Clinical Case Summary

A 62-year-old female, followed for hypothyroidism and is receiving Levothyroxine at a dosage of 100 µg daily, with a prior surgical removal of a subcutaneous lipoma located on the dorsal region, presented with isolated persistent postprandial vomiting over the past four months. Physical examination revealed mild dehydration; the abdomen was soft with no palpable mass. Laboratory tests showed a hypercalcemia, no other abnormalities were noted.
Gastroscopy revealed an erythematous gastric mucosa and a mass protruding into the antrum with normal overlying mucosa and a yellow hue; a sponge-like sinking impression was observed as the biopsy forceps was gently pushed into the lesion. Systematic gastric biopsies revealed a chronic nonspecific gastritis, the mass was not biopsied. An abdominal computed tomography (CT) scan depicted a gastric homogenous low-density mass of fatty tissue and three intramuscular masses with the same characteristics in the thigh, the largest measuring 5cm. the CT scan also revealed a suspicious osteolytic lesion of the iliac crest. An endoscopic ultrasound (EUS) showed a hypoechoic well-defined mass arising from the third parietal layer consistent with a lipoma. A thigh magnetic resonance imaging (MRI) revealed intramuscular lesions with the circumscribed, low attenuation mass compatible with lipomas. A biopsy of the osteolytic lesion revealed a multiple myeloma. The patient is scheduled to receive chemotherapy for the multiple myeloma as for the lipomas, no treatment was warranted.

Clinical Case Summary

A 58-year-old female patient with a history of repeated colon resections for fistulizing Crohn's disease on biological therapy with vedolizumab, comes in for dark urine and jaundice. Laboratory examination revealed elevated obstructive enzymes and bilirubin. Sonography showed dilated intrahepatic and extrahepatic bile ducts without signs of choledocholithiasis. We perform endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy. Cholangiogram shows irregular dilated left-sided bile ducts and unclear findings in the hilum area. A brush cytology was taken and a stent was inserted into the right-sided bile ducts. Reactive changes of biliary epithelia in inflammatory terrain were found in brush cytology. MRCP shows pathological masses in the hepatic junction, which have a higher signal than bile in T1W, similar changes in a short section of dist. choledochus just above the papilla. We performed a second ERCP with wedge biopsy and brush cytology from both hilum and distal choledochus, which were evaluated as malenoma metastasis. A review of the patient's medical history revealed the removal of malignant melanoma of the skin 7 years ago. The extent of the disease did not allow surgical resection and the patient was referred to a specialized centre for oncological treatment.
Conclusion: Metastasis of melanoma in the common bile duct is an extremely rare cause of jaundice. It should be thought of in patients with obscure masses in the bile ducts with hyperintense signal on T1W MR sequences. Taking a thorough medical history is particularly important.

Introduction

The clinical value of combined resection of important hepatic vessels in hilar cholangiocarcinoma remains controversial. We aimed to compare the short-term and long-term outcome of combined versus non-combined major vessel resection in patients undergoing radical resection for hilar cholangiocarcinoma.

Aims & Methods

This single centre retrospective cohort study of patients with hilar cholangiocarcinoma was conduct from January 2007 to December 2018. Patients who underwent radical re-resection were enrolled. The short-term and long-term clinical outcomes of the groups were compared after propensity score matching.

Results

A total of 310 patients were included. There was no statistically significant difference in perioperative clinical outcomes between VR group (PVR and AVR) and non-VR group after 1:2 PSM. Patients who received PVR had significantly longer OS (p=0.023) and DFS (p=0.010) compared to those in the non-PVR group. AVR group was associated with improved OS (p=0.036) and DFS (p=0.029) compared with non-AVR group following the curative-intent resection. The postoperative complications of combined VR would not worsen long-term survival for patients (OS: p=0.159; DFS: p=0.112).

Conclusion

Combined vascular resection (VR) would improve the long-term survival for patients with hilar cholangiocarcinoma. The postoperative complications of combined VR would not worsen long-term survival. Therefore, radical surgical resection should be actively performed in these patients.

Disclosure

The authors declare that they have no competing interests.

Introduction

Non-alcoholic steatohepatitis (NASH) is a chronic liver disease characterized by liver steatosis and inflammation which abnormal immune responses involved in pathogenesis, and there is no approved therapeutic drug. Rhein, one of the main bioactive components of Rheum palmatum, has exerted anti-inflammatory properties. However, the mechanism by which Rhein exerts beneficial effects against NASH is far from elucidated. Here, our study aimed to investigate the therapeutic effects of Rhein on liver steatosis and inflammation and elucidate the related mechanisms of immunoregulation.

Aims & Methods

Male C57BL/6 mice were given high-fat diet for 10 weeks to induce NASH, followed by Rhein suspension administration at a dose of 100mg/kg and 200mg/kg for 4 weeks. The therapeutic effect of NASH was estimated by body weight, liver weight, LW/BW, food intake, the liver appearance and the histological analysis of liver section stained with hematoxylin and eosin. The proportion of lymphocyte cells in the mesenteric lymph nodes (MLNs) was detected by flow cytometry.

Results

Our findings demonstrated that high-fat diet treatment resulted in severe liver inflammation and severe steatosis, while Rhein appreciably reverse these phenomenon, as evidenced by the reduction of body weight, liver wet weight, LW/BW, and liver size in mice. Histological analysis of liver section revealed that administration of Rhein exhibited improvement of severe steatosis, elimination of inflammatory cells and resolution of balloon-like changes when compared to mice in the HFD group. Interestingly, there were no significant differences in food intake among groups of mice, suggesting that the protective effect of Rhein is not achieved by inhibiting appetite. Mechanistically, flow cytometry analysis showed that higher Th1 and Th17 polarized response were detected in the MLN compartments in HFD-induced mice, evidenced by the detection of increased numbers of Th1 cells (CD3+CD4+IFN-γ+) and Th17 cells (CD3+CD4+IL-17+), and Rhein intervention showed significant decrease numbers of Th1 and Th17 in MLNs. In contrast, Rhein treatment significantly increased the numbers of Treg cells (CD3+CD4+Foxp3+) with anti-inflammatory effects in the MLN of NASH mice.

Conclusion

Our results provide novel insights into the protective role of Rhein in modulating the liver steatosis and inflammation, with therapeutic potential for immunology-targeted strategy in the treatment of NASH.

References

[1] Cheng L, Chen Q, Pi R, Chen J. A research update on the therapeutic potential of rhein and its derivatives. Eur J Pharmacol. 2021,899:173908. doi:10.1016/j.ejphar.2021.173908.
[2] Gebru YA, Gupta H, Kim HS, et al. T Cell Subsets and Natural Killer Cells in the Pathogenesis of Nonalcoholic Fatty Liver Disease. Int J Mol Sci. 2021,22(22):12190. doi:10.3390/ijms222212190

Disclosure

The authors declare that there are no conflicts of interest regarding the publication of this paper.