Segment 4 Research Articles

Volumetric Evaluation of 3D Multi-Gradient-Echo MRI Data to Assess Whole Liver Iron Distribution by Segmental R2* Analysis: First Experience.

MR transverse relaxation rate R2* has been shown to be useful for monitoring liver iron overload. A sequence enabling acquisition of the whole liver in a single breath hold is now available, thus allowing volumetric hepatic R2* distribution studies. We evaluated the feasibility of computer-assisted whole liver segmentation of 3 D multi-gradient-echo MRI data, and compared whole liver R2* determination to analyzing only a single slice. Also, segmental R2* differences were studied. The liver of 44 patients, investigated by multi-gradient echo MRI at 1.5 T, was segmented and divided into nine segments. Segmental R2* values were examined for all patients together and with respect to two criteria: average R2* values, and reason for iron overload. Correlation of single-slice and volumetric data was tested with Spearman's rank test, segmental and group differences were evaluated by analysis of variance. Whole-liver R2* values correlated excellent to single slice data (p < 0.001). The lowest R2* occurred in segment 1 (S1), differences of S1 with regard to other segments were significant in five cases and highly significant in two cases. Patients with high average R2* showed significant differences between S1 and segments 2, 6, and 7. Disease-related differences with respect to S1 were significant in segments 3 to 5 and 7. Our results suggest inhomogeneous hepatic iron distribution. Low R2* in S1 may be explained by its special vascularization. · Hepatic R2* distribution is not as homogeneous as previously thought.. · Liver segments might have a functional relevance.. · Segmental and total liver R2* values coincide best in segment 8.. · Wunderlich AP, Cario H, Kannengießer S et al. Volumetric Evaluation of 3D Multi-Gradient-Echo MRI Data to Assess Whole Liver Iron Distribution by Segmental R2* Analysis: First Experience. Fortschr Röntgenstr 2023; 195: 224 - 233.

Development of a rapid and sensitive reverse transcription real-time quantitative PCR assay for detection and quantification of grass carp reovirus II

Hemorrhagic disease of grass carp, which is induced by grass carp reovirus II (GCRV-II), leads to mass mortality in grass carp culture and causes enormous economic loss. However, there is currently no quantitative analysis method for the detection of GCRV-II, which is greatly restricted the etiological and epidemiological study of the disease. In this study a reverse transcription TaqMan PCR (RT-qPCR) assay was developed for the quantitative detection of GCRV-II. The probe and primers targeted location is the segment 6 (S6) region of the GCRV-II genome which is highly conserved. Standard curves were drawn and criteria were confirmed after the determination of the optimum reaction conditions. The species-specific assay showed that the method is highly specific and has no cross reactions with other pathogens. The assay was sufficiently sensitive to detect as low as 10 copies of virus RNA. Moreover, the method has a very good repeatability for batches and inter-batches sample detection. Then the method was applied to detect the virus in tissue samples from clinically infected grass carp, compared with conventional RT-seminested PCR, the RT-qPCR represents a specific value for detection rate of positive samples. In summary, the RT-qPCR was applied and achieved high sensitivity and specificity for GCRV-II detection.

Binding epitope for recognition of human TRPM4 channel by monoclonal antibody M4M

Mouse monoclonal antibody M4M was recently designed to block human TRPM4 channel. The polypeptide for generating M4M is composed of peptide A1 between the transmembrane segment 5 (S5) and the pore, and a second peptide A2 between the pore and the transmembrane segment 6 (S6). Using peptide microarray, a 4-amino acid sequence EPGF within the A2 was identified to be the binding epitope for M4M. Substitution of EPGF with other amino acids greatly reduced binding affinity. Structural analysis of human TRPM4 structure indicates that EPGF is located externally to the channel pore. A1 is close to the EPGF binding epitope in space, albeit separated by a 37-amino acid peptide. Electrophysiological study reveals that M4M could block human TRPM4, but with no effect on rodent TRPM4 which shares a different amino acid sequence ERGS for the binding motif. Our results demonstrate that M4M is a specific inhibitor for human TRPM4.

