Hepatocellular Carcinoma with Acute Spinal Cord Compression as the Initial Presentation

Multiple myeloma presenting with acute bony spinal cord compression and mechanical instability successfully managed nonoperatively

Objective To explore the clinicopathological features, imaging features and treatment of spinal cord myeloma in patients with spinal cord compression as the first symptom. Methods The retrospective cross-sectional study was conducted which the clinical data of five patients with spinal myeloid sarcoma confirmed by bone marrow aspiration and pathology from January 2014 to December 2017 in Changzheng Hospital. There were 3 males and 2 females, aged from 15 to 54 years old. the tumors were located in 3 cases of thoracic vertebrae and 2 cases of lumbar vertebrae. Four cases were treated with open surgery. After discharge, they were treated with chemotherapy and hematological tumors according to bone marrow puncture and pathological results. Another patient underwent conservative treatment (anti-inflammatory analgesia, nutritional support, chemotherapy, etc.). The observation items were analysed. Results All the 5 patients had a low back pain, three of them had a lower limbs weakness, and one of them was accompanied by paralysis of both lower limbs. X-ray examination showed no abnormal findings. CT and MRI showed bone destruction or soft tissue shadow. Bone marrow aspiration and postoperative pathological examination showed that five cases were leukemia including four acute myeloid leukemia(AML)and one chronic myeloid leukemia(CML). All patients' preoperative symptoms were relieved after treatment. All patients were followed up. One patient underwent IA regimen chemotherapy for five courses, and was treated with allogeneic hematopoietic stem cell transplantation. It had been followed up for 28 months after surgery and still in good condition without tumor recurrence. The other four patients relapsed after chemotherapy, all died of infection, and the survival period was from 5 to 26.5 months. Conclusions Spinal cord compression caused by myeloid sarcoma as an initial symptom is rare. The imaging manifestations of the myeloid sarcoma are lack of specificity and and it is easy to be misdiagnosed. Bone marrow aspiration and pathological examination can confirm the diagnosis. When the symptoms of spinal cord compression occur, it is recommended to perform early tumor decompression. The allogeneic hematopoietic stem cell transplantation and systemic chemotherapy should be performed after surgery. Key words: Sarcoma, myeloid; Leukemia; Spinal compression; Diagnosis; Treatment outcome

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality and healthcare expenditure in patients with chronic liver disease. There are no consensus guidelines on diagnosis and management of HCC in India. The Indian National Association for Study of the Liver (INASL) set up a Task-Force on HCC in 2011, with a mandate to develop consensus guidelines for diagnosis and management of HCC, relevant to disease patterns and clinical practices in India. The Task-Force first identified various contentious issues on various aspects of HCC and these issues were allotted to individual members of the Task-Force who reviewed them in detail. The Task-Force used the Oxford Center for Evidence Based Medicine-Levels of Evidence of 2009 for developing an evidence-based approach. A 2-day round table discussion was held on 9th and 10th February, 2013 at Puri, Odisha, to discuss, debate, and finalize the consensus statements. The members of the Task-Force reviewed and discussed the existing literature at this meeting and formulated the INASL consensus statements for each of the issues. We present here the INASL consensus guidelines (The Puri Recommendations) on prevention, diagnosis and management of HCC in India.

EUS-guided FNA could be another important tool for the early diagnosis of hepatocellular carcinoma

Spinal cord compression secondary to spinal extradural myeloid sarcoma in acute myeloid leukaemia: A case report and literature review

Recognizing the significant prevalence of hepatocellular carcinoma (HCC) in Saudi Arabia, and the difficulties often faced in early and accurate diagnoses, evidence-based management, and the need for appropriate referral of HCC patients, the Saudi Association for the Study of Liver diseases and Transplantation (SASLT) formed a multi-disciplinary task force to evaluate and update the previously published guidelines by the Saudi Gastroenterology Association. These guidelines were later reviewed, adopted and endorsed by the Saudi Oncology Society (SOS) as its official HCC guidelines as well. The committee assigned to revise the Saudi HCC guidelines was composed of hepatologists, oncologists, liver surgeons, transplant surgeons, and interventional radiologists. Two members of the task force served as guidelines editors. A wide based search on all published reports on all aspects of the epidemiology, natural history, risk factors, diagnosis, and management of HCC was performed. All available literature was critically examined and available evidence was then classified according to its strength. The whole document and the recommendations were then discussed in details by members and consensus was obtained. All recommendations in these guidelines were based on the best available evidence, but were tailored to the patients treated in Saudi Arabia. We hope that these guidelines will improve HCC patient care and enhance the multidisciplinary care needed for these patients.

