Genomic alterations in ovarian endometriosis and subsequently diagnosed ovarian carcinoma.

STUDY QUESTION: Can the alleged association between ovarian endometriosis and ovarian carcinoma be substantiated by genetic analysis of endometriosis diagnosed prior to the onset of the carcinoma? SUMMARY ANSWER: The data suggest that ovarian carcinoma does not originate from ovarian endometriosis with a cancer-like genetic profile; however, a common precursor is probable. WHAT IS KNOWN ALREADY: Endometriosis has been implicated as a precursor of ovarian carcinoma based on epidemiologic studies and the discovery of common driver mutations in synchronous disease at the time of surgery. Endometrioid ovarian carcinoma and clear cell ovarian carcinoma are the most common endometriosis-associated ovarian carcinomas (EAOCs). STUDY DESIGN, SIZE, DURATION: The pathology biobanks of two university hospitals in Sweden were scrutinized to identify women with surgically removed endometrioma who subsequently developed ovarian carcinoma (1998-2016). Only 45 archival cases with EAOC and previous endometriosis were identified and after a careful pathology review, 25 cases were excluded due to reclassification into non-EAOC (n = 9) or because ovarian endometriosis could not be confirmed (n = 16). Further cases were excluded due to insufficient endometriosis tissue or poor DNA quality in either the endometriosis, carcinoma, or normal tissue (n = 9). Finally 11 cases had satisfactory DNA from all three locations and were eligible for further analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS: Epithelial cells were collected from formalin-fixed and paraffin-embedded (FFPE) sections by laser capture microdissection (endometrioma n = 11) or macrodissection (carcinoma n = 11) and DNA was extracted. Normal tissue from FFPE sections (n = 5) or blood samples collected at cancer diagnosis (n = 6) were used as the germline controls for each included patient. Whole-exome sequencing was performed (n = 33 samples). Somatic variants (single-nucleotide variants, indels, and copy number alterations) were characterized, and mutational signatures and kataegis were assessed. Microsatellite instability and mismatch repair status were confirmed with PCR and immunohistochemistry, respectively. MAIN RESULTS AND THE ROLE OF CHANCE: The median age for endometriosis surgery was 42 years, and 54 years for the subsequent ovarian carcinoma diagnosis. The median time between the endometriosis and ovarian carcinoma was 10 (7-30) years. The data showed that all paired samples harbored one or more shared somatic mutations. Non-silent mutations in cancer-associated genes were frequent in endometriosis; however, the same mutations were never observed in subsequent carcinomas. The degree of clonal dominance, demonstrated by variant allele frequency, showed a positive correlation with the time to cancer diagnosis (Spearman's rho 0.853, P < 0.001). Mutations in genes associated with immune escape were the most conserved between paired samples, and regions harboring these genes were frequently affected by copy number alterations in both sample types. Mutational burdens and mutation signatures suggested faulty DNA repair mechanisms in all cases. LARGE SCALE DATA: Datasets are available in the supplementary tables. LIMITATIONS, REASONS FOR CAUTION: Even though we located several thousands of surgically removed endometriomas between 1998 and 2016, only 45 paired samples were identified and even fewer, 11 cases, were eligible for sequencing. The observed high level of intra- and inter-heterogeneity in both groups (endometrioma and carcinoma) argues for further studies of the alleged genetic association. WIDER IMPLICATIONS OF THE FINDINGS: The observation of shared somatic mutations in all paired samples supports a common cellular origin for ovarian endometriosis and ovarian carcinoma. However, contradicting previous conclusions, our data suggest that cancer-associated mutations in endometriosis years prior to the carcinoma were not directly associated with the malignant transformation. Rather, a resilient ovarian endometriosis may delay tumorigenesis. Furthermore, the data indicate that genetic alterations affecting the immune response are early and significant events. STUDY FUNDING/COMPETING INTEREST(S): The present work has been funded by the Sjöberg Foundation (2021-01145 to K.S.; 2022-01-11:4 to A.S.), Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (965552 to K.S.; 40615 to I.H.; 965065 to A.S.), Swedish Cancer Society (21-1848 to K.S.; 21-1684 to I.H.; 22-2080 to A.S.), BioCARE-A Strategic Research Area at Lund University (I.H. and S.W.-F.), Mrs Berta Kamprad's Cancer Foundation (FBKS-2019-28, I.H.), Cancer and Allergy Foundation (10381, I.H.), Region Västra Götaland (A.S.), Sweden's Innovation Agency (2020-04141, A.S.), Swedish Research Council (2021-01008, A.S.), Roche in collaboration with the Swedish Society of Gynecological Oncology (S.W.-F.), Assar Gabrielsson Foundation (FB19-86, C.M.), and the Lena Wäpplings Foundation (C.M.). A.S. declares stock ownership and is also a board member in Tulebovaasta, SiMSen Diagnostics, and Iscaff Pharma. A.S. has also received travel support from EMBL, Precision Medicine Forum, SLAS, and bioMCC. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The Impact of COVID-19 Pandemic: Daily Work Stress and Work Performance between Work from Home (WFH), Work from Office (WFO) and Hybrid in Indonesia.

