Hepatic Hilar Node Research Articles

Clinical significance of aberrant hepatic artery arising from superior mesenteric artery in liver cancer and gastric cancer operations

Objective To analyze the clinical significance of aberrant hepatic artery which originated from superior mesenteric artery in liver cancer and gastric cancer operations.Method Four hundred liver cancer patients who underwent digital subtraction angiography (DSA) and multislice spiral computed tomography angiography (MSCTA) and 86 gastric cancer patients who underwent MSCTA between June 2008 and June 2010 and operated at the First Affiliated Hospital of Guangxi Medical University were included in this study.Preoperatively,the origins of the aberrant hepatic arteries from superior mesenteric arteries were detected by medical imaging.Postoperatively,immunohistochemistry of lymphoid tissues around the aberrant hepatic arteries of the gastric cancer patients were performed using recombinant human cytokeratin 20 (CK20) and carcino-embryonic antigen (CEA) to determine the incidence of lymph node metastases around the aberrant arteries.Results Among 486 patients,49 patients with liver cancer and 14 patients with gastric cancer had an aberrant hepatic artery which originated from the superior mesenteric artery.The rate was 12.96％ (63/486).The hepatic artery ran in front of the pancreas in 2 patients (3.17％) and behind the pancreas in 61 patients (96.83％).Immunohistochemical analyses of CK20 and CEA were negative which revealed no metastases in the lymphoid tissues surrounding the aberrant arteries.Conclusions Aberrant hepatic artery originated from the superior mesenteric artery can be classified into the pre-pancreas type and postpancreas type.The majority of aberrant hepatic artery belonged to the post-pancreas type.The clinical significance of aberrant hepatic artery is that the hepatic hilar lymph nodes should be dissected in liver cancer and gastric cancer operations. Key words: Aberrant; Hepatic artery; Tumor; Operation

Incidental Cystic Tumor in the Pancreas: Observe or Operate?

Question: A 27-year-old woman of Asian descent was referred to our department for resection of an incidentally diagnosed cystic pancreatic head tumor. The patient reported episodic back and epigastric pain as well as fatigue for 2 months, which led to the diagnostic workup. There was no history of pancreatitis, jaundice, vomiting, weight loss, fever, or night sweats. Physical examination and laboratory tests were unremarkable. She had last visited her home country, Thailand, >1 year ago. Magnetic resonance imaging (MRI; Figure A) showed a mass of the pancreatic head (encircled) with solid (blunt arrow) and cystic (arrow) areas. The mass was irregularly enhanced in the solid portion and the cystic wall when gadolinium was used. Heterogeneous iso- and hypointensity associated with high signal intensity corresponding to hemorrhage were observed. The portal vein was severely compressed and possibly infiltrated by the tumor (short arrow). Magnetic resonance cholangiopancreatography (MRCP; Figure B) disclosed a discrete compression and extrahepatic dilatation (long arrow) of the distal bile duct. The pancreatic duct did not show signs of obstruction (short arrow). There was evidence of enlarged peripancreatic and hepatic hilar lymph nodes on MRI and endosonography. Chest x-ray was normal. What is the diagnosis in this case? Should a Whipple procedure be performed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. At laparotomy, frozen section examination of lymph nodes of the hepatoduodenal ligament disclosed caseating granulomas. There was destructive infiltration of the portal vein by the pancreatic head mass, so a pylorus-preserving pancreatoduodenectomy with en bloc portal venous resection was performed (Figure C; square, pancreatic head; triangle, duodenum; encircled, area of massive caseating granulomatous inflammation; *, portal venous resection margin; long arrow, compressed bile duct; short arrow, pancreatic duct; blunt arrow, enlarged peripancreatic lymph node). Histopathologic workup disclosed massive granulomatous inflammation (Figure D, E, triangle mark) and caseating necrosis (Figure E, square mark). DNA specific for Mycobacterium tuberculosis was detected in the pancreatic lesion. Computed tomography of the chest showed diffuse, micronodular, parenchymal lesions reminiscent of miliary tuberculosis. Tuberculostatic therapy was started. Three months after the operation, the patient is free of complaints. Pancreatic tuberculosis is a very rare finding, even in the setting of miliary tuberculosis, which represents the most common cause.1Evans J.D. Hamanaka Y. Olliff S.P. et al.Tuberculosis of the pancreas presenting as metastatic pancreatic carcinoma A case report and review of the literature.Dig Surg. 2000; 17: 183-187Crossref PubMed Scopus (23) Google Scholar The typical patient is a young woman from a region with a high prevalence of tuberculosis, presenting with a short history of abdominal pain and a cystic pancreatic head mass. Unlike malignancy or chronic pancreatitis, tuberculotic lesions usually do not cause irregularities of the pancreatic duct seen on endoscopic retrograde cholangiopancreatography or MRCP.1Evans J.D. Hamanaka Y. Olliff S.P. et al.Tuberculosis of the pancreas presenting as metastatic pancreatic carcinoma A case report and review of the literature.Dig Surg. 2000; 17: 183-187Crossref PubMed Scopus (23) Google Scholar Vascular complications of pancreatic tuberculosis have only been reported in three cases as stenosis of the portal vein, encasement of the splenic vein,2De Backer A.I. Mortele K.J. De Keulenaer B.L. et al.Vascular involvement secondary to tuberculosis of the abdomen.Abdom Imaging. 2005; 30: 714-718Crossref PubMed Scopus (14) Google Scholar and massive gastrointestinal bleeding from a peripancreatic artery.1Evans J.D. Hamanaka Y. Olliff S.P. et al.Tuberculosis of the pancreas presenting as metastatic pancreatic carcinoma A case report and review of the literature.Dig Surg. 2000; 17: 183-187Crossref PubMed Scopus (23) Google Scholar Because of the life-threatening complications of vascular involvement, we advocated for a Whipple procedure with en bloc portal venous resection in this case.