Treatment for Hepatocellular Carcinoma in South Asia

Background: Spinal cord compression is a formidable complication of advanced cancer, and clinicians of copious specialities often have to encounter significant complex challenges in terms of diagnosis, management, and prognosis. Metastatic lesions from cancer are a common cause of spinal cord compression, affecting a substantial portion of oncology patients, and only in the US has the percentage risen to 10%. Acute metastasis-correlated spinal cord compression poses a considerable clinical challenge, necessitating timely diagnosis and intervention to prevent neurological deficits. Clinical presentation is often non-specific, emphasizing the importance of thorough evaluation and appropriate differential diagnosis. Diagnostic workup involves various imaging modalities and laboratory studies to confirm the diagnosis and assess the extent of compression. Treatment strategies focus on pain management and preserving spinal cord function without significantly increasing patient life expectancy, while multidisciplinary approaches are often required for optimal outcomes. Prognosis depends on several factors, highlighting the importance of early intervention. We provide an up-to-date overview of acute spinal cord compression in metastases, accentuating the importance of comprehensive management strategies. Objectives: This paper extensively explores the pathophysiology, clinical presentation, diagnostic strategies, treatment modalities, and prognosis associated with spinal cord metastases. Materials and Methods: A systematic literature review was conducted in accordance with the PRISMA guidelines. Conclusions: We aim to help healthcare professionals make informed clinical decisions when treating patients with spinal cord metastases by synthesizing current evidence and clinical insights.

Hepatocellular carcinoma (HCC) is the most common primary hepatic malignancy and aggressive neoplasms with high metastatic potential to the lung, regional lymph nodes, and bone. Metastatic spinal cord compression due to HCC is a rare, unusual initial presentation and is a neurosurgical emergency. We present two cases of HCC where spinal cord compression was the initial presentation before the diagnosis of HCC. Our first patient presented with bilateral flank pain. The biopsy of the chest wall showed HCC. However, a CT scan of the abdomen showed metastatic involvement of the T11 vertebra. He was found to have severe spinal canal stenosis on MRI of the back without neurological deficit. He underwent an emergent tumor decompression of the T11 vertebra with kyphoplasty. Our second patient was a young man who presented with cord compression symptoms, which included bilateral leg weakness and an inability to void. An urgent laminectomy with decompression of the lumbar spine was performed. He received radiotherapy for spinal metastasis and started systemic therapy for HCC. Unfortunately, he failed multiple lines of systemic therapy, and the progression of the disease complicated his clinical course with spinal cord compression for the second time.

Acute spinal cord compression with myelopathy is a neurologic emergency. Recognition of spinal cord compression, timely imaging, and treatment are important to restore and preserve neurologic function. This chapter reviews the causes and clinical approach to spinal cord compression. Traumatic and nontraumatic causes of spinal cord compression are addressed together because of their overlapping symptoms and management. The chapter concludes with a brief discussion of peripheral nerve injury.