Mucinous cystic neoplasm of the liver with polypoid nodule prolapsing into the bile duct: a case report and review of literature

BackgroundMucinous cystic neoplasm of the liver (MCN-L) is a rare cystic tumor as defined by the 2010 World Health Organization classification. MCN-L usually does not communicate with or grow into the bile duct. Herein, we present a rare case of MCN-L with a polypoid nodule protruding into the bile duct.Case presentationA 69-year-old woman was referred to our hospital for elevated serum liver enzyme levels and obstructive jaundice. The patient also complained of abdominal pain in the right hypochondriac region. Abdominal ultrasonography showed a cystic lesion in segment 4 (S4) of the liver. Computed tomography revealed a 4-cm multilocular cystic lesion with a thick wall and multiple septal formations, showing a cyst-in-cyst appearance in S4. Endoscopic retrograde cholangiography showed a contrast defect between the left hepatic duct and the common bile duct, which was suspected to be a nodular lesion in the bile duct. Bile cytology and biopsy of the nodular lesion showed no malignant findings. Based on these findings, the differential diagnosis in this patient included intraductal papillary neoplasm of the bile duct and MCN-L, which had malignant potential. The patient underwent left hemihepatectomy, including caudate lobe excision with bile duct resection and right hepatocholangiojejunostomy. Macroscopic findings showed a 40 × 29 mm multilocular cystic lesion with a polypoid nodule that protruded into the left intrahepatic bile duct. As an ovarian-like stroma was observed in both cystic and polypoid lesions microscopically, the histopathological diagnosis was MCN-L. The postoperative course was uneventful, and the patient was discharged 24 days after surgery. The patient is currently alive without recurrence 22 months after the surgery.ConclusionAlthough MCN-L rarely communicates with the bile duct, it is necessary to consider that MCN-L could grow into the bile duct, occasionally causing obstructive jaundice.

Standardized and Feasible Laparoscopic Approach for Tumors Located in the Caudate Lobe

Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure. Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy. In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis. Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach.

Laparoscopic liver resection of segment 8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein

BackgroundPure laparoscopic liver resection (LLR) of segment 8 (S8) is still rarely performed due to the lack of an appropriate surgical approach. This article discusses the technical tips and operation methods for LLR of S8 via a hepatic parenchymal transection-first approach.MethodsClinical data of 22 patients who underwent LLR of S8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein (MHV) in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from May 2017 to February 2020 were retrospectively analyzed.ResultsThe mean age was 51.1 ± 11.6 years; mean operation time, 186.6 ± 18.4 min; median blood loss, 170.0 ml (143.8–205.0 ml); and median length of hospital stay, 8.0 days (7.0–9.0 days). There was no case of open conversion. Pathologic findings revealed all cases of hepatocellular carcinoma (HCC). Pathology showed free surgical margins. Post-operative complications included liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. All patients survived tumor-free.ConclusionsLLR of S8 is still quite challenging at present, and it is our goal to design a reasonable procedure with accurate efficacy and high safety. We use hepatic parenchymal transection-first approach guided by the MHV for LLR of S8. This technique overcomes the problem of high technical risk, greatly reduces the surgical difficulty and achieves technological breakthroughs, but there are still many problems worth further exploration.

Optimal Ablation Settings Predicting Durable Scar Detected Using LGE-MRI after Modified Left Atrial Anterior Line Ablation.

