2001 Feb 24;322(7284):477-80 [Texto
ABC of diseases of liver, pancreas, and biliary system.
Beckingham IJ, Krige JE
Department of Surgery, Queen's Medical Centre, Nottingham, UK.
Clin Radiol 2001 Feb;56(2):138-45
Pre-operative detection of malignant hepatic tumours: value of combined
helical CT during arterial portography and biphasic CT during hepatic
Matsuo M, Kanematsu M, Inaba Y, Matsueda K, Yamagami T, Kondo H, Arai Y,
Department of Radiology, Gifu University School of Medicine, 40
Tsukasamachi, Gifu 500-8705, Japan.
AIMS: The purpose of our study was to evaluate the observer performance
with combined helical CT during arterial portography (CTAP) and
biphasic CT hepatic arteriography (CTHA) in the pre-operative detection of
malignant hepatic tumours. METHODS: Computed tomography images obtained in
41 patients with suspected hepatic tumours were retrospectively reviewed.
In a blind fashion, three off-site, independent radiologists reviewed CTAP
and early-phase CTHA combined for the first review, then late-phase CTHA
was added for the second review. Statistical analysis was conducted on
lesion-by-lesion and segment-by-segment bases; a total of 328 liver
segments including 65 segments with 74 malignant hepatic tumours ranging
in size from 5 to 100 mm (mean, 21.4 mm) were analysed. RESULTS:
Sensitivity for detection of liver segments harbouring tumours of CTAP and
biphasic CTHA combined (82%) was identical to that of CTAP and early-phase
CTHA combined (82%). Specificity of CTAP and biphasic CTHA combined (93%)
was greater than that of CTAP and early-phase CTHA combined (90%, P <
0.005). The mean confidence level for the 74 tumours significantly
increased by adding late-phase CTHA (P < 0.0005). The mean confidence
level for 100-142 benign perfusion abnormalities detected with CTAP and
early-phase CTHA combined significantly decreased by adding late-phase
CTHA (P < 0.0005). CONCLUSION: By combining late-phase CTHA with CTAP
and early-phase CTHA information, the specificity for the detection of
malignant hepatic tumours rises significantly, allowing more accurate
preoperative tumour detection. Copyright 2001 The Royal College of
Clin Liver Dis 2001 Feb;5(1):87-107, vi
Epidemiology of hepatocellular carcinoma.
Sections of Gastroenterology and Health Services Research, Houston VA
Medical Center, and Baylor College of Medicine, Houston, Texas, USA.
The epidemiology of hepatocellular carcinoma (HCC) is characterized by
marked differences between genders, ethnic groups, and geographic regions.
These variations are explained by the nature, frequency, and time of
acquisition of the major risk factors for cirrhosis--namely hepatitis B
virus, hepatitis C virus (HCV), and alcoholic cirrhosis. The incidence and
mortality of HCC has been rising in the US over the last two decades and
is progressively affecting younger persons. The evidence indicates that
HCV infection is responsible for the current trends.
Clin Liver Dis 2001 Feb;5(1):69-85
Pathogenesis of hepatocellular carcinoma.
Queensland Institute of Medical Research and the Department of Medicine,
University of Queensland, Brisbane, Queensland, Australia.
The pathogenesis of HCC is poorly understood at present. There is
insufficient understanding to propose a robust general model of hepatic
carcinogenesis, partly because pathogenic host and environmental factors
show significant regional variation, making such generalization difficult.
Figure 4 is a model based on data presented in this article. Multiple risk
factors for HCC have been identified, including cirrhosis, male gender,
increasing patient age, toxins, chronic viral hepatitis, and other
specific liver diseases. The understanding of how the individual risk
factors result in genetic changes is rudimentary, and there is even less
understanding about interactions between risk factors. Future studies
should acknowledge the geographic origin of the HCCs studied and consider
the effects of cirrhosis, gender, and age. A more rigorous approach to
these factors may help explicate the interaction with specific liver
diseases so that a comprehensive model of hepatic carcinogenesis can be
Clin Liver Dis 2001 Feb;5(1):259-81, viii-ix
Hepatic tumors in children.