Accuracy and disagreement of computed tomography and magnetic resonance imaging for the diagnosis of small hepatocellular carcinoma and dysplastic nodules: role of biopsy. Serste T, Barrau V, Ozenne V, Vullierme MP, Bedossa P, Farges O, Valla DC, Vilgrain V, Paradis V, Degos F. Hepatology 2012;55:800-806. Hepatocellular carcinoma (HCC) is the 6th most common cancer in the world and the third most common malignant tumor following stomach and lung cancers in Korea.1,2 Approximately 90% of HCCs are associated with a known underlying risk factor. The most frequent risk factors include chronic viral hepatitis (hepatitis B virus, hepatitis C virus) and alcohol intake. Cirrhosis is an important risk factor for HCC, and may be caused by chronic viral hepatitis, alcohol, non-alcoholic fatty liver disease and inherited metabolic diseases. Tests that can be used in HCC surveillance include serological and imaging examinations. The imaging test most widely used for HCC surveillance is ultrasound (US). US has an acceptable diagnostic accuracy when used as a HCC surveillance test (sensitivity, 58-89%; specificity, >90%).3,4 Alpha-fetoprotein (AFP) is the most widely tested biomarker in HCC. However, analysis of recent studies showed that AFP determination lacks adequate sensitivity and specificity for effective surveillance and for diagnosis of HCC.5,6 Accurate diagnosis of small liver nodules is of paramount importance. Diagnosis of HCC is based on noninvasive criteria or pathology. The noninvasive diagnostic criteria are relevant for the management of patients with suspicion of HCC when small nodule is found in liver.7 In 2001, a panel of experts on HCC reported for the first time noninvasive diagnostic criteria for HCC based on a combination of imaging and laboratory findings.8 In 2005, the European Association for the Study of the Liver (EASL) panel of experts and the American Association for the Study of Liver Diseases (AASLD) guidelines adopted a new HCC radiological hallmark, i.e. hypervascularization on arterial phase imaging and washout in the portal or delayed phase. In the presence of cirrhosis, noninvasive diagnosis of HCC can be obtained by one dynamic imaging technique in nodules above 2 cm showing the HCC radiological hallmark and two coincidental dynamic imaging techniques with nodules of 1-2 cm in diameter. Dynamic imaging techniques include contrast-enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI).9 Recent updated guidelines have proposed that one dynamic imaging technique (contrast-enhanced CT or MRI) showing the HCC radiological hallmark suffices for diagnosing nodules of 1-2 cm in diameter. When the typical vascular patterns are not present, either other contrast-enhanced study or biopsy is recommended. CEUS may offer false positive HCC diagnosis in patients with intrahepatic cholangiocarcinoma.10 Thus, CEUS has been dropped from the diagnostic imaging techniques because of its inability to adequately differentiate cholangiocarcinoma from HCC. The application of dynamic imaging criteria should be applied only to patients with cirrhosis of any etiology and to patients with chronic hepatitis B.11 Serste et al investigated the diagnostic accuracy of noninvasive techniques in US-detected 1-2 cm nodules in 75 consecutive patients with chronic liver disease (CLD) or cirrhosis.12 Sensitivity and specificity of the typical vascular pattern of HCC on enhanced multiphase CT and MRI were assessed with biopsy for the diagnosis of dysplastic nodules (DNs) and small HCC. This study revealed that all patients (31 of 31; 100%) who had conclusive coincidental findings (i.e., arterial enhancement and portal/delayed phase washout) on both examinations had HCC or high-grade dysplastic nodule (HGDN) (sensitivity, 57%; specificity, 100%). Interestingly, all patients (51 of 51; 100%) who had conclusive findings on at least one of the two examinations had HCC or HGDN (sensitivity, 96%; specificity, 100%). There was a disagreement regarding imaging findings between CT and MRI in 21 of 74 (28%) patients and no washout on both examinations in 23 of 74 patients (31%). In these 44 patients, liver biopsy provided an accurate diagnosis. This study showed the high specificity and low sensitivity of combined contrast-enhanced CT and MRI for the diagnosis of HCC in patients with CLD or cirrhosis with small (≤2 cm) hepatic nodules. This suggests that the noninvasive diagnosis of HCC or HGDN can be achieved if arterial enhancement and portal/delayed washout are found in one dynamic imaging examination. In one study including 89 cases of nodules between 0.5 and 2 cm detected within surveillance programs in patients with cirrhosis showed that noninvasive criteria are accurate for the diagnosis of HCC, with specificity of 93-97%.7 Unfortunately, sensitivity of these noninvasive criteria is 33%, meaning that two-thirds of nodules required pathological confirmation. The other study suggested that the use of a sequential algorithm would maintain an absolute specificity and increase the sensitivity, with significant savings in terms of liver biopsy examinations for 1-2 cm nodules detected during surveillance in cirrhotic patients.13 Khalili et al have focused on the optimization of imaging diagnosis of small HCC and have shown that the best sequential diagnostic strategy consisted of MRI followed by CT (if MRI was inconclusive).14 In conclusion, in patients with cirrhosis or chronic hepatitis B with hepatic nodules, the noninvasive diagnosis of HCC can be achieved if arterial hypervascularity and portal/delayed washout are found in one dynamic imaging technique. When a first imaging modality does not provide a conclusive diagnosis, either a second sequential imaging study or liver biopsy is recommended. Further prospective studies to confirm the accuracy of this approach are needed.