(1) Background: The modified anterior line (MAL) has been described as an alternative to the mitral isthmus line. Despite better ablation results, achieving a bidirectional line block can be challenging. We aimed to investigate the ablation parameters that determine a persistent scar on late-gadolinium enhancement magnet resonance imaging (LGE-MRI) as a surrogate parameter for successful ablation 3 months after MAL ablation. (2) Methods: Twenty-four consecutive patients who underwent a MAL ablation have been included. The indication for MAL was perimitral flutter (n = 5) or substrate ablation in the diffuse anterior left atrial (LA) low-voltage area in persistent atrial fibrillation (AF) (n = 19). The MAL was divided into three segments: segment 1 (S1) from mitral annulus to height of lower region of left atrial appendage (LAA) antrum; segment 2 (S2) height of lower region of LAA antrum to end of upper LAA antrum; segment 3 (S3) from end of upper LAA antrum to left superior pulmonary vein. Ablation was performed using a contact force irrigated catheter with a power of 40 Watt and guided by automated lesion tagging and the Ablation Index (AI). The AI target was left to the operator’s choice. An inter-lesion distance of ≤6 mm was recommended. The bidirectional block was systematically evaluated using stimulation maneuvers at the end of procedure. All patients underwent LGE-MRI imaging at 3 months, regardless of symptoms, to identify myocardial lesions (scars). (3) Results: Bidirectional MAL block was achieved in all patients. LGE-MRI imaging revealed scarring in 45 of 72 (63%) segments. In all three segments of MAL, ablation time and AI were significantly higher in scarred areas compared with non-scar areas. The mean AI value to detect a durable scar was 514.2 in S1, 486.7 in S2 and 485.9 in S3. The mean ablation time to detect a scar was 20.4 s in S1, 22.1 s in S2 and 20.2 s in S3. Mean contact force and impedance drop were not significantly different between scar and non-scar areas. (4) Conclusions: Targeting optimal AI values is crucial to determine persistent left atrial scars on an LGE-MRI scan 3 months after ablation. AI guided linear left atrial ablation seems to be effective in producing durable lesions.

First report of successful isolation of a HPR0-like variant of the infectious salmon anaemia virus (ISAV) using cell culture.

ISAV is the causative agent of the infectious salmon anaemia (ISA), a disease listed by the OIE that has caused important economic losses to the Atlantic salmon (Salmo salar) industry. ISAV variants are identified as pathogenic or non‐pathogenic based on the presence or absence of a deletion in the highly polymorphic region (HPR) of segment 6 (S6). HPRΔ variants (pathogenic) are the only forms of the virus known to grow in cell culture. This is the first report of a HPR0 variant isolated in cell culture. The isolate is, however, atypical as it shows a marker of virulent variants on another segment (S5), which has never been reported for any other HPR0 variants. The significance of this finding remains unclear until more in‐depth work is carried out but does challenge current knowledge.

Expression and purification of S5196-272 and S6200-317 proteins from Tilapia Lake Virus (TiLV) and their potential use as vaccines

Tilapia Lake Virus Disease (TiLVD) is caused by Tilapia Lake Virus (TiLV), and it has a cumulative mortality rate of up to 90% in Nile tilapia (Oreochromis niloticus). TiLV is a negative enveloped single-stranded RNA virus with 10 genomic segments. Segment 5 (S5) and segment 6 (S6) were predicted to include a signaling peptide, suggesting that the encoded proteins of these two segments may exist as part of the virus envelope. Based on bioinformatic predictions, the S5 and S6 proteins in this study were produced, including S527-343, S527-172, S5196-272, S630-317, S630-190, and S6200-317. All proteins were tested for their expression in Escherichia coli. Only S5196-272 and S6200-317 were expressed as soluble and insoluble proteins, respectively. The soluble protein was purified using affinity chromatography, whereas the insoluble protein was solubilized using 6 M urea lysis buffer before purification. Both proteins were further purified using gel filtration chromatography, and the results showed a symmetric peak of both proteins suggested a high degree of uniformity in the conformation of these proteins. Antigenicity results indicated that these proteins were recognized by serum from TiLV-infected fish. The immunization tests revealed that serum antibodies levels in Nile tilapia produced by S5196-272 and S6200-317 were significantly increased (p-value < 0.05) at 7 days post-immunization (dpi) compared to antibody levels on Day 0 (D0). All the results combined suggested a potential vaccine candidate of S5 and S6 for TiLV protection in Nile tilapia.

