïve cases treated with RFA, tumor numbers in the post-CEUS group were larger than those of the pre-CEUS group (1.15±0.48 vs. 1.40±0.67; P<0.01). CEUS with Sonazoid, therefore, makes it possible to perform RFA in a considerable number of HCC cases that would otherwise be invisible by conventional B-mode US.

Diagnostic value of sonazoid for hepatic metastasis: comparison with FDG PET/CT.

BACKGROUND/AIMS: This study was conducted to evaluate the diagnostic efficacy of contrast enhanced ultrasonography (CEUS) with perflubutane (Sonazoid) for hepatic metastasis and compared it with that of 18-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) computed tomography (CT). METHODOLOGY: From January 2007 to July 2009, 109 Japanese patients with gastrointestinal tract cancer were enrolled, of whom 4 had esophageal cancer, 28 gastric cancer, 1 duodenal cancer, and 76 colorectal cancer. After a bolus injection with Sonazoid (0.5 ml/body), the liver was scanned in both arterial and Kupffer phases. The results of PET/CT and other abdominal imaging examinations were not shown to the CEUS operators. We compared diagnostic efficacy between CEUS and PET/CT. RESULTS: Average values for age, body mass index, and maximum diameter of the hepatic metastasis were 68.7 +/- 11.0 years, 21.2 +/- 4.2, and 29.2 +/- 20.5mm, respectively. Hepatic metastasis were suspected in 31 patients based on PET/CT findings and 32 by CEUS. Finally, hepatic metastasis was diagnosed in 30 patients. The sensitivity, specificity, and accuracy rates for CEUS and PET/CT were similar (100% vs. 100%, 97.5% vs. 98.7%, and 95.5% vs. 93.6%, respectively). CONCLUSION: CEUS had a diagnostic value similar to that of PET/CT for hepatic metastasis.

Brain metastasis from hepatocellular carcinoma treated with a cyber-knife.

A 70-year-old right-handed Japanese man who had undergone surgical resection for hepatocellular carcinoma (HCC) 2 years earlier was diagnosed with lung metastasis 3 months before consulting our hospital with a headache and visual field disturbance. Head computed tomography revealed a brain tumor with an intracerebral hemorrhage. Using (99m)Tc-PMT (pyridoxal-5-methly-triptophan) scintigraphy, we determined that the brain tumor was metastasis from the HCC and utilized the cyber-knife for treatment. The prognosis of patients with brain metastasis from HCC has been reported to be poor. Use of the cyber-knife was non-invasive, and proved to be effective for improving prognosis and quality of life.