INTRODUCTION: The purpose of this research aimed to investigate the difference between daily work stress and work performance in respondents who work from home (WFH), office (WFO), or vice versa on a scheduled basis during the pandemic COVID-19 period. MATERIALS AND METHODS: A total of 400 respondents were recruited, from all over the province in Indonesia. Instruments utilized were structured questionnaires including a demographic questionnaire, work performance scale (WPS), daily work stress scale. The design used was cross-sectional with a nonprobability sampling method and the data analysis with Chi-Square. The respondents were 400 respondents. RESULTS: Shows that both respondents who had high, moderate, and low-stress levels on work from home (p>0.001), work from office (p>0.001), and Hybrid (p>0.001). Respondents also had good work performance with all varied work methods. CONCLUSIONS: Based on this research, each worker has more varied work stress, even though they still carry out their jobs well, and have good performance.

[Intestinal tuberculosis: Easier overlooked than diagnosed]. / Darmtuberkulose: leichter zu übersehen als zu sichern.

Intestinal tuberculosis: Easier overlooked than diagnosed. The medical history of two Asian immigrants suffering from intestinal tuberculosis demonstrates the difficulties in finding the correct diagnosis. Intestinal tuberculosis resembles Crohn's disease with regard to clinical symptoms, macroscopic and microscopic intestinal findings. Sonographic, radiologic, endoscopic, and histological examinations facilitate distinguishing both entities. Diagnosis of intestinal tuberculosis is made by identification of the causative microorganism in tissue specimens. As this may be difficult and time-consuming, a therapeutic trial with anti-tuberculous agents may be warranted.

Autoimmune hepatitis associated with coagulation disorders and immunethyreopathy.

We present the case of a 42-year-old female patient with the diagnoses of autoimmune hepatitis type I and autoimmune thyroiditis. Furthermore this patient had an unusual combination of coagulation disorders with homozygous Factor V Leiden mutation (APC resistance) and presence of antiphospholipid antibodies, leading to deep vein thromboses and miscarriages. Only few cases with the combination of autoimmune hepatitis and antiphospholipid antibodies have been described and almost all of them had become symptomatic with the antiphospholipid syndrome. As both autoimmune phenomenons furthermore share similar HLA-patterns, their coincidence is probably not as uncommon as the limited number of case reports suggests. Therefore attention in patients with autoimmune hepatitis should be focused on thrombophilia.

Surgical removal of a distinct subcutaneous metastasis of multilocular hepatocellular carcinoma 2 months after initial percutaneous ethanol injection therapy.

Subcutaneous tumor seeding after percutaneous ethanol injection therapy (PEI) for hepatocellular carcinoma is a rarely seen complication. It is reported due to needle track seeding during PEI after a distance of 6-46 months. Metastatic tumor spread is described subcutaneously, to the chest wall, abdominal wall and diaphragm. We report the case of a 76-year-old patient with chronic hepatitis B infection and cirrhosis which let to a multilocular hepatocellular carcinoma who underwent PEI. This patient developed 2 months after primary PEI a subcutaneous tumor formation confined to the right lower chest wall. Surgical tumor resection was performed. The histopathological evaluation confirmed subcutaneous seeding of the preknown hepatocellular carcinoma with a maximum of 30 mm in diameter. As a risk of PEI subcutaneous metastasis of the primary tumor should be considered even in early stage of therapy and close follow-up of the patient during treatment is required. Surgical tumor resection to ensure the curative intention of PEI is advisable.

Hepatitis C and the leptin system: bound leptin levels are elevated in patients with hepatitis C and decrease during antiviral therapy.