A case of laparoscopic partial hepatic S7 resection for postoperative liver metastasis of rectal malignant melanoma

BackgroundAnorectal malignant melanoma (ARMM) has an extremely poor prognosis, and there is no report of resection of liver metastases so far. We report herein a rare case of postoperative laparoscopic partial hepatic S7 resection for rectal malignant melanoma.Case presentationA 51-year-old female patient with a diagnosis of an ARMM underwent a laparoscopic rectal amputation. Eleven months later, computed tomography (CT) revealed a 14-mm nodule in liver segment 7 (S7), which was diagnosed as a hepatic recurrence of the ARMM. Because no other recurrences were found, a laparoscopic partial resection of S7 was performed. Pathological analysis found intracellular melanin deposition, and immunostaining was S-100 (+), HMB-45 (+), and SOX-10 (+). Based on these findings, a liver metastasis of malignant melanoma was diagnosed. The patient is alive 7 months after the second surgery and has so far experienced no recurrences.ConclusionWe reported an extremely rare case of a laparoscopic resection of a liver metastasis following surgery for ARMM.

Left Intercostal Approach for Laparoscopic Isolated Total Caudate Lobectomy (with Video)

BackgroundLaparoscopic total caudate lobectomy remains a challenging procedure because of its deep location (Xu et al., Surg Endosc. 35:1138–47, 2021). Placement of intercostal ports can overcome the barriers of the ribcage for laparoscopic access (Hayashi et al., PLoS One.15:e0234919, 2020). We herein present a novel technique in which a left intercostal port was used as the main working port during laparoscopic caudate lobectomy. MethodsAn 84-year-old man with a 1-cm intrahepatic cholangiocarcinoma located in segment 1 (S1) was referred to our hospital. We planned laparoscopic isolated caudate lobectomy using a left intercostal port as the main working port. The patient was placed in the supine position. A 12-mm left intercostal port with a balloon was introduced in the seventh intercostal space as the main working port. After Arantius’ ligament was divided, the left Glissonean pedicle of S1 (G1) was divided using an endo-stapling device. The surgeon moved to the right side of the patient and divided the right G1, followed by transection to the inferior right hepatic vein. Again, the surgeon moved to the left side, and the left intercostal port was used for mobilization of the Spiegel lobe and parenchymal resection using a cavitron ultrasonic surgical aspirator, exposing the root of the left and middle main hepatic veins for completion of total caudate lobectomy. ResultsThe operative time was 264 min and blood loss was 400 mL. The patient was discharged on a postoperative day 9 without complications. ConclusionsA laparoscopic approach to the caudate lobe using a left intercostal port is a new and ideal technique providing effective manipulation.

Laparoscopic ultrasound-guided superselective portal vein injection combined with real-time indocyanine green fluorescence imaging and navigation for accurate resection of localized intrahepatic bile duct dilatation: a case report

BackgroundPrimary intrahepatic bile duct dilatation can be very harmful to patients although it belongs to benign biliary disease. It can occur in any part of the liver, intraoperative laparoscopic ultrasound (LUS) guidance combine with real-time indocyanine green (ICG) fluorescence navigation are the means of choice for accurate surgical resection.Case presentationHerein we reported a 43-year-old female patient presented with repeated right upper abdominal pain and distension for 3 years and aggravated for half a year, without fever and jaundice. A diagnosis of localized bile duct dilatation with lithiasis in segment 4 (S4) was made on the basis of preoperative imaging. Correspondingly, we selected to perform a laparoscopic surgery with LUS guided real time ICG fluorescence imaging (ICG-FI) and navigation to make the operation more simply and accurately, as well as to retain normal tissues in a certain extent. Laparoscopic resection of S4b and partial S4a was successfully performed, without any complications.ConclusionLaparoscopic anatomical surgery for intrahepatic bile duct dilatation is a technically challenging operation. The combined use of preoperative three-dimensional computerized tomography (CT) planning, intraoperative LUS guided super-selection, ICG hepatic segment staining and real-time fluorescence navigation could help surgeons accurately complete the segmentectomy or subsegmentectomy with minimized trauma and maximized liver tissue preservation.

