Hepatocellular carcinoma with silent and cirrhotic non-alcoholic steatohepatitis, accompanying ectopic liver tissue attached to gallbladder.

A 70-year-old man had been obese since youth. He had been treated for hypertension and diabetes mellitus. An abdominal ultrasound showed a mass in the liver. He was admitted to St Marianna University School of Medicine Hospital for further evaluation. There was no history of alcohol use, and hepatitis viral markers and autoantibodies were all negative. Several imaging studies showed overt hepatocellular carcinoma (HCC). Transcatheter arterial embolization was performed, followed by surgical resection. Histopathological examination revealed moderately differentiated HCC. The non-tumor areas had pseudolobules in a diffuse pattern similar to alcoholic cirrhosis. The histological findings in the ectopic liver tissue attached to the gallbladder, which was also resected during surgery, were that there was no cirrhosis, but fine fibrosis with inflammatory cell infiltration of sinusoids. These findings were consistent with non-alcoholic steatohepatitis (NASH). There was probably a progression of similar findings that had developed into cirrhosis. These findings confirmed a diagnosis of HCC, cirrhosis, and underlying NASH in this patient. The present case is important for investigation of the development into cirrhosis and carcinogenesis of NASH. The present case demonstrates the importance of evaluating obese patients with fatty liver for underlying NASH and ongoing follow up for development of cirrhosis and HCC.

Pancreatic involvement in chronic viral hepatitis.

AIM: To elucidate the frequency and characteristics of pancreatic disorders in the course of chronic viral hepatitis. METHODS: We prospectively assessed the serum pancreatic enzyme levels and imaging findings in patients with chronic viral hepatitis and healthy control subjects. RESULTS: Serum amylase (t-Amy), salivary amylase (s-Amy), pancreatic amylase (p-Amy) and serum lipase levels were higher in hepatitis patients in comparison to control subjects. However, in asymptomatic viral carriers, only the serum t-Amy levels were higher than those of the controls. The levels of each enzyme rose with the progression of liver disease in patients with hepatitis B or C; whereas the levels of each enzyme within the same clinical stage of the disease did not differ between patients diagnosed with either hepatitis B or hepatitis C virus. Imaging findings demonstrated chronic pancreatitis in only 1 out of 202 patients (0.5%). CONCLUSION: Our data suggest that serum levels of pancreatic enzymes increase with the progression of liver disease in patients diagnosed with viral hepatitis. Pancreatic disease, asymptomatic in most cases, may represent an extrahepatic manifestation of chronic viral hepatitis.

Strategy for hepatic hyperplastic nodules in heavy drinkers.

BACKGROUND: Increased detection of nodular lesions that have not yet been definitively diagnosed as hepatocellular carcinoma (HCC) has occurred with the use of advanced imaging techniques. In heavy drinkers, the differential diagnosis between a hyperplastic nodule and early HCC on the basis of results of fine-needle biopsy is often difficult. Negation of diagnosis of HCC after surgical resection has been reported, and nodular lesions have been found to decrease during follow-up observation. On the basis of findings, a suitable strategy for the management of such lesions is suggested. METHODS: We identified six patients who had hepatic nodular lesions on ultrasonography and were heavy drinkers. This group included five men and one woman with a mean age of 45.3 +/- 3.8 years. Two patients had solitary lesions; four had multiple lesions, and of these, two were hepatitis C virus antibody positive (C+). In the five men, the nodular lesions were detected during hospitalization for ruptured or prophylactic treatment of gastroesophageal varices. RESULTS: Five of the six patients had hypervascular lesions characterized by increased hepatic artery blood flow. However, dynamic computed tomography and magnetic resonance imaging studies during late-phase imaging could not confirm any decrease in portal blood flow. HCC was diagnosed by detailed imaging studies and liver biopsy in one C+ patient with a solitary nodule. In two of the other four patients, imaging findings were compatible with hypervascular HCC. Findings on liver biopsy do not always permit an easy differential diagnosis between a regenerative lesion (hyperplastic nodule) and a dysplastic or neoplastic lesion. One patient with a hypovascular lesion was C+, and liver biopsy showed a dysplastic nodule. CONCLUSION: Heavy drinkers with alcoholic liver disease often develop hypervascular, hyperplastic nodules. The accurate diagnosis of these nodules requires careful consideration of clinical factors, including a combination of images and histologic examination. However, some cases were still difficult to distinguish between HCC by applying advanced imaging techniques and biopsy results.