BACKGROUND: Serum leptin levels are elevated in alcoholic liver cirrhosis and thus might be involved in the anorexia and hypermetabolism often seen in those patients. We hypothesized that the leptin system is modulated in patients with hepatitis C and might be affected by antiviral therapy. The aim of this study was to investigate the different leptin components in serum of patients with hepatitis C before, during and after interferon alpha and ribavirin therapy and in controls. METHODS: 25 patients (11 female, 14 male) with chronic hepatitis C were compared with body mass index, gender and age-matched controls (n = 25). Patients were treated with interferon alpha alone (3 MU tiw) or in combination with ribavirin for 6-12 months. Free leptin and bound leptin levels were measured using specific radioimmunoassays before interferon therapy, at 12 weeks of therapy and after 3 months of follow-up. RESULTS: Free leptin levels were higher in female than in male subjects, both for patients (P < 0.01) and controls (P < 0.05). Bound leptin levels were elevated in both female (P < 0.05) and male (P < 0.001) patients compared to controls. No alteration of free leptin levels was found during therapy, whereas bound leptin levels decreased after 3 months of therapy (P < 0.005) and re-increased to the baseline levels 3 months after therapy was stopped. Responder but not non-responder had decreased bound leptin levels (P < 0.01) comparing pre- and posttreatment levels. However, no significant correlations were determined between any of the leptin components to virus load, ALT, TNF alpha receptor levels (sTNFR-75, sTNFR-55) and histopathology at any time point. CONCLUSION: Since no correlation was found between the different leptin components and any of the inflammatory markers, the decrease in bound leptin levels during antiviral therapy suggests either a direct interferon-dependent effect on the leptin system or an alteration of other leptin secretagogues.

[Follow-up of differentiated thyroid cancer patients using rhTSH--preliminary results]. / Nachsorge des differenzierten Schilddrüsenkarzinoms unter Verwendung von rhTSH--vorläufige Ergebnisse.

AIM: In the follow-up of patients with advanced stage thyroid cancer radioiodine scintigraphy, F-18-FDG PET and tumormarker hTg using stimulation with recombinant human TSH (rhTSH) were compared to the results of same diagnostic procedures during TSH-suppression or endogenous TSH-stimulation. METHODS: 30 patients were investigated in hypothyroidism and after application of rhTSH regarding the serum hormone concentrations, hTg, radioiodine scans and FGD-PET scans. RESULTS: Radioiodine avidity and FDG uptake were significantly higher in 7/30 and 3/5 patients, respectively, compared to endogenous stimulation or TSH-suppression. In about one third of patients hTg increased more than 30%. CONCLUSION: Our preliminary results indicate a sufficient feasibility and sensitivity of rhTSH not only in the follow-up by hTg and radioiodine scan but also in FDG-PET.

Outcome after radioiodine therapy in 107 patients with differentiated thyroid carcinoma and initial bone metastases: side-effects and influence of age.

Initial bone metastases in patients with differentiated thyroid carcinoma are rare, especially in younger patients. Long duration of therapy and high activities of radioiodine are often necessary to induce remission of metastatic disease. The curative potential of radioiodine therapy, in particular in younger patients, has not yet been determined. In this retrospective study we evaluated the therapeutic outcome, total radioiodine activities and associated side-effects in 107 patients with initial bone metastases. Eight of the 107 patients were younger than 45 (37.5+/-7.3) years, and were classified as group 1 (stage II, "low risk", WHO classification). The remaining 99 patients were older than 45 (64.1+/-9.5) years, and formed group 2 (stage IV, "high risk", WHO classification). Total or partial remission was more frequently achieved in group 1 than in group 2 (62.5% vs 49.5%). Lower activities were needed in group 1 (18.89+/-15.08 GBq vs 41.97+/-31.25 GBq), and there were less marked alterations in the blood count in this group. In group 1, blood count alterations reached only grade I or II (WHO classification), whereas grade III and grade IV alterations as well as acute leukaemia were observed in group 2. In group 1, complete remission was achieved with radioiodine therapy (11.1 GBq) in three out of four patients with < or =3 bone metastases. Additional pulmonary metastases (present in 44 out of 107 patients) did not influence prognosis. We conclude that initial bone metastases in differentiated thyroid carcinoma can be treated with curative intent by means of radioiodine therapy, and that this approach has a particularly realistic chance of success in younger patients and those with a small number of metastases.

Elevated bound leptin correlates with energy expenditure in cirrhotics.

