Autopsy-Confirmed Undifferentiated Carcinoma of the Liver With Rapid Bone Metastasis.

A male in his late 70s, with progressive hip pain, was diagnosed with a metastatic iliac bone tumor, initially misinterpreted as septic arthritis. Despite extensive imaging, the primary tumor site was undetected until autopsy, which confirmed undifferentiated carcinoma of the liver with secondary lung involvement. The patient's poor performance status and rapid health decline precluded aggressive treatment, leading to his demise. This case underscores the difficulties in diagnosing such carcinomas and suggests that early identification and innovative therapies like nivolumab could potentially extend life in similar cases.

[A case of Crohn's disease concomitant with IgA nephropathy].

A 34-year-old woman with underlying IgA nephropathy was admitted to our hospital with chief complaints of abdominal pain and pyrexia. Computed tomography showed increased mural thickness of the ileum and increased mesenteric fat density. Colonoscopic findings revealed a longitudinal ulcer in the terminal ileum and irregularly shaped ulcers and a longitudinal ulcer scar in the descending colon. Histopathological analysis of biopsy specimens from the ileum and descending colon showed non-caseating epithelioid cell granuloma. On the basis of these findings, the condition of the patient was diagnosed as ileocolonic Crohn's disease, and the patient received parenteral nutrition, followed by elemental diet. The patient was responsive to nutrition therapy, and the amount of uric protein decreased as her Crohn's disease activity index decreased. In conclusion, we assume that the Crohn's disease activity correlated with that of IgA nephropathy.

[A case of infliximab-related liver damage -case report and literature review].

A 50-year-old woman was admitted to our hospital with complaints of loss of vision, diarrhea and arthralgia. She was given a diagnosis of Behçet disease and given infliximab (IFX) to halt the progression of acute vision loss. Liver damage was detected after the fourth IFX dose. We assumed that this was a drug-induced condition caused by salazosulfapyridine (SASP). However, the liver damage worsened, and the condition did not improve even after discontinuing SASP. Thus, therapy to enhance hepatic function was initiated. Histological analysis of liver biopsy specimens showed centrilobular spotty necrosis and periportal hepatitis. We diagnosed autoimmune hepatitis rather than drug-induced liver damage. Because of liver function deterioration, we initiated steroid treatment and rapid improvement was observed. Therefore, liver function should be carefully monitored during IFX administration for patients with genetic predispositions to autoimmune hepatitis, such as human leukocyte antigen-DR4.

Comparison of therapeutic effects between radiofrequency ablation and percutaneous microwave coagulation therapy for small hepatocellular carcinomas.

BACKGROUND: Although thermal ablation therapies have gained fairly wide acceptance as an effective treatment for small hepatocellular carcinoma (HCC), there have been only a few clinical studies comparing the response to radiofrequency ablation (RFA) and percutaneous microwave coagulation therapy (PMCT). We evaluated the therapeutic efficacy and safety of these two procedures for the treatment of small HCC measuring < or = 2 cm in diameter. METHODS: Thirty-four patients who had 37 nodules were treated by RFA and were compared with 49 patients (56 nodules) who underwent PMCT. Treatment was repeated until complete tumor necrosis was confirmed by contrast computed tomography (CT) scanning. The therapeutic efficacy and complications were retrospectively compared between the two procedures. RESULTS: (i) There were significantly fewer treatment sessions (P < 0.001) in the RFA group than in the PMCT group, but the necrotic area was significantly larger (P < 0.001) in the former group. (ii) The local recurrence rate was significantly lower (P = 0.031) after RFA than after PMCT, although the ectopic recurrence rate showed no significant difference. (iii) The cumulative survival rate was significantly higher (P = 0.018) after RFA than after PMCT. (iv) The incidence of pain and fever after treatment was significantly higher in the PMCT group. Bile duct injury, pleural effusion, and ascites were also significantly more common in the PMCT group. CONCLUSIONS: RFA is more useful than PMCT for the treatment of small HCC because it is minimally invasive and achieves a low local recurrence rate, high survival rate, and extensive necrosis after only a few treatment sessions.

[Pyogenic liver abscess complicated by gastric fistula and bacterial meningitis].

