Tumors of the ampulla of Vater treated by local resection: a report of five cases.

The clinical features, diagnostic work-up and difficulties in establishing a diagnosis on endoscopic biopsy specimens were retrospectively analysed in five patients with ampullary tumors. In addition, the technique of local papillary resection is reported. Indications for local resection are: elderly patients with severe co-existing diseases, patients with benign ampullary tumors which are either adenomatous or show epithelial dysplasia or patients with inconclusive preoperative endoscopic biopsy or peroperative frozen sections.

The incidence, multiple presentation and recurrence of aggressive cysts of the jaws.

The incidence, multiple presentation and recurrence rate of aggressive cysts of the jaws is discussed, based on a study of 677 cysts in 651 patients. Cysts that are considered aggressive include: cysts in which carcinoma develops, unicystic ameloblastoma, keratocysts and calcifying odontogenic cysts. Based on literature studies and on our own material, the incidence and multiplicity of these lesions is calculated. Recommendations for treatment include careful preoperative assessment and treatment of suspicious lesions with excision of the overlying mucosa and fixation of the defect with Carnoy's solution. The cyst in which carcinoma develops should be treated as a true malignancy i.e. by resection. Long term follow-up is necessary to eliminate the possibility of recurrence.

A protocol for the treatment of hypertrophic scars and keloids.

Hypertrophic scars and keloids still present problems in both white and pigmented skin. A treatment protocol is proposed: Hypertrophic scars are primarily treated with intralesional injections of corticosteroids or with compression therapy. Surgical scar revision is only secondarily indicated. Recurrent and resistant hypertrophic scars are surgically excised and postoperatively irradiated (twice with 400-cGy 7-MeV electron irradiation).

Glafenine-associated hepatic injury. Analysis of 38 cases and review of the literature.

Glafenine was associated with hepatic injury in 38 cases. The causal relationship was assessed on the basis of the temporal relationship with drug use, course and exclusion of other causes. In 27 cases a causal relationship was considered likely, i.e. 'probable' (12 cases) or 'possible' (15 cases), whereas in 11 cases it was either unlikely or unclassifiable. In both the 'probable' and 'possible' groups 60-70% of individuals were women. Jaundice was present in three-quarters of cases in both groups. Eosinophilia was more frequent in the group of 'probable' cases, and this group had the highest case-fatality rate (42%). Onset varied from 2 days (after a rechallenge) to 8 months, but most cases appeared between 2 weeks and 4 months after starting therapy. Histology in 22 cases showed a predominantly hepatocellular pattern, varying from spotty panlobular necrosis, centrilobular and (sub)massive necrosis (acute pattern) to fibrosis and cirrhosis (chronic pattern). The chemical structure of glafenine and the clinicopathological pattern it induces resemble that of cinchophen. The incidence is unknown. Either metabolic idiosyncrasy or an immunoallergic mechanism seems to be responsible.

Ketoconazole-associated hepatic injury. A clinicopathological study of 55 cases.

Fifty-five cases of ketoconazole-associated hepatic injury, reported to the Netherlands Centre for Monitoring of Adverse Reactions to Drugs, were analysed in detail. In 50 cases a causal relationship was considered likely, i.e. 'probable' (27 cases) or 'possible' (23 cases). Eighty-four % of individuals were women. Forty-six % of patients were over 50 years of age which suggests that, considering the lower prescription rate in this age group, the elderly are more vulnerable to ketoconazole. In 60% of all cases hepatic injury appeared within the first 6 weeks of therapy but in the group of 'probable'-cases the onset was mostly later. Jaundice was present in 44% of all cases but in 63% of the group of 'probable'-cases. Eosinophilia (10%), fever (6%) and rash (2%) were uncommon. Biochemically the pattern was hepatocellular in 54%, cholestatic in 16% and mixed cholestatic-hepatocellular in 30%. Histology (14 cases) showed a predominantly hepatocellular pattern in 57% with extensive centrilobular necrosis and mild to moderate bridging. In 43% cholestasis predominated. None of the cases had a fatal course. The incidence of symptomatic hepatic injury may be estimated at approximately 1:2000 but is probably higher. The mechanism of ketoconazole-induced hepatic injury seems to be based on metabolic idiosyncrasy although it is not excluded that in some patients an immunoallergic mechanism is causative.