BACKGROUND & AIMS: Leptin, found to be elevated in patients with liver cirrhosis, may contribute to the inadequate energy expenditure and malnutrition associated with a negative prognosis for these patients. Our aim was to characterize leptin components and their relationships to body composition, resting energy expenditure (REE), and substrate use in patients with posthepatic liver cirrhosis. METHODS: Using specific radioimmunoassays, we measured free leptin and bound leptin in 27 cirrhotics and 27 matched control subjects. In the cirrhotic group, body composition and REE were determined. RESULTS: Free leptin was not different in cirrhotics and control subjects and was related to body mass index (controls: r = 0.34, P < 0.05; cirrhotics: r = 0.55, P < 0.005) and to fat mass (cirrhotics: r = 0.76, P < 0.0001). Bound leptin was significantly higher in cirrhotic subjects than in controls (P < 0.001) and was related to REE x fat-free mass(-1) (r = 0.57, P < 0.005) or to the difference between measured and estimated REE (r = 0.55, P < 0.005). CONCLUSIONS: Free leptin reflects fat mass in controls and cirrhotics. Increased serum leptin in cirrhotics is a result of increased bound leptin serum concentrations, which are positively related to energy expenditure. Moreover, bound leptin may be a useful marker for inadequate energy expenditure in patients with liver cirrhosis.

Free and bound leptin levels during human pregnancy.

Leptin is a hormone secreted from adipocytes and trophoblasts which might influence energy metabolism during gestation. In this study we evaluated the course of free and bound leptin levels in 22 healthy pregnant women and compared these values to those in non-pregnant women matched for body mass index (BMI) and age. Serum concentrations of both leptin components and plasma levels of estradiol, progesterone, insulin, non-esterified fatty acids and glucose were measured at each trimester. The BMI increased from the first to the second trimester (22.8 +/- 3.1 and 24.7 +/- 2.9, respectively; p < 0.05) and remained stable thereafter (third trimester 25.3 +/- 2.9 kg/m2). Free leptin and bound leptin did not differ between patients and controls in the first trimester of pregnancy. Free leptin levels increased from the first (122 (60)) to the second trimester (181 (60) pmol/l; p < 0.05) and remained constant (third trimester 181 (76) pmol/l; difference between second and third trimesters, NS). Bound leptin increased from the second (0.43 (0.16)) to the third trimester (0.57 (0.21) nmol/l; p < 0.05). Only bound leptin was higher in the patient group in the third trimester compared to controls (p < 0.01). Our findings of a shift in free leptin to bound leptin in late pregnancy may indicate different physiological roles for both components. Free leptin may reflect maternal fat stores, whereas bound leptin may regulate maternal metabolism via central effects on food intake and energy expenditure.

Practicality and accuracy of prehospital rapid venous blood glucose determination.

Blood glucose testing plays an important role in emergency medicine. Although the use of visual reagent test strips is widely established in this setting, the accuracy of reflectometric blood glucose determinations under emergency conditions has rarely been investigated. In a prospective study, 522 of a total of 3,217 patients undergoing emergency blood glucose testing had parallel blood glucose measurements performed using a specific enzymatic method. These 522 patients (aged 61.4 years, 54% men, 90 cases of severe hypoglycemia) had an intravenous access placed at the scene of the emergency. Venous whole blood from the introducer needle of the access was applied to the test strip and the glucose measured with a GlucoTouch reflectometer (LifeScan, Inc.). A blood sample from the intravenous access was then immediately collected in a monovette for subsequent glucose determination in a chemical laboratory (hexokinase method) within 20 to 40 minutes. The emergency glucose measurements (mean: 7.3 mmol/L [95% confidence interval [CI] 6.9 to 7.7]; range: 0.55 to 27.7) correlated well with the reference laboratory results (Pearson's r = .98; linear regression analysis: slope 1.0, axial intercept 1.74). Error grid analysis also showed good agreement between corresponding measurements: zone A 96.7%, B 2.5%, C 0% and D 0.8%. The mean difference using the Bland-Altman method was 0.14 mmoVL; 2 SD 1.8 mmol/L; minimum -7.0 mmol/L; maximum 4.4 mmol/L. The accuracy of the rapid venous blood glucose determination by constantly changing emergency teams was high. Especially in 90 hypoglycemic patients, there were no deviations from the reference method that could have led to clinically relevant wrong decisions. The method of collecting whole blood directly from the venous access is simple and robust, and is independent of the hemodynamic status of the patient.

Expression of leptin and leptin receptor isoforms in the human stomach.