A 77-year-old woman was admitted suffering from fever and headache. On laboratory examination, bacterial meningitis and sepsis due to Klebsiella pneumoniae were diagnosed. In addition, a hepatic cystic lesion measuring 13 cm in diameter in the left lobe was indicated on diagnostic imaging. After treatment with antibiotics, her signs of infection improved and the hepatic lesion decreased in size. After discharge, however, the cystic liver mass increased and a gastric fistula developed. Hepatic and gastric resections were performed because of the possibility of biliary cystadenocarcinoma and gastric invasion. Pathologically, a pyogenic liver abscess complicated by gastric fistula was diagnosed.

Radiofrequency ablation versus percutaneous microwave coagulation therapy for small hepatocellular carcinomas: a retrospective comparative study.

BACKGROUND/AIMS: Although local ablation procedures are useful in eradication treatment for small hepatocellular carcinoma (HCC), there have only been a few clinical studies comparing the response to radiofrequency ablation (RFA) and percutaneous microwave coagulation therapy (PMCT). We evaluated the clinical effect and safety of these two procedures for the treatment of small HCCs measuring 2cm or less in diameter. METHODOLOGY: Twenty-four patients with HCC who were treated by RFA and were compared with 39 patients with HCC who underwent PMCT. These procedures were repeated until complete tumor necrosis was achieved. The therapeutic and adverse effects were retrospectively compared between the two procedures. RESULTS: (1) There were significantly fewer treatment sessions (P < 0.001) in the RFA group than the PMCT group, and the necrotic area was significantly larger (P < 0.001) in the former group. (2) The local recurrence rate was significantly lower (P = 0.012) after RFA than after PMCT, even though the ectopic recurrence rate showed no significant difference. 3) The cumulative survival rate was significantly higher (P = 0.028) in the RFA group. (4) The incidence of pain and fever after treatment was significantly higher after PMCT than after RFA. Bile duct injury and pleural effusion were also more frequent in the PMCT group. CONCLUSIONS: RFA is more useful than PMCT in the treatment of small HCCs because it is minimally invasive and achieves a low local recurrence rate, high survival rate, and extensive necrosis after only a few treatment sessions.

[Hepatocellular carcinoma occurring after 11 year-long sustained viral response to interferon therapy for chronic hepatitis C].

The patient was a 61-year-old man with chronic hepatitis C who achieved a sustained virological response to interferon therapy in 1993. As a result, the status of his liver improved pathologically from F2A2 to F1A1. Eleven years later, however, a tumor measuring 15 mm in diameter in segment 6 of the liver was indicated by CT. A well-differentiated hepatocellular carcinoma was detected by a fine needle biopsy. The lesion was treated by transcatheter arterial chemoembolization combined with radiofrequency ablation. Even if patients with chronic hepatitis C have achieved a sustained virological response to interferon therapy, patients with risk factors for the development of hepatocellular carcinoma, such as being a male of advanced age and with progressive fibrosis of the liver, should receive careful long-term follow-up.

CO2-enhanced sonographically guided radiofrequency ablation and transcatheter arterial chemoembolization for small hepatocellular carcinoma poorly defined on conventional sonography.

We report a case of hepatocellular carcinoma located just below the right hemidiaphragm that was diagnosed as having hepatitis C virus-related cirrhosis 12 years ago. Although the lesion was not clear on conventional sonography, it was clearly defined on CO(2)-enhanced sonography, allowing safe and accurate radiofrequency ablation. By combining radiofrequency ablation with transcatheter arterial chemoembolization, extensive cauterization and complete tumor necrosis were obtained with only 1 session of treatment. The patient had no serious adverse effects and has shown no recurrence during 35 months of follow-up.

Thermal ablation therapy for hepatocellular carcinoma: comparison between radiofrequency ablation and percutaneous microwave coagulation therapy.

BACKGROUND/AIMS: To evaluate the initial therapeutic effect and safety of radiofrequency ablation (RFA) and percutaneous microwave coagulation therapy (PMCT) for the treatment of small hepatocellular carcinomas (HCCs). METHODOLOGY: Forty-eight patients with HCC were treated by RFA and 70 patients with HCC were treated by PMCT. These procedures were repeated until complete tumor necrosis was confirmed by contrast CT scanning. The therapeutic and adverse effects were compared between the two procedures. RESULTS: 1) The number of treatment sessions was significantly lower in RFA patients, and the necrotic area was significantly larger. 2) The local recurrence rate was significantly lower after RFA than after PMCT, while the ectopic recurrence rate showed no significant difference between the two procedures. 3) The survival rate was significantly higher after RFA compared with PMCT. 4) The incidence of pain and fever after treatment was significantly higher in PMCT patients. Occurrence of bile duct injury, pleural effusion and ascites were also significantly more common in PMCT patients. CONCLUSIONS: RFA is more useful for the treatment of small HCCs compared with PMCT because it is minimally invasive and achieves a low local recurrence rate, a high survival rate, and extensive necrosis after only a few treatment sessions.