Laparoscopic Anatomic Liver Resection of the Dorsal Part of Segment 8 Using an Hepatic Vein-Guided Approach

Laparoscopic anatomic liver resection is considered highly challenging, especially in segment 8 (S8), owing to the limited angle of the laparoscope and limited manipulation of the surgical instrument1,2. Additionally, resection is technically difficult when approaching the more peripheral branches since the Glissonean pedicle of S8 has several variations3 and is far from the hepatic hilum. The hepatic vein (HV)-guided approach involves entering from the cranial side of the liver while overcoming these difficulties with the unique view and techniques of laparoscopy4,5. We describe laparoscopic anatomic resection of the dorsal part of S8 using the HV-guided approach for hepatocellular carcinoma. The drainage vein of segment 8 (V8), which often runs between the ventral and dorsal parts of S86,7, was exposed from the confluence of the middle HV to the periphery. The dorsal Glissonean branch of S8 (G8dor) was identified by deep dissection of the parenchyma on the right side of the V8. The right HV (RHV) was exposed toward the periphery after dissecting the G8dor. Liver parenchymal dissection was completed by connecting the demarcation line and the RHV. The total operation time was 319 min, estimated blood loss was 5mL, and the patient was discharged on postoperative day 6 with no complications. Laparoscopic anatomic resection of the dorsal parts of S8 could be safely performed by exposing the HVs from their roots and using the HVs as a landmark to identify the intrahepatic Glissonean pedicles.

Possible spontaneous regression of hepatocellular carcinoma with unique histopathological features confirmed by surgical resection: a case report

BackgroundSpontaneous regression of hepatocellular carcinoma (HCC) is a rare event, and its clinicopathological features and underlying mechanism are not fully understood.Case presentationAn 84-year-old female with hepatitis C virus infection and diabetes mellitus was referred to our hospital for further examination. Abdominal ultrasonography showed a 3.4-cm solid tumor with a heterogeneous irregular center and no fibrous capsule in liver segment 8 (S8). An enhanced computed tomography (CT) scan revealed a tumor in S8 with heterogeneous enhancement in the arterial phase and washed out insufficiently in the portal and equilibrium phase. The enhanced pattern on magnetic resonance imaging was similar to that of CT. Although the imaging findings were not typical for HCC, liver resection (S8) was performed with HCC as the most probable diagnosis. Histopathological examination of the resected specimen showed that the tumor was well to moderately differentiated HCC with unique features. Approximately half of the tumor was composed of well-differentiated HCC that was focally accompanied by dense lymphocyte infiltration. The other half of the tumor was fibrotic tissue that resembled an inflammatory pseudotumor. Several foci of moderately differentiated HCC were scattered within the tumor with a nodule-in-nodule appearance, and the foci totally showed coagulative necrosis. On immunostaining, lymphocytes in the tumor stroma were positive for CD8 and programmed death 1. The expression of programmed death-ligand 1 was observed in carcinoma cells and macrophages specifically within the lymphocyte-rich area of HCC.ConclusionsWe consider this case representative of spontaneous regression of HCC, and the immune response against HCC might contribute to tumor regression, leading to complex histopathological appearances. This case may provide insight into the mechanism of spontaneous regression of HCC.