BACKGROUND: Leptin is an important regulator of food intake and energy expenditure. Initially it was thought to be expressed exclusively in and secreted by adipocytes. Recently, leptin expression was also noted in other tissues, including rat gastric mucosa. Information on leptin and leptin receptor expression in the human stomach is lacking. AIM: To investigate expression of leptin and its corresponding receptors in human gastric epithelial cells. METHODS: Fundic and antral gastric mucosal biopsies, primary cultures of human gastric epithelial cells, and the human gastric cancer cell line AGS were screened for expression of leptin and different leptin receptor isoform mRNA by reverse transcriptase-polymerase chain reaction. Immunohistochemistry was performed for localisation of leptin and leptin receptor proteins in gastric mucosa. RESULTS: mRNA of leptin and its four receptor isoforms (huOB-R, long receptor isoform; huB219.1-3, short receptor isoforms) was detected in gastric mucosal biopsies, cultured human gastric epithelial cells, and gastric cancer cells. Immunohistochemistry demonstrated that chief as well as parietal cells were reactive to leptin and leptin receptors. CONCLUSIONS: Leptin and leptin receptors are expressed in human gastric mucosa. These findings suggest a paracrine and/or autocrine effect of leptin on gastric epithelial cell function.

An unusual cause of retrograde ejaculation and hypertension.

A 39-year-old man presented with a 1-year history of retrograde ejaculation and a 10-year history of drug-resistant hypertension. Diagnostic abdominal ultrasound revealed an open bladder neck during the filling phase and a retroperitoneal tumor. After surgical excision histology revealed an extra-adrenal pheochromocytoma, which should be included in the differential diagnosis of patients presenting with retrograde ejaculation and hypertension.

Determinants of within-subject variation of fasting serum leptin concentrations in healthy subjects.

The hormone leptin is considered to contribute to body weight regulation through modulation of feeding behavior and energy expenditure. The aim of the present study was 1) to assess the day-to-day within-subject variation (biovariability) of serum leptin concentrations in healthy subjects and 2) to investigate whether this variation is associated with food intake, exercise, anthropometric measurements or various metabolic covariates (insulin, C-peptide and glucagon, glucose, lactate, 3-hydroxybutyrate (3-OHB), triglycerides, non-esterified-fatty acids and glycerol). Serum leptin levels were taken daily on 12 consecutive days after an overnight fast in 12 healthy subjects with a mean (SD) age of 22.7 (1.5) yr. and a BMI of 22.8 (1.6) kg/m2. Food intake, exercise, anthropometric measurements and various metabolic covariates were also determined during this period. The overall mean of serum leptin concentration was 33.3 pmol/L with a within-subject SD range of 27-41 pmol/L and a between-subject SD range of 18-61 pmol/L. The within-subject variance of serum leptin as a proportion of total variance was 9.5%. Within-subject variation of serum leptin concentrations is small in relation to between-subject variation in healthy, normal weight subjects. This has implications for the power of interventional or prospective studies. In men, 6.7% of the variation in serum leptin concentration was associated with body weight measured on the same day (p= 0.037). In women, however, 66% of the variation was negatively associated with 3-OHB measured on both the same and the previous day (p=0.0003 and 0.002), and positively associated with triglyceride concentration measured on the previous day (p=0.0017) and insulin measured on the same day (p=0.0002). Within-subject associations in women could be due to phasic changes in unmeasured variables, possibly related to the menstrual cycle or might suggest that energy balance may exert a delayed influence on serum leptin levels, with plasma 3-OHB and triglycerides acting as markers for the state of the fat stores that regulate leptin secretion. The differences between the genders remain unexplained, however.

Free serum leptin but not bound leptin concentrations are elevated in patients with end-stage renal disease.

BACKGROUND: Leptin is a 16-kDa protein that is thought to be a regulator of food intake and body weight. Although total serum leptin levels have been reported to be elevated in obese and normal weight patients with end-stage renal disease (ESRD), it is not known whether serum-free leptin concentrations are also increased in patients with ESRD with no apparent nutritional problems. Furthermore, there are no data on how different dialysis modes (high-flux haemodiafiltration and low-flux dialysis) influence serum leptin subfractions. METHODS: We measured fasting serum free and bound leptin levels in three groups of male subjects: patients on haemodiafiltration with high flux dialysers (n=11), patients on haemodialysis with low-flux dialysers (n=17) and healthy age (61+/-8 years) and BMI (23.8+/-3.1 kg/m(2)) matched control subjects (n=28). Both leptin components were determined before and after a single dialysis session. RESULTS: Body mass indices were correlated with serum free leptin levels in both patients (r=0.69, P<0.001) and controls (r=0.77, P<0.001). Mean (SD) serum free leptin levels were significantly higher in ESRD patients than in control subjects (91+/-33 vs 41+/- 21 pmol/l; P<0.01). Bound leptin levels did not differ in both groups (0.67+/-0.12 vs 0.56+/-0.11 nmol/l, NS). Elevated serum-free leptin levels in ESRD patients could be reduced by haemodiafiltration with high-flux membranes, but not with low-flux haemodialysis membranes. The former led to a reduction of initial serum free leptin values to 76+/-17% (P<0.01), whereas bound leptin remained unaffected. CONCLUSION: Serum-free leptin levels are elevated in ESRD without any apparent effect on body weight. In contrast, serum bound leptin levels remain stable, thus central feedback regulation via the bound form of the hormone may serve as an alternative explanation in the regulation of food intake and energy expenditure in chronic patients on haemodialysis with no apparent nutritional problems.