Department of Pathology, F. Edward Hebert School of Medicine, Uniformed
Services, University of the Health Sciences, Bethesda, Maryland, USA.
Although they account for only 1% to 4% of solid tumors in children,
hepatic tumors and pseudotumors offer a diagnostic challenge to the
clinician seeing only an occasional case. Metastatic lesions such as
neuroblastoma, Wilms' tumor, and lymphoma are the most common neoplasm
seen in the liver, but 10 distinct primary tumors and pseudotumors of the
liver occur with some regularity, and a few others may be seen rarely,
including leiomyosarcoma, rhabdoid tumor, and endodermal sinus tumor. Five
of these neoplasms--hepatoblastoma, infantile hemangio-endothelioma,
mesenchymal hamartoma, undifferentiated embryonal sarcoma, and embryonal
rhabdomyosarcoma of the biliary tree--occur only in children and are the
major focus of the article.
Clin Liver Dis 2001 Feb;5(1):219-57, viii
Mesenchymal tumors of the liver.
Mani H, Van Thiel DH
Department of Pathology, Indian Navy Health Service, Asvini, Colaba,
Primary angiosarcoma of the liver accounts for up to 2% of all primary
liver tumors and is the second most common primary malignant neoplasm of
the liver. Approximately 10 to 20 new cases are diagnosed every year in
the United States and the prevalence varies from 0.14 to 0.25 per million.
In an autopsy series from Chicago, one hepatic angiosarcoma was noted for
every 30 cases of hepatocellular carcinoma.
Can J Gastroenterol 2000 Sep;14(8):703-9
Epidemiology of hepatocellular carcinoma.
Yu MC, Yuan JM, Govindarajan S, Ross RK
Department of Preventive Medicine, University of Southern California/Norris
Comprehensive Cancer Center, Keck School of Medicine, Los Angeles
90089-9176, USA. firstname.lastname@example.org
Although rare in Canada and the United States, hepatocellular carcinoma (HCC)
ranks as the eighth most common cancer in the world. High-risk regions are
East and Southeast Asia, and sub-Saharan Africa. Independent of race and
geography, rates in men are at least two to three times those in women;
this sex ratio is more pronounced in high-risk regions. Rates of HCC in
the United States have increased by 70% over the past two decades.
Registry data in Canada and Western Europe show similar trends. In
contrast, the incidence of HCC in Singapore and Shanghai, China, both high-risk
regions, has declined steadily over the past two decades. Among white and
black Americans, there is an inverse relationship between social class
status and HCC incidence. Chronic infection by the hepatitis B virus (HBV)
is by far the most important risk factor for HCC in humans. It is
estimated that 80% of HCC worldwide is etiologically associated with HBV.
In the United States, although the infection rate in the general
population is low, HBV is estimated to account for one in four cases of
HCC among non-Asians. Chronic infection by the hepatitis C virus is
another important risk factor for HCC in the United States; however, this
virus is believed to play a relatively minor role in the development of
HCC in Africa and Asia. Dietary aflatoxin exposure is an important
codeterminant of HCC risk in Africa and parts of Asia. In Canada and the
United States, excessive alcohol intake, cigarette smoking and oral
contraceptive use in women also are risk factors for HCC.
Magn Reson Imaging Clin N Am 2000 Nov;8(4):757-68
MR imaging of hepatocellular carcinoma.
Onaya H, Itai Y
Department of Radiology, National Cancer Center Hospital East, Kashiwa,
MR imaging is useful in the diagnosis and early detection of HCC.
Characteristic findings for overt HCC, a pseudocapsule and an intratumoral
mosaic pattern, are better demonstrated on MR imaging than by other
imaging modalities such as ultrasound and CT scanning. Signal intensity on
T2-weighted images is useful in evaluating the grade of malignancy of
hepatocytic nodular lesions. Hyperintensity on T1-weighted MR imaging is
almost always seen in precancerous hepatocellular lesions and in about one
third of overt HCC tumors, whereas other hepatic tumors show hypointensity
on T1-weighted MR imaging. In evaluating tumor vascularity, gadolinium-enhanced
dynamic MR imaging is an essential and powerful tool.