Laparoscopic anatomical S8 segmentectomy by Glissonian approach after dissection of the midplane of the liver

Anatomical resection of the liver in HCC is important in terms of oncologic benefit. However, laparoscopic anatomical segment 8 (S8) resection is anatomically complex and technically difficult. Ultrasonography guided dye or ICG injection technique can be a good option, but it is technically demanding and experience dependent. A 56-year-old female with underlying chronic hepatitis B virus was diagnosed with 1.8 cm sized HCC in S8. The tumor was suspected of the microvascular invasion near the middle hepatic vein (MHV) in MRI. Laparoscopic ultrasonography was used to identify the location of mass and the relation to the vasculature. The lower 2/3 of the midplane of the liver was dissected. The branches of MHV draining S4 were divided to get resection margin. After dissection around the right anterior Glissonian pedicle, ligation of S8 pedicle was done. Then, lateral border of S8 was dissected along the ischemic line. MHV was crossed over during the dissection of the upper 1/3 of the midplane of the liver. S8 was anatomically resected. The operative time was 185 minutes, and the estimated blood loss was 100 mL. The final pathology was HCC and the size of tumor was 18 mm with 2 cm safety margin. Follow up CT scan showed congestion in S4 and S5, but no other problems. The patient was discharged on postoperative day 5 without complication. Laparoscopic anatomical resection of S8 using Glissonian approach after dissection of the midplane of the liver was feasible and it is simpler and easier to apply than dye injection technique.

High Incidence of Anterior Cruciate Ligament Injuries Within the First 2 Months of the Season in Amateur Team Ball Sports.

The incidence of anterior cruciate ligament (ACL) injuries is commonly reported as an annual incidence rate. There is relatively little information about the seasonal aspects of these injuries. The aim of the current study was to analyze the distribution of ACL injuries during the season in nonprofessional soccer, handball, and basketball based on a retrospective analysis of a hospital-based registry. ACL injuries in soccer, handball, and basketball were more common within the first 2 months of the season in comparison with the rest of the year. Case series. Level 4. Injury occurrence during the calendar year was divided into 6 periods of 2 months, with segment 1 (S1) representing the first 2 months of the season. For soccer, S1 corresponded to September and October. The season started 1 month later for handball and basketball, so S1 represented October and November. Chi-square tests were used to analyze the distribution of ACL injuries among segments according to gender, age, sports, and injury mechanism (contact/noncontact). A total of 371 ACL injuries were included (soccer, 258, handball, 56, basketball, 57). Overall, the distribution of ACL injuries was not uniform across the segments (P < 0.01). Almost one-third of the ACL injuries occurred in S1 (n = 104; 28%). Significant differences could be observed according to sports (P < 0.01). There were fewer ACL injuries in S2 for soccer compared with basketball (P < 0.05). In S5, there were significantly more ACL injuries in soccer compared with handball and basketball (P < 0.05). A high occurrence of ACL injuries was reported immediately within the first 2 months of the season in nonprofessional soccer, handball, and basketball sports. These findings indicate that ACL injury prevention programs should be started in the preseason period to allow for gradual increases of load.

Robotic left ventral segmentectomy.

We present a video of an 84-year-old woman, a former smoker (30 packs per year) diagnosed with suspected stage I (cT2 N0 M0) primary lung cancer in the left segment 3 (S3). The patient's medical history included moderate chronic obstructive pulmonary disease, obstructive sleep apnea syndrome, and cerebral aneurysm. Considering the high surgical risk (eg, age, diffusing capacity for carbon monoxide, and pathological underlying lungs) she was scheduled for a robotic S3 segmentectomy with radical node harvest.

Pancreaticoduodenectomy for hepatic portal lymph node metastasis after hepatic resection for hepatocellular carcinoma: A clinical case report.