Use of intra-arterial carbon-dioxide-enhanced ultrasonography for guidance of radiofrequency ablation and transcatheter arterial chemoembolization in hepatocellular carcinoma.

A 73-year-old man with hepatitis-C-related cirrhosis and an elevated alpha-fetoprotein level and tumor in segment 3 of his liver was referred for interventional radiologic treatment. He was not a candidate for surgical resection due to impaired liver function and his personal preferences. On conventional ultrasonography no lesion could be detected, but the tumor was clearly depicted by intra-arterial carbon-dioxide-enhanced ultrasonography. Radiofrequency ablation was performed safely and accurately under the guidance of carbon-dioxide-enhanced ultrasonography. By concomitant performance of transcatheter arterial chemoembolization with radiofrequency ablation, extensive necrosis was obtained and adequate tumor volume reduction achieved with only one treatment session.

Carbon dioxide-enhanced sonographically guided radiofrequency ablation plus transcatheter arterial chemoembolization for hepatocellular carcinoma.

A 78-year-old man had a history of blood transfusion and hepatitis C virus-related liver cirrhosis. He was admitted to the authors' hospital with a hepatocellular carcinoma just below the right hemidiaphragm. Although the lesion was not well visualized with standard sonography, it was clearly defined by performance of sonography with intraarterial injection of carbon dioxide, allowing safe and accurate radiofrequency ablation. To increase the extent of tumor ablation, transcatheter arterial chemoembolization was performed immediately before radiofrequency ablation. By concomitant application of these two techniques, complete tumor necrosis was achieved without the need to perform additional ablation.

Improved prognosis of cirrhosis patients with esophageal varices and thrombocytopenia treated by endoscopic variceal ligation plus partial splenic embolization.

The aim of this study was to assess the efficacy of the combination of endoscopic variceal ligation (EVL) and partial splenic embolization (PSE) compared with EVL alone in cirrhosis patients with thrombocytopenia. In a prospective study, 84 cirrhosis patients with esophageal varices and thrombocytopenia (platelet count < 50,000/mm(3)) underwent EVL plus PSE (N = 42) or EVL alone (N = 42). Primary end points assessed during the follow-up period included the recurrence of varices, progression to variceal bleeding, and death. Comparison between combined treatment and variceal ligation alone by multivariate analysis showed a hazard ratio of 0.44 for the recurrence of varices (P = 0.02), 0.19 for progression to variceal bleeding (P = 0.01), and 0.31 for death (P = 0.04). These results suggest that the combination of EVL plus PSE can prevent the recurrence of varices, progression to variceal bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.

Carbon dioxide-enhanced sonographically guided radiofrequency ablation combined with transcatheter arterial chemoembolization for sonographically undetectable hepatocellular carcinoma.

A 73-year-old man was diagnosed as having hepatitis C virus-related liver cirrhosis 11 years ago. Two years ago, he developed hepatocellular carcinoma in segment 6 of the right lobe and received radiofrequency ablation. This time, he was admitted to our hospital with a local recurrence in segment 6 of the liver. Standard sonography could not visualize the lesion clearly. However, carbon dioxide-enhanced sonogram clearly showed the whole lesion, so a needle electrode could be inserted precisely, allowing safe and accurate radiofrequency ablation. By combining radiofrequency ablation with transcatheter arterial chemoembolization, complete tumor necrosis was achieved without the need to perform additional ablation. In conclusion, carbon dioxide-enhanced sonographically guided radiofrequency ablation combined with transcatheter arterial chemoembolization is useful for complete cure of localized tumors, such as recurrent hepatocellular carcinoma, which cannot be detected clearly by conventional sonography.

Maintenance of cold-preserved porcine hepatocyte function with UW solution and ascorbic acid-2 glucoside.