Magn Reson Imaging Clin N Am 2000 Nov;8(4):741-56
MR imaging in the evaluation of hepatic metastases.
Imam K, Bluemke DA
Russel H. Morgan Department of Radiology and Radiological Sciences, The
Johns Hopkins University School of Medicine, Baltimore, Maryland 21287,
Optimal detection of focal hepatic lesions in patients with metastases can
alter patient management and result in significant cost savings by
reducing the number of unnecessary laparotomies for unresectable disease.
Liver-specific MR imaging contrast agents (reticuloendothelial and
hepatobiliary agents) offer greater lesion-to-liver contrast than the
conventional extracellular fluid space MR imaging contrast agents (gadolinium
chelates), which have a nonspecific distribution. For the detection of
hepatic metastases, although the work of Seneterre et al suggests that the
accuracy of ferumoxide-enhanced MR imaging is equivalent to that of CTAP,
other studies find CTAP to be superior. Comparisons of reticuloendothelial
agents and hepatobiliary agents for imaging liver metastases are lacking
in the literature. Further studies comparing MR imaging enhanced with
liver-specific contrast agents to CTAP are needed to determine if hepatic
MR imaging can replace CTAP for the preoperative evaluation of hepatic
metastases. For the characterization of focal liver lesions, MnDPDP and
ferumoxides have been added to the small list of FDA-approved contrast
agents, and both can help to increase diagnostic specificity. Two of the
hepatobiliary agents which are not yet approved, Gd-BOPTA and Gd-EOB-DTPA,
have the potential of characterizing liver lesions during dynamic contrast
enhancement (similar to Gd-DTPA) and during the hepatocyte phase (similar
to MnDPDP), and may increase the detection of focal liver lesions.
Endoscopy 2000 Nov;32(11):884-9
Laparoscopy, minimally invasive surgery, and percutaneous treatment of
Bispebjerg Hospital, Copenhagen, Denmark. email@example.com
Ann Oncol 2000;11 Suppl 3:153-9
Pancreatic and hepatobiliary cancers: adjuvant therapy and management of
Department of Oncology, Radiology and Clinical Immunology, University
Hospital, Uppsala, Sweden.
J Hepatol 2000 Oct;33(4):667-72
Radiofrequency ablation in the treatment of hepatocellular carcinoma--a
Grasso A, Watkinson AF, Tibballs JM, Burroughs AK
Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London,
Surgery 2000 Oct;128(4):686-93
Hepatic resection: effective treatment for primary and secondary tumors.
Buell JF, Rosen S, Yoshida A, Labow D, Limsrichamrern S, Cronin DC, Bruce
DS, Wen M, Michelassi F, Millis JM, Posner MC
Department of Surgery, and Health Studies, University of Chicago, Pritzker
School of Medicine, Chicago, Ill. 60637, USA.
BACKGROUND: Hepatic resection is an accepted therapeutic modality for
isolated colorectal metastases (CRM) and primary hepatobiliary cancers
(PC). Controversy continues regarding the safety, efficacy, and
appropriateness of resection for noncolorectal metastases (NCM). METHODS:
A retrospective review of 167 resections in 160 patients was performed to
evaluate the impact of demographics and perioperative data on survival and
recurrence. Statistical analyses were performed by Student t test,
analysis of variance, and Kaplan-Meier survival estimates. RESULTS:
Resections were performed for CRM, 110 of 167 (66%), NCM, 31 of 167 (19%),
and PC, 26 of 167 (15%). The interval from primary to metastases was
significantly longer in the NCM group than the CRM group (34.7+/-45.1 vs.
18.7+/-23.7 months; P<.01). Mean number of lesions was not different
between groups; however, NCM were larger than CRM (5.9+/-4.5 vs 4.5+/-2.9
cm; P<.05). Operative complications were significantly greater for PC
(54%) versus CRM and NCM (21% and 19%, respectively; P<.01), although
length of stay was similar between groups. Perioperative mortality was 2%.