IntroductionIn 2018, Hepatocellular carcinoma (HCC) was predicted to be the sixth most commonly diagnosed cancer. Extra-hepatic metastasis due to HCC is a poor prognostic factor, depending on the stage of the disease.Presentation of caseWe report a case of a 52-years old male who had undergone Segment 5 (S5) hepatectomy for HCC of 4.7 × 2 cm. Transcatheter arterial chemoembolization (TACE) four times postoperatively was performed based on a preoperative diagnosis of a recurrent tumour at the S1. After 2 years, the solitary tumour (7.5 × 2.5 × 3.5 cm) is located behind the right lobe of the liver and the head of the pancreas. The tumour was abnormally supplied with blood from the superior mesenteric artery (SMA) and the gastroduodenal artery (GDA). The patient was underwent pancreaticoduodenectomy (PD) to remove a large tumour. Postoperative pathology and immunohistochemical staining showed metastatic HCC. There was no tumour recurrence after 6 months.DiscussionThe organs in the body that liver cancer cells most often spread to are the lungs (44%), the portal vein (35%), the hepatobiliary ganglion (27%), and a small number of cases of bone, eye socket, bronchus metastases. Otherwise, recurrence of lymph nodes (LNs) after hepatectomy for HCC is very rare.ConclusionsHCC can metastasize to the hepatic pedicle LN after hepatectomy and maybe confused with recurrent liver tumours in the S1. Indications for PD are feasible for solitary metastatic at peri-pancreas. Pathology incorporating immunohistochemistry can determine the origin of metastases.

A case of simultaneous abdominal wall metastasis of hepatocellular carcinoma with long-term relapse-free survival after laparoscopic resection

We report our experience of an extremely rare case of a simultaneous extrahepatic metastasis of hepatocellular carcinoma (HCC) with long-term relapse-free survival, treated by laparoscopic resection of an abdominal wall tumor and subsequent radiofrequency ablation (RFA) of an intrahepatic lesion. A 76-year-old man visited a local clinic for right lower abdominal pain. He was treated with antibiotics and the symptom resolved. However, a mass was detected in the same region and he was referred to our hospital for further evaluation. Computed tomography (CT) of the abdomen showed a mass 5 cm in diameter, raising suspicions of an intra-abdominal tumor. Laparoscopic surgery was performed, and the tumor was found in the abdominal wall and completely resected. Histopathological examination yielded a diagnosis of extrahepatic HCC. Post-operative positron emission tomography (PET)-CT showed increased uptake of fluorodeoxyglucose in segment 3 (S3) of the liver. On performing a liver biopsy, HCC was diagnosed. Subsequently, the S3 lesion was treated with radiofrequency ablation. The patient has remained relapse-free for 6 years without further treatments.

Laparoscopic hepatectomy for hepatic angiomyolipoma with preoperative diagnosis of other malignancy: a report of 2 cases

BackgroundHepatic angiomyolipoma (HAML) is a rare liver tumor, and hepatectomy is the only effective treatment. Due to the difficulty of correct diagnosis of HAML before surgery by image studies, more than 36.6% of reported HAMLs are misdiagnosed as other malignant liver tumors before surgery. As there are only few reported cases in which HAMLs were removed using laparoscopic hepatectomy, the effectiveness of laparoscopic hepatectomy for such HAMLs in which are diagnosed as other malignant liver tumor before surgery has not been reported.Case presentationCase 1: a 58-year-old female with a history of treatment for autoimmune hepatitis was preoperatively diagnosed with hepatocellular carcinoma (size: 20 mm) in segment 7 (S7) of the liver. The tumor was removed by laparoscopic partial resection and was diagnosed as a HAML through a pathological examination. The patient’s postoperative course was good, and she was recurrence-free at 37 months after the hepatectomy. Case 2: a 29-year-old female with a history of surgery for a right mature cystic teratoma was referred to our department to receive treatment for a growing 20-mm liver tumor with some calcification, which arose in S3 of the liver. A metastatic liver tumor derived from the mature cystic teratoma was suspected, and laparoscopic left lateral sectionectomy was performed. The liver tumor was diagnosed as a HAML after a pathological examination. The patient’s postoperative course was unremarkable, and more than 54 months have passed since the hepatectomy without any recurrence.ConclusionsTwo cases in which HAMLs were preoperatively diagnosed as other malignant liver tumor were successfully removed by laparoscopic hepatectomy with a correct postoperative diagnosis. Laparoscopic hepatectomy for the present 2 cases of HAML seemed to be effective for providing a correct diagnosis after the curative removement of liver tumor with a smaller invasion compared to open hepatectomy, and for denying risk of dissemination of the malignant tumor by needle biopsy that had to be considered before ruling out malignant tumor.