Metastatic Carcinoid from a Nodule Localized by Complete Double-Balloon Enteroscopy: A Small Lesion with Big Potential

Purpose: Carcinoid tumors are rare, slow growing tumors originating from enterochromaffin cells. They generally do not become symptomatic until already metastasized while the primary tumor is still small with the most common site of origin being the small bowel. Double-balloon enteroscopy (DBE) is increasingly becoming an important part of the diagnostic algorithm of primary small bowel neuroendocrine tumor (NET) localization, especially since their surgical excision leads to a better prognosis, even in metastasized NET. A 55-year-old Caucasian woman was diagnosed as having metastatic well-differentiated neuroendocrine tumor lesions of the liver positive for chromogranin and synaptophysin in 2009 per liver biopsy after initially presenting with unexplained fevers and abdominal pain since 2005 but no carcinoid syndrome symptoms. As part of the search for her primary tumor she underwent endoscopic ultrasound of the pancreas and esophagogastroduodenoscopy at our institution. This demonstrated no pancreatic mass but three hepatic hilar and periportal lymph nodes were consistent with benign lymphoid tissue. A MRI of the abdomen and pelvis revealed innumerable arterial enhancing nodules and masses in all segments of the liver consistent with metastatic disease. The largest lesion was in the dome of the liver at the left hepatic lobe, measuring 3.6 cm x 3.5 cm. Additionally, a wireless capsule enteroscopy (WCE) and CT chest were negative. Of note, chromogranin A, serotonin, pancreastatin, pancreatic polypeptide, and gastrin levels were within normal limits. She then underwent a retrograde DBE to the point of maximal insertion, which was the proximal ileum. At the level of the distal ileum there was a 3 mm yellowish nodule removed in one pass. There were no other lesions seen, and the pathology was consistent with a submucosal carcinoid strongly positive for chromogranin, synaptophysin; histochemical stains were positive for Fontana and Grimelius, consistent with mid-gut origin; and the Ki67 proliferation marker was positive in less than 1% of cells. She then underwent an oral DBE to evaluate for other multifocal carcinoid mid gut lesions and the enteroscope was advanced all the way to the cecum with no other lesions identified. An exploratory laparotomy was subsequently performed in order to evaluate for a possible primary tumor; however, despite the small bowel being run in its entirety four times there was neither a macroscopic nor histologic abnormality identified, including in eight regional lymph nodes. This case highlights the metastatic potential of a smaller ileal lesion than has been previously reported in the literature per DBE despite negative imaging, WCE, and exploratory laparotomy.