Actuarial survival at 1 year, 3 years, and 5 years was CRM 91%, 54%, and
40%, PC 75%, 60%, and 38%, and NCM 68%, 36%, and not available,
respectively (CRM vs. NCM; P<.01 at 3 years). CONCLUSIONS: Hepatic
resection for primary and secondary malignancy can be performed with
minimal morbidity and mortality. Resection of NCM is associated with a
lower overall survival compared with CRM and PC. The disease-free interval
from resection of the primary to metastasectomy is prolonged and hepatic
recurrence infrequent after resection in the NCM group. These results
suggest that tumor biology is a critical determinant of outcome after
hepatic resection of primary and secondary hepatic tumors.
Surg Clin North Am 2000 Aug;80(4):1203-11
Laparoscopic management of benign liver disease.
Katkhouda N, Mavor E
Department of Surgery, University of Southern California School of
Medicine, USA. firstname.lastname@example.org
Minimally invasive techniques may be used for treating a variety of benign
hepatic lesions in selected patients. The size of the lesions is less
important than the anatomic location in anterolateral regions.
Laparoscopic unroofing of solitary liver cysts is the surgery of choice
for this indication. The laparoscopic management of patients with PLD
should be reserved for patients with a few, large, anteriorly located,
symptomatic cysts. Active hydatid cysts present technical difficulties
because of their complex biliovascular connections and the inherent nature
of the parasite. The authors' results do not support the widespread use of
laparoscopy in these cases. Uncomplicated benign liver tumors located in
the left lobe or in the anterior segments of the right lobe can be
resected safely using a four-hand technique. Open surgery is the treatment
of choice when primary tumors are malignant, located posteriorly, or in
proximity to major hepatic vasculature. Laparoscopic resection of liver
metastases with a safety margin of 1 cm, when the total number is less
than four, is not unreasonable and can be offered to patients without
evidence of extrahepatic disease.
Surg Clin North Am 2000 Aug;80(4):1111-26
Role of laparoscopy in the staging of malignant disease.
Pratt BL, Greene FL
Department of General Surgery, Carolinas Medical Center, Charlotte, North
Although diagnostic laparoscopy has been used by surgeons and
gastroenterologists since the early 1900s, today's surgical oncologists
have been relatively slow to embrace this technology. Together with the
fervor and benefits afforded by laparoscopic therapeutic interventions in
the management of patients with benign disease and the diagnostic
usefulness in blunt trauma and abdominal pain, awareness has been
rekindled regarding the advantages of laparoscopy for the staging of
abdominal malignancy. As surgeons begin to realize that extirpative
procedures are doomed to failure in curing patients with diffuse abdominal
metastases disclosed on laparoscopic assessment, palliative measures, such
as stent placement, ablative procedures, balloon dilatation, intraluminal
high-dose radiation, and laser techniques will be used commonly by
surgical endoscopists and gastroenterologists. Similarly, it is hoped that
the use of systemic chemotherapy will achieve better specificity in cell
destruction in patients identified laparoscopically to have uncontained
disease in the abdominal cavity. The sensitivity of sonography combined
with laparoscopy has been shown to approach that of celiotomy in the
evaluation of solid organs, thereby avoiding unnecessary laparotomy and
its associated morbidities. Using sonography as a complement to
laparoscopy will extend the usefulness of both techniques. The application
of laparoscopy and the advent of miniaturized laparoscopic instrumentation
(Fig. 7), both diagnostic and therapeutic, in the management of patients
with abdominal malignancy will be limited only by the creativity and
expertise of physicians and instrument makers.
Gastroenterol Clin Biol 2000 May;24(5 Pt 2):B92-4
[Screening for hepatocellular carcinoma in cirrhotic patients].