Malignant peritoneal mesothelioma with mimicry of pseudomyxoma peritonei in a patient with a history of perforated sigmadiverticulitis.

We describe a 57-year-old man who presented with diffuse abdominal pain, abdominal enlargement, vomitus, dyspnea and a weight loss of 30 kg within 6 months. These acute symptoms were preceded by an episode of ascites and an acute sigmadiverticulitis 7 months ago. Ultrasonography and computed tomography were suggestive of pseudomyxoma peritonei. However, malignant mesothelioma peritonei was diagnosed by open surgery with biopsy for histological examination. Despite R-2-resection of the tumor and following open hyperthermic intraperitoneal chemotherapy with initial remarkable recovery the patient died 5 months after therapeutical intervention. Malignant peritoneal mesothelioma is an extremely rare tumor with great diagnostic and therapeutic difficulties. We report a case including diagnostical work up and the medical surgical therapy of this disease.

Uncommon metastasis of a glioblastoma multiforme in liver and spleen.

A case of a glioblastoma multiforme is presented. Craniotomy was performed with total resection of the right temporal tumor. Postoperatively, the patient received adjuvant radiotherapy, but 6 months after therapy he developed severe nausea and weight loss. Recurrence of an intracranial tumor in the right temporal region with nodules in the liver and spleen were detected by CT scan. Fine-needle biopsies of the liver confirmed the diagnosis of a glioblastoma metastasis with characteristic immunohistochemical staining for glial fibrillary acidic protein. This rare case of an intracerebral glioblastoma metastasizing to liver and spleen was managed by systemic chemotherapy.

[Sonographic diagnosis of an unusual recurrence of Chilaiditi syndrome after hemicolectomy]. / Sonographische Diagnose eines ungewöhnlichen Rezidivs des Chilaiditi-Syndroms nach Hemikolektomie.

A 71-year old patient presented with acute abdominal pain, nausea and emesis 3 months after right hemicolectomy for Chilaiditi's syndrome. The initial ultrasound examination revealed a loop of thick walled small intestine between the anterior surface of the right liver lobe and the diaphragm. In addition, small amounts of perihepatic fluid were found. The chest x-ray confirmed a recurrence of Chilaiditi's syndrome with intestinal gas under the right diaphragm. Elongation and flaccid of intestinal and hepatic suspensory ligaments are thought to be the principal predisposing factors. However, in our patient, a wedge-shaped enlarged lobus caudatus served as a guide rail for the bowel and facilitated access to the space under the right diaphragm. Although the patient recovered completely after 3 days of conservative therapy a high risk of recurrence remains. In summary, ultrasound examination can reliably diagnose Chilaiditi's syndrome and should also be used, as the method of choice in the follow-up of this rare syndrome, thus avoiding unnecessary x-ray exposure.

Hepatic hemangiosarcoma: imaging findings and differential diagnosis.

Primary hepatic angiosarcoma is a rare mesenchymal tumor of the liver that usually presents with nonspecific symptoms in elderly men. We present four cases of hepatic hemangiosarcoma and discuss the imaging characteristics of this entity. Our series shows that this tumor is not uncommon in younger patients with no associated risk factors such as previous exposure to thorotrast or vinyl chloride. Our experiences on a limited number of patients suggests that the combined use of angiography and dual-phase helical CT provides a better identification of the tumor and its complications. Analysis of imaging studies in patients with hepatic hemangiosarcoma reveals hypervascular lesions. Common complications were portal vein thrombosis, Budd-Chiari syndrome, as well as arterio-venous or arterio-portal shunts. Due to the vascularity of the tumor, percutaneous liver biopsy is hazardous.