Objective To investigate the effect of protein induced by vitamine K absence or antagonist-Ⅱ(PIVKA-Ⅱ)and AFP on the diagnosis and therapeutic monitoring of hepatocellular carcinoma (HCC). Methods A total of 280 cases of liver diseases were selected, including 198 cases of HCC (60 cases of viral hepatitis, 98 cases of liver cirrhosis, 40 cases of other liver diseases) and 82 cases of HCC (52 cases in early stage, 30 cases in late stage), in the same period, 40 healthy people were selected from the department of laboratory for serological examination, the levels of PIVKA-Ⅱ and AFP in the serum of patients with liver disease and normal population were detected by an automatic immunoanalyzer. The ROC-AUC, sensitivity and specificity of PIVKA-Ⅱ and AFP were analyzed separately and jointly for the diagnosis of HCC. Results There were significant differences in PIVKA-Ⅱ and AFP between healthy control group and primary liver cancer group (early and late stage), viral hepatitis group, liver cirrhosis group and other liver disease group (P<0.05). The differences of PIVKA-Ⅱ and AFP among patients with primary liver cancer (early and late stage), and viral hepatitis group, liver cirrhosis group, other liver disease group and healthy control group were significant (P<0.05). And the difference of PIVKA-Ⅱ and AFP between the early primary liver cancer group and the advanced primary liver cancer group was significant (P<0.05). In the diagnosis by PIVKA-Ⅱ, 48 cases were not consistent with the results of gold standard, false positive in 24 cases, false negative in 24 cases, the sensitivity of the test results was 70.73%, specificity was 89.92%, accuracy was 85%; AFP alone, 74 cases were not consistent with the results of the gold standard, false positive in 41 cases, false negative in 33 cases, the sensitivity of the test results was 59.76%, specificity was 82.77%, accuracy was 76.88%; combined diagnosis scheme 1: there were 43 cases with the gold standard results, false positive in 4 cases, false negative in 39 cases, the sensitivity of the test results was 52.44%, specificity was 98.32%, accuracy was 86.56%; combined diagnosis scheme 2: there were 70 cases with the gold standard results, false positive in 56 cases, false negative in 14 cases, the sensitivity of the test results was 82.93%, specificity was 76.47%, the accuracy was 78.13% (combined diagnosis scheme 1 was as follows: when the joint diagnostic program was positive for all the two indexes, and HCC was the same as the one of the two indicators of the joint diagnostic program, which could be diagnosed as HCC). The sensitivity and specificity of PIVKA-Ⅱ test results were significantly better than those of AFP. The specificity of combined diagnostic scheme 1 and the sensitivity of the combined diagnostic scheme 2 was better than that of other tests. Conclusions PIVKA-Ⅱ detection is more valuable for the diagnosis of HCC than AFP, and PIVKA-Ⅱ combined with AFP for detecting HCC can significantly improve the sensitivity and specificity of the diagnosis. Key words: Protein induced by vitamine K absence or antagonist-Ⅱ; Alpha fetoprotein; Sensitivity; Specificity

Metastatic hepatocellular carcinoma presenting as gynecomastia in male: A diagnostic dilema in fine needle aspiration cytology

Impact of Surveillance on Survival of Patients With Initial Hepatocellular Carcinoma: A Study From Japan

Acute compression of the spinal cord is a devastating but treatable disorder. Diseases that cause acute spinal cord compression constitute a special category because they originate in the spinal column and narrow the spinal canal. This review addresses the disorders that account for most instances of acute spinal cord compression: trauma, tumor, epidural abscess, and epidural hematoma. The pathophysiological features and management of these disorders are similar to those of other acute and serious spinal conditions. The medical context of spinal cord compression determines the diagnosis and directs treatment. Traumatic cord compression is often self-evident. Cord compression in patients with . . .