Normal human hepatocytes are an ideal source of liver-targeted cell therapies, such as hepatocyte transplantation and bioartificial livers, but availability of human donor livers for liver cell isolation is severely limited. To effectively utilize scarce donor organs for cell therapies, it is of extreme importance to establish an efficient isolation technique and an effective cold preservation solution for transportation of isolated cells. A lateral segment of the liver was surgically resected from pigs weighing 10 kg and a four-step collagenase and dispase digestion was conducted. Isolated hepatocytes were subjected to 8-h cold storage on ice. The following preservation solutions were tested: 1) University of Wisconsin (UW) solution, 2) UW with 100 microg/ml of ascorbic acid-2 glucoside (AA2G), 3) 100% fetal bovine serum (FBS), and 4) Dulbecco's modified Eagle's medium (DMEM) supplemented with 100% FBS. The mean viability of porcine hepatocytes was 95.5 +/- 2.5% when isolated in three independent experiments. Viability, plating efficiency, membrane stability, and ammonia metabolic capacity of cold-preserved hepatocytes were significantly better maintained by the use of UW solution. When AA2G (100 microg/ml) was combined with UW solution, such parameters were further improved. It was explained by inhibition of caspase-3 activation and retention of ATP at high levels of hepatocytes preserved with UW solution containing AA2G. The present work demonstrates that a combination of UW solution with AA2G (100 microg/ml) would be a useful cold preservation means for the development of cell therapies.

Hepatocyte isolation and transplantation in the pig.

Hepatocyte transplantation (HTX) has received great expectation for the treatment of a wide spectrum of liver diseases. Considering the severe shortage of human livers for hepatocyte isolation, porcine hepatocytes are an attractive alternative to normal human hepatocytes. To develop such therapy, establishment of an efficient hepatocyte isolation and transplantation model that enables accurate assessment of safety and efficacy of HTX is extremely important. Porcine hepatocytes were isolated from a surgically removed liver segment with a four-step retrograde perfusion using dispase and collagenase. The resultant hepatocytes of > 84% viability were used for transplantation experiment in a pig model of acute liver failure induced by intravenous administration of D-galactosamine (D-gal) (0.5 mg/kg). Twenty-four hours after D-gal injection, transplantation of freshly isolated porcine hepatocytes (1 x 10(9)) was safely conducted and prolonged the survival of D-gal-treated pigs. We describe an efficient porcine hepatocyte isolation and subsequent cell transplantation in pigs with D-gal-induced liver failure.

Cryopreservation of primarily isolated porcine hepatocytes with UW solution.

Development of liver-targeted cell therapies, such as hepatocyte transplantation and bioartificial livers, requires a large amount of functional hepatocytes as needed. To achieve this development, establishing an excellent cryopreservation method of hepatocytes is an extremely important issue. Therefore, we performed a comparative review of cryoprotective effects of various cryopreservation solutions using primarily isolated porcine hepatocytes. Porcine hepatocytes were isolated with a four-step dispase and collagenase perfusion method. The obtained hepatocytes with the initial viabilities of 76%, 84%, and 96% were assigned to the following four groups for cryopreservation at -80 degrees C: Dulbecco's modified Eagle's medium (DMEM) + 10% fetal bovine serum (FBS) + 12% dimethyl sulfoxide (DMSO) (group A), University of Wisconsin (UW) solution + 12% DMSO (group B), Cell Banker 1 (group C), and Cell Banker 2 (group D). The hepatocytes in each group were thawed at 3 days, 10 days, and 5 months of cryopreservation and subjected to comparative analyses, including viability, plating efficiency, LDH release, ammonia removal test, and lentiviral gene transfer. These parameters were the most favorable in the hepatocytes cryopreserved with UW solution. Approximately 5% of thawed cryopreserved porcine hepatocytes expressed LacZ activity after lentiviral transduction. Intrasplenic transplantation of UW solution-cryopreserved hepatocytes improved the survival of rats treated with D-galactosamine. UW solution maintained the functions of cryopreserved porcine hepatocytes.

Establishment of an immortalized human hepatic stellate cell line to develop antifibrotic therapies.