Quantitative multilevel mapping of hepatic blood flow by xenon computed tomography using aorta.

A noninvasive and quantitative technique has been developed to measure human hepatic blood flow by xenon computed tomography (Xe-CT). Accurate data on time-dependent xenon concentrations in the arterial blood are indispensable for Xe-CT to ensure quantitativeness of measured blood flow. A method has been established by our group to use both aorta and end-tidal data to obtain arterial xenon information. Multilevel (3 levels) maps of arterial blood flow (Fa), portal blood flow (Fp), and partition coefficient (lambda) were created for patients with chronic hepatitis. A method to objectively evaluate Fa, Fp, and lambda values for the whole liver has also been developed by our group.

Outcomes of small nodular lesions in heavy drinkers.

BACKGROUND: Increased detection of nodular lesions in patients not yet definitively diagnosed with hepatocellular carcinoma (HCC) has occurred with the use of advanced imaging techniques. In heavy drinkers, decrease in the size of nodular lesions during on-going observation, and negation of diagnoses of HCC after surgical resection have been reported, suggesting the need for caution in diagnosis in such cases. METHODS: The subjects were eight heavy drinkers with small nodular lesions, 20 mm or less in diameter. All patients were male, with a mean age of 53 years. Five had single and three had multiple nodular lesions. Five of the eight patients were followed up for more than 4 years after an initial biopsy, while three patients were recent cases. Of the three recent cases, two were positive for antibody to hepatitis C virus (HCV) and two had hypervascular nodular lesion. Biopsies were performed percutaneously, under ultrasonography, for histological diagnosis of all cases, and the recent cases were also assessed using a variety of imaging techniques. RESULTS: On initial biopsy, no atypism (NO) was found in two patients, and borderline lesions (Border) were present in six patients. Of the five cases followed up long-term, only one of the two with NO progressed to HCC, and the three with Border showed disappearance, decrease, and no change, respectively, during the follow-up period. Of the three recent cases, no changes in size or morphology as revealed by imaging were observed following biopsy. CONCLUSIONS: In heavy drinkers, no fixed relationship was observed between initial biopsy finding and clinical course, suggesting that indication for biopsy requires reassessment, refinement, and discussion. Furthermore, tumor staining may occur in hyperplastic nodules, which are histologically similar to early HCC by needle biopsy, and care needs to be exercised for diagnosis in heavy drinkers.

A case of complete necrosis of well-differentiated early hepatocellular carcinoma by percutaneous transhepatic portal embolization.

The patient was a 49-year-old male under observation for chronic hepatitis B. In July 1997, abdominal ultrasonography showed multiple hyperechoic nodules in the right lobe, the largest with a diameter of 3.5 cm. Abdominal computed tomography did not reveal enhanced nodules, and the patient was hospitalized for suspected multiple liver tumors. All biochemical tests were normal, except for a slight decrease in platelets. The patient was positive for HBs antigen, negative for HBe antigen and positive for anti-HBe antibody. Hepatocellular carcinoma (HCC) with patent portal blood flow was strongly suspected based on the results of various imaging techniques. A tumor biopsy was conducted, and findings of multiple early hepatocellular carcinoma of a well-differentiated type were observed. Based on the HCC stage and liver function, an extensive right hepatectomy was indicated. Before the surgical resection, a percutaneous transhepatic portal embolization (PTPE) was performed using gerfoam sponzel in the right portal vein. Complete necrosis of the tumor lesions was observed in the resected liver. Early HCC thought to have developed multifocally concurrently with chronic inactive hepatitis was observed. It is highly possible that complete necrosis of these tumors occurred due to PTPE, suggesting that they are supplied by the portal blood flow.