An anatomic investigation of radical resection of tumor in the hepatic duct confluence.

The fetal umbilical vein in the ligamentum teres can be reopened to provide a 10 centimeter long vein, as wide as the left portal vein or the central splenic vein, that gives access to the left portal vein in the umbilical fissure of the liver. By cutting the ligamentum teres, this potential autologous venous graft is lost and, therefore, the ligamentum teres should never be sacrificed without reason. The umbilical side of the reopened umbilical vein can be anastomosed with the splenic vein to form a portal vein bypassing conduit that enters the liver in the umbilical fissure and take over function of the portal vein. From the results of this postmortem investigation, it can be concluded that radical block resection of the area consisting of the hepatic duct confluence, classic right hepatic lobe and complete hepatoduodenal ligament, preceded by construction of a complete separate afferent blood supply of the classic left hepatic lobe, is possible both anatomically and technically. There is no indication denying the supposition that the result of such a procedure is functionally analogous to standard extended right lobectomy with bilioenteric reconstruction.

Hepatitis B virus DNA detected in formalin-fixed liver specimens and its relation to serologic markers and histopathologic features in chronic liver disease.

To examine the relationship of hepatitis B virus (HBV) DNA sequences in the liver with histopathologic features and antigenic markers, the authors determined the hepatocytic status of viral DNA by in situ hybridization in formalin-fixed liver sections using a biotinylated probe in 45 patients with various chronic liver diseases. The results were compared retrospectively with the HBV serologic markers and histopathologic features including the presence of ground-glass cells or Shikata staining positivity. The specificity of this in situ detection of HBV DNA has been proven excellent in a double-blind control study in 18 patients in whom liver HBV DNA was also determined by DNA extraction, gel electrophoresis, and the Southern blotting technique. In 41 patients, the findings of HBV DNA and serologic markers were concordant (17 positive and 24 negative). Twelve of the 20 HBV-DNA-positive patients were HBsAg-positive (6 with chronic hepatitis, 3 with cirrhosis, and 3 with hepatocellular carcinoma). Ground-glass cells or Shikata positivity were found in 10 of these 12 patients. HBV DNA sequences were found in the liver of all patients with chronic liver disease and serologic positivity for HBV infection. In liver with normal histologic features, HBV DNA was not demonstrable, despite the positive anti-HBc and anti-HBs. However, a positive HBV DNA was found in 3 serologically negative patients. In another patient the interpretation of findings was impossible because of severe hemosiderosis. From this study, it is concluded that in situ detection of HBV DNA in formalin-fixed liver sections has a clinical value and is suitable for routine use.

Anovulation presumably due to the gonadotrophin-resistant ovary syndrome.

The clinical syndrome of the resistant ovary is described in a 24-yr-old woman (XX genotype) with secondary amenorrhea and primary infertility. She presented an increased secretion of gonadotrophins with a decreased secretion of estrogens. In the ovarian tissue only primary ovarian follicles and a thickened tunica albuginea were found. The elevated serum gonadotrophins could be further increased by the administration of exogenous LHRH and incompletely suppressed by exogenous estrogens (50 micrograms ethynylestradiol daily). However, serum LH concentration started with a further rise (positive feedback?) during this estrogen administration. Results of treatment with Cyclocur and ethynylestradiol (100 micrograms daily) in higher dosages are presented. Following discontinuation of the estradiol therapy regular menses resumed, which became ovulatory. The patient became pregnant 23 months after stopping the estradiol therapy.