Abstract 4740: Selective ablation of metastatic disease with integrin ανβ3 targeted nanoparticle drug delivery

Abstract Angiogenic blood vessels found within growing tumors express high levels of integrin ανβ3 while mature vessels fail to express this integrin. Based on this we developed a ανβ3-targeted nanoparticle (NP) in an attempt to selectively deliver therapeutics to the tumor neovasculature. A cyclic peptide ligand (cRGDfK) coupled to a phospholipid and incorporated into a nanoparticle demonstrated specific binding to ανβ3 on cultured endothelial cells. To characterize the in vivo targeting capacity of these NPs, we monitored NP accumulation using intravital microscopy of tumor neovasculature. A dorsal skin-fold window chamber implanted with GFP-labeled melanoma cells lacking integrin ανβ3 were imaged at various times after NP injection into the bloodstream. By 5h post injection, the cRGDfK NPs targeted the neovasculature at the angiogenic tips adjacent to the tumor margin, whereas untargeted (cRADfK) NPs failed to bind. After establishing in vivo targeting, these ανβ3-targeted NPs were loaded with doxorubicin via an ammonium phosphate gradient for therapeutic studies. The cRGD-Dox particles disrupted angiogenesis in the mouse matrigel model leaving only small fragments of disrupted vessels within the FGF loaded plugs. Next, we utilized an orthotopic pancreatic cancer model to study the ability of the NPs to target the vasculature of both primary pancreatic tumors as well as metastatic sites including the hepatic hilar lymph node and mesenteric lymph nodes. cRGD-Dox particles injected systemically at 1 mg/kg produced a profound anti-metastatic effect while only marginally influencing the pre-established primary tumor within the pancreas. This is much improved compared to the free doxorubicin treatments in which 1 mg/kg of free doxorubicin had no effect and 15 mg/kg of free doxorubicin was required for a similar therapeutic effect in this orthotopic model. Animals treated with 15 mg/kg of free doxorubicin lost over 20% of their body weight within 7 days, whereas no decrease in body weight was observed in the cRGD-Dox treated animals, confirming the reduction in overall toxicity. Histology confirmed that the cRGD-Dox particles induced apoptosis in regions co-localized with β3 expressing tumor vasculature. Additionally, we tested the cRGD-Dox particles in an orthotopic renal cell carcinoma model. Similar to the pancreatic carcinoma, the cRGD-Dox particles had a slight effect on primary tumor growth but greatly reduced metastasis to several sites including the pancreas, liver, spleen, and diaphragm. These findings reveal that ανβ3 targeted NP drug delivery may preferentially disrupt newly forming metastatic lesions by delivery of chemotherapeutic agents to sites of active angiogenesis in which the endothelium expresses high levels of ανβ3.

Incidence and prognosis of N4 node involvement in gastric cancer.

We have undertaken a prospective study of the frequency and prognosis associated with N4 node metastases in gastric cancer in 136 patients referred for surgical treatment between 1976 and 1983. N4 node metastases (pre-aortic or hepatic hilar nodes) were present in 20 of 31 patients who had a laparotomy without resection (64 per cent), in 2 of 8 patients who had a 'palliative' resection in the presence of distant metastases (25 per cent) and, in 19 of 85 patients who had a 'curative' resection (22 per cent). The median survival in patients having a 'curative' resection with N4 nodes was 4.5 months which was only marginally longer than in patients having a 'palliative' resection (median survival 3 months). In view of these findings and since immediate imprint cytology can be used to detect nodal metastases at operation, involvement of N4 nodes might be a contra-indication to extensive gastric resection in non-obstructing gastric cancer.