Because human hepatic stellate cells (HSCs) perform a crucial role in the progress of hepatic fibrosis, it is of great value to establish an immortalized human cell line that exhibits HSC characteristics and grows well in tissue cultures for the development of antifibrotic therapies. Thus, we engineered an immortalized human hepatic stellate cell (HSC) line TWNT-4 by retrovirally inducing human telomerase reverse transcriptase (hTERT) into LI 90 cells established from a human liver mesenchymal tumor. Parental LI 90 entered replicative senescence, whereas TWNT-4 showed telomerase activity and proliferated for more than population doubling level (PDL) 200 without any crisis. TWNT-4 expressed platelet-derived growth factor-beta receptor (PDGF-betaR), alpha-smooth muscle actin (alpha-SMA), and type I collagen (alpha1) and was considered to be an activated form of HSCs. Treatment of TWNT-4 cells with either 100 U/ml of IFN-gamma or 1 ng/ml of rapamycin (Rapa) for 14 days led to lower expression of type I collagen (alpha1) at RNA and protein levels. Exposure of TWNT-4 cells to both of IFN-gamma (10 U/ml) and Rapa (0.1 ng/ml) for 14 days effectively decreased the expression of type I collagen (alpha1), PDGF-betaR, and alpha-SMA expression and suppressed TGF-beta1 secretion of TWNT-4 cells. We successfully induced apoptosis by transducing TNF-related apoptosis-inducing ligand (TRAIL) into TWNT-4 cells using adenovirus vectors Ad/GT-TRAIL and Ad/PGK-GV-17. These findings suggested that immortalized activated HSC line TWNT-4 would be a useful means to develop antifibrotic therapies.

Establishment of immortalized human hepatic stellate scavenger cells to develop bioartificial livers.

BACKGROUND: Maintenance of liver-specific functions has been shown to be stabilized by co-cultivation of hepatocytes with hepatic stellate cells (HSC). Because the limited lifespan of human HSC is a major hurdle to their use, the authors report here the amplification of human HSC populations in vitro by retroviral transfer of human telomerase reverse transcriptase (hTERT). METHODS: Human HSC strain LI 90 cells were transduced with a retroviral vector SSR#197 expressing hTERT and green fluorescent protein (GFP) cDNA flanked by a pair of loxP. TWNT-1, one of SSR#197-immortalized HSC, was characterized. Differentiated liver functions were evaluated in an immortalized human hepatocyte NKNT-3-TWNT-1 co-culture system. RESULTS: TWNT-1 cells showed differential functions of HSC, including uptake of acetylated low-density lipoproteins and synthesis of collagen type I and hepatocyte growth factor. Efficient excision of the retrovirally transferred hTERT and GFP cDNAs was achieved by TAT-mediated expression of the Cre recombinase and subsequent GFP-negative cell sorting. When co-cultured with TWNT-1 cells, NKNT-3 increased protein expression of the detoxifying cytochrome P450-associated protein isoenzymes 3A4 and 2C9 and urea synthesis. CONCLUSIONS: TWNT-1 cells could be valuable in the study of integrated liver functions and contribute to the optimization of liver cell therapies and bioartificial livers.

Transduction of immortalized human hepatocytes with p21 to enhance differentiated phenotypes.

We previously constructed an immortal human hepatocyte line NKNT-3 with a simian virus 40 T antigen (SV40T) to develop cell-based biological therapies. p21 is a molecule that regulates the transition from the G1 phase to the S phase of the cell cycle. Investigators have demonstrated that overexpression of p21 induces differentiation in various cell lines. In the current study we examined the effect of p21 on differentiated phenotypes of SV40T-immortalized NKNT-3 cells. A replication-deficient adenovirus vector expressing a human wild-type p21 cDNA under the control of the CMV promoter (Ad5CMVp21) and a human wild-type p21 protein fused to the protein transduction domain from the human immunodeficiency virus (HIV) TAT protein (TAT/p21) were utilized to achieve efficient delivery of p21 into NKNT-3 cells. Morphological alterations, cell cycle progression, and expression of albumin and p-450 associated enzymes (CYPs) 3A4 and 2C9 were evaluated in NKNT-3 cells treated with Ad5CMVp21 and TAT/p21. Efficient adenovirus-based p21 transfer and TAT-mediated p21 protein delivery were confirmed in NKNT-3 cells in an immunofluorescence study and Western blotting analysis. Transduction of NKNT-3 cells with p21 predominantly arrested the cell cycle at the G1 checkpoint, resulting in differentiated hepatic phenotypes in morphology and improvement in protein expression of albumin, CYP 3A4, and CYP C29. We here show that exogenous expression of p21 augments cellular differentiation in immortalized human NKNT-3 cells.