[Article in French]
Service d'Hepato-Gastroenterologie, Hopital Jean Verdier, 93143 Bondy
Med Clin (Barc) 2000 Apr 8;114(13):506-10
[Current status of the treatment of hepatic metastases of colorectal
[Article in Spanish]
Cubillo A, de Castro J, Feliu J, Gonzalez Baron M
Servicio de Oncologia Medica, Hospital La Paz, Universidad Autonoma de
Postgrad Med 2000 May 1;107(5):117-24 [Texto
Hepatocellular carcinoma. A concise guide to its status and management.
Department of Internal Medicine, University of Utah School of Medicine,
Salt Lake City, USA. Sculmer@yahoo.com
Although common worldwide, hepatocellular carcinoma is relatively rare in
the United States. However, for unknown reasons, the incidence is rising.
Multiple causes exist, but chronic viral hepatitis in the setting of
cirrhosis is probably the most common. Despite limitations, AFP
measurement and multiple-phase abdominal CT are the most sensitive tests
for diagnosis. Surgical resection and liver transplantation are at present
the only treatment options that offer potential for long-term survival or
cure in limited-stage hepatocellular carcinoma. Otherwise, the prognosis
is poor, and 1-year survival is rare. Future efforts should focus on
improving detection of early-stage disease and improving preventive
measures to reduce viral hepatitis infection, transmission, and
Surg Clin North Am 2000 Apr;80(2):603-32
Tsao JI, DeSanctis J, Rossi RL, Oberfield RA
Department of Surgery, Tufts University School of Medicine, Burlington,
The battle against malignancies of the liver is far from over, although
tremendous strides have been made in the past decade, such as improved
diagnostic capabilities, safe surgical resection, availability of safe
nonsurgical ablative modalities, multimodality therapy, and aggressive
approach to recurrent disease. Even after the best attempts at curative
treatment, recurrence of primary and secondary malignancies of the liver
continues to be the cause of demise for more than 70% of treated patients.
The battle continues in the laboratories, where investigations are focused
on delineating the pathophysiology of cancer on the molecular and genetic
levels and mapping the patterns of cancer emergence and spread. The new
millennium holds promise for formulating therapies that may improve
disease-free survival for patients with malignancies of the liver.
Surg Clin North Am 2000 Apr;80(2):495-503
Role of videoscopic-assisted techniques in staging malignant diseases.
Department of Surgery, University of Pennsylvania Medical School,
Preoperative radiographic studies fail to uncover a significant number of
patients with unresectable malignancies. Small peritoneal studs of tumor,
lymph node involvement, and small liver metastases are common causes of
understaging by imaging studies. Videoscopic staging offers a higher
degree of accuracy among these patients, with minimal complications and a
shorter recovery time than with exploratory laparotomy. The addition of
laparoscopic sonography and peritoneal lavage may further increase
sensitivity to unresectable disease. Staging videoscopy has been applied
to hepatobiliary and gastrointestinal malignancies, pleural and pulmonary
tumors, and gynecologic malignancies. The author believes that videoscopic
staging will become increasingly common as it is further studied and the
best applications are delineated.
Postgrad Med J 2000 Jan;76(891):4-11
The Guy's, King's College & St Thomas' Medical School, London, UK.
Primary hepatocellular carcinoma is one of the 10 most common tumours, and
the most common primary liver malignancy, in the world. In the majority of
cases, it occurs against a background of hepatitis B or C viral infection
and/or liver cirrhosis, and is associated with a dismal prognosis of a few
months. Current treatments in routine clinical practice are surgical
resection and liver transplantation, but these therapies are applicable to
only a small proportion of patients and prolongation of survival is
restricted. Other treatment options include intra-arterial chemotherapy,
transcatheter arterial chemoembolisation, percutaneous ethanol injection,
cryotherapy, thermotherapy, proton therapy, or a wide range of their
possible combinations. The current lack of definitive data, however,
limits the use of these therapies. Another option is gene therapy, which
although in its infancy at the present time, may have a significant role
to play in the future management of hepatocellular carcinoma.
N Engl J Med 1997 Jun 26;336(26):1889-94
Imaging of the hepatobiliary tract.
Department of Radiology, Massachusetts General Hospital and Harvard
Medical School, Boston 02114, USA.