Severe cholestatic granuloumatous hepatitis in sarcoidosis disease with minimal pulmonary involvement

Extrapulmonary manifestations of sarcoidosis are frequently reported. Liver involvement is usually inapparent, with only mild elevation of liver function tests, whereas progressive cholestasis and/or cirrhosis are rarely reported. Sarcoidosis prevalence differs among racial and ethnic groups, and it is known to affect blacks more acutely and more severely than it does people of other races. We report the case of a black nigerian 35-yr old woman, living in Italy since 1988, admitted because fever, itching and increased cholestatic liver tests (GT 1837 IU, ALP 3854 IU, total bilirubin 3.5 mg/dl, AST 71 IU, ALT 84 IU, Cholesterol 448 mg/dl). Abdominal US revealed gallstones and associated cholecystitis, and hepatosplenomegaly. She underwent laparoscopic cholecystectomy: during the procedure an enlarged lymph node close to the gallbladder was collected and a liver biopsy was performed. Histology showed multiple confluent non caseating granulomas, with epitheliod and multinucleated giant cells. All serological and antibodies tests, and microbiological cultures were negative. Chest X-ray, CT and HRCT were normal, whereas abdominal CT confirmed an important hepatosplenomegaly, with numerous hypodense nodular splenic lesions, and hepatic hilar-node enlargement. No significant pulmonary physiologic abnormalities were detected, nevertheless a broncoscopy was performed, with transbronchial lung biopsy and bronco-alveolar-lavage collections. Lung biopsies confirmed the presence of granulomatous involvement and the BAL showed a typical sarcoidosis pattern. Serum ACE (angiotensin-converting-enzyme) activity was 70 U/L. Corticosteroid therapy was started (prednisolone 50 mg daily, with gradual tapering of the dose), plus azatioprine (150 mg daily) and ursodeoxycholic acid (1350 mg daily). After six month of treatment transaminases, bilirubin and ACE levels were in the normal range, whereas GT and ALP decreased significantly (1249 and 1331, respectively). This single case of sarcoidosis presented to the clinician almost exclusively with liver disease; it confirms that in Africans the disease is characterized by more severe extrapulmonary involvement. The consideration of sarcoidosis in such cases is of utmost importance, since the differential diagnosis of hepatic granulomas includes infectious diseases in which treatment with corticosteroids could be fatal.

The endoscopic retrograde cholangiopancreatographic manifestations of histopathologically diagnosed hepatocellular carcinoma with obstructive jaundice.

To study the manifestations of endoscopic retrograde cholangiopancreatography (ERCP) in patients of obstructive jaundice associated with HCC, 32 cases of histopathologically diagnosed HCC with obstructive jaundice were successfully examined with routine ERCP. 31 patients were demonstrated by ERCP as having malignant obstructive jaundice. Among them, 19 were hepatic perihilar bile duct stricture, 7 bile ductile tumorous thrombus, 3 perihilar bile duct stricture complicated with thrombus, 2 metastasis to hilar lymph node, and 1 common bile duct stone as proven by sphincterotomy. The malignant perihilar stricture was all of type III and IV by Bismuth standard of Klastin tumor. In patients identified as having bile duct tumor thrombus, by the Ueda classification, none was of type I and II; 1 type III a; 4 III b; 2 type IV. HCC with obstructive jaundice was mainly caused by the malignant infiltration of tumor, and most stricture was of serious nature. When major extra-hepatic bile duct was involved by tumor thrombus, obstructive jaundice might develop. Malignant perihilar stricture and tumor thrombus might coexist in some patients. Jaundice was rarely caused by hepatic hilar lymph node metastasis. Jaundice was not necessarily caused by tumors and sometimes, it might be caused by common bile stones. Care should be exercised in differentiation diagnosis in such patients.

Propagation and characterization of lymphocytes infiltratiti livers of patients with primary biliary cirrhosis and autoimmune hepatitis

Lymphocytes were prolagated with interleukin 2 from liver tissue removed at transplantation from patients with primary biliary cirrhosis or autoimmune chronic active hepatitis. Phenotypic analysis of the cultured lymphocytes as well as the infiltrating cells in situ indicated that the culture technique did not select for a particular phenotype. Eight cultures were tested for cell-mediated lympholysis activity against a bile duct tumor line as well as a hepatocellular carcinoma line, but no specific killing was seen. In addition, no natural killer activity was detected. However, the lymphocytescultures were able to kill the targets in a lectin-dependent cytotoxicity assay, indicating their cytolytic effector activity. Preliminary studies have demonstrated that lymphocytes extracted from hepatic tissue and hilar lymph nodes from a patient with primary biliary cirrhosis proliferated in response to autologous biliary epithelial cells. These methods might be useful in studying the pathogenesis of primary biliary cirrhosis and other liver diseases with autoimmune features.

Distant Metastasis of Renal Adenocarcinoma in Patients with a Tumor Thrombus in the Renal Vein and/or Vena Cava

Autopsy records of renal adenocarcinoma cases were analyzed to investigate the mode of metastatic spread in instances of a tumor thrombus in the renal vein and/or vena cava. In this series of 1,828 cases 137 (7.5 per cent) had a tumor thrombus. Analysis revealed no significant differences in the incidence of the tumor thrombus between sexes or sides of primary renal involvement, or whether nephrectomy had been performed. The cases with a tumor thrombus showed higher frequencies of metastases in the liver, hepatic hilar lymph nodes and ureter, while metastases in the bones, contralateral kidney and brain were less frequent. The results suggest that bypass routes or lymphogenous spread of the tumor might be facilitated in some cases with a tumor thrombus.

The role of computed tomography in the initial staging and subsequent management of the lymphomas.

To assess the full potential of computed tomography (CT) in the investigation and management of malignant lymphomas, a series of 160 patients with both Hodgkin's and non-Hodgkin's lymphomas was reviewed. Eighty-eight patients were newly diagnosed and previously untreated, while the remaining 72 who had already received treatment presented either as problems of management or with suspected recurrence of the disease. Computed tomography compared favorably with lymphography as a valuable investigation in the assessment of abdominal and pelvic lymph node involvement. Furthermore, CT added extra information on the full extent of the disease, particularly in those areas not detectable by conventional studies (high paraaortic, retrocrural, mesenteric, splenic, and hepatic hilar nodes). The overall distribution of lymph node involvement both above and below the diaphragm in the two groups of lymphomas was assessed prior to treatment and any obvious differences noted. At the same time, extranodal involvement was analyzed and found to be more difficult to interpret. The value of CT in changing the staging across the diaphragm was recognized. Clinical, CT, and laparotomy findings were correlated in 22 untreated patients with Hodgkin's lymphoma. In conclusion, the role of CT in the initial treatment planning, in the subsequent monitoring of treatment response, and in the assessment of disease recurrence was evaluated.

Exploratory laparotomy and splenectomy in the diagnosis of Hodgkin's disease in children

Thirty-three children with histologically proved Hodgkin's disease underwent exploratory laparotomy with splenectomy and biopsy of lumbar lymph nodes, liver, and bone marrow. In 13 patients (39%) the lesion of spleen and/or splenic hilar lymph nodes was diagnosed. The involvement of spleen was mostly found in patients with mixed cellularity type, in the presence of systemic symptoms ("B"), and in the biological stage "b." Involvement of the liver was found in 1 patient, of the hepatic hilar lymph nodes in 3 patients, and of the bone marrow in 4 patients. The lymphographic and histologic data as regards lumbar lymph nodes coincided in 65% of cases. After operation the stage of the disease was changed in 48% patients. The early and late complications were not numerous.