Novel Strategy for Diagnosis of Focal Nodular Hyperplasia Using Gadolinium Ethoxybenzyl Diethylenetriaminepentaacetic Acid: Enhanced Magnetic Resonance Imaging and Magnetic Resonance Elastography

Focal nodular hyperplasia (FNH) is the second most frequent benign liver tumor, and it is a fiber-rich stiff lesion. Typically, FNH can be diagnosed by imaging without biopsy. However, liver biopsy and diagnostic resection may be required to differentiate atypical FNH from other liver tumors, such as hepatocellular adenoma (HCA). Therefore, improved noninvasive diagnostic methods are needed. We experienced 2 cases where combination of magnetic resonance elastography (MRE) and gadolinium ethoxybenzyl diethylenetriaminepentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) helped diagnose FNH. A 36-year-old woman and 17-year-old boy with liver tumors measuring 40 mm in diameter each showed hypointense nodule centers, indicating a central scar, surrounded by hyperintense signals during the hepatobiliary phase of Gd-EOB-DTPA-enhanced MRI. To rule out HCA, we performed MRE and liver biopsy. On MRE, the mean stiffness of the mass was 11.6 kPa (mean stiffness of the background liver was 1.7 kPa) and 11.1 kPa (mean stiffness of the background liver was 2.4 kPa) in the first and second patients, respectively. Histological examination of both specimens showed CK7-positive bile-ductular proliferations, abundant fibrous tissue, and few Ki-67-positive cells. Based on these results, we diagnosed these tumors as FNH. Combination of Gd-EOB-DTPA-enhanced MRI and MRE can evaluate the character and stiffness of lesion and help in the diagnosis of FNH

Down-regulation of hepatic AMP-activated protein kinase and up-regulation of CREB coactivator CRTC2 for gluconeogenesis under calorie-restricted conditions at a young age

AMP-activated protein kinase (AMPK) is a key molecule that controls energy homeostasis at cellular and whole body levels. Calorie restriction (CR) may exhibit the anti-aging effect through modulation of AMPK activity. We investigated the hepatic AMPK pathways for gluconeogenesis (the transducer of regulated cyclic adenosine monophosphate response element-binding protein (CREB) 2; CRTC2) and cell growth (mammalian target of rapamycin, mTOR). Male F344 rats at 2.5 months (mo) and 18 mo of age were subjected to 4-mo-long 30% CR; control rats were fed ad libitum (AL) throughout the experiment. Rats were killed 15 min after saline or glucose injection to evaluate activation of signal molecules under transient hyperglycemic and subsequent hyperinsulinemic conditions. Western blot analyses demonstrated a modest reduction of threonine-172-phosphorylated (p)-AMPKα levels and an increment of nuclear CRTC2 in the young CR group as compared with the agematched AL group. We also confirmed the increased binding of CRTC2 and CREB and up-regulation of gluconeogenic genes (PGC-1α and PEPCK) in the CR group. However, there was no CR-specific alteration in total or phosphorylated mTOR levels. The results suggest down-regulation of hepatic AMPK activity by CR for metabolic adaptation that promotes gluconeogenesis. The effect of CR on mTOR remains elusive

Giant Hepatic Cyst with Septal Structure: Diagnosis and Management

The hepatic cyst is a common benign liver tumor, and no surgical treatment is necessary. However, it is difficult to correctly diagnose the giant hepatic cyst containing the solid septal structures inside, from the malignant cystadenocarcinomas. The various imaging modalities such as computed tomography, magnetic resonance imaging, and ultrasonography, have been developed and are useful for the diagnosis of these liver tumors. Reviewing the other reports in this paper, the combination of more than 2 modalities will help to diagnose these tumors; however, the malignant potential is unable to be excluded if the tumor is huge. Therefore, the surgical resection should be considered for the huge hepatic cysts with septal structures if the correct diagnosis is unable to be made. For example, when the hemorrhages cause the granulation in the septa which often shows neovascularization, the imaging modalities are unable to define this situation from the malignant tissue with hypervascularity. Therefore, with the careful review of other reports, we conclude that if the imaging studies show the possible malignant potential or the sizing-up is marked, the surgical treatment should be considered with the consent from the patients

Early Detection of Hepatocellular Carcinoma Recurrence Using the Highly Sensitive Fucosylated Fraction of Alpha-Fetoprotein

Alpha-fetoprotein (AFP)-L3 was originally reported as a hepatocellular carcinoma (HCC)-specific tumor marker, and recent accumulation of evidence has revealed that AFP-L3 frequency predicts the biological malignancy potential of HCC. However, AFP-L3 elevation from undetectable levels after curative treatment could not be discussed due to the difficulties of calculating AFP-L3 concentrations when serum AFP levels were low. Here, as a novel method, we used highly sensitive AFP-L3 frequency to predict HCC recurrence after curative treatment. Our cases illustrate that recognizing elevation of AFP-L3 from undetectable levels led to the early detection of recurrent HCC due to more careful surveillance

EpCAM- and/or NCAM-Expressing Hepatocellular Carcinoma in Which Behavior of Hepatic Progenitor Cell Marker-Positive Cells Are Followed

Hepatic progenitor cell (HPC) marker-positive hepatocellular carcinomas (HCCs) have recently been extensively analyzed, and their prognosis has been reported as poor compared to HPC marker-negative HCCs. However, previous studies have analyzed the existence of HPC marker-positive cancer cells only in primary lesions, as well as the recurrence rate and prognosis of such tumors. Here, we are the first to report the behavior of HPC marker-positive cancer cells during vascular invasion and metastasis of an HCC. We concurrently analyzed EpCAM- and/or NCAM-expressing cancer cells in the primary, vascular invasion, and metastatic lesions of an HCC. An HCC which includes EpCAM- and/or NCAM-expressing cancer cells has not been previously reported. EpCAM- and/or NCAM-positive cancer cells invaded the vessels and formed heterogeneous populations of these HPC marker-positive cancer cells with HPC marker-negative cancer cells. The frequency of HPC marker-positive cancer colonies and cells in vessels was higher than that in the primary HCC. In the metastatic lesions, EpCAM-positive cancer cells were more frequently detected than NCAM-positive cancer cells, indicating that EpCAM may be more important than NCAM for cancer cell settlement in the metastatic lesions. Furthermore, bigger metastatic tumors tended to include HPC marker-positive cancer cells, suggesting that HPC marker-positive cancer cells have a growth advantage in the metastatic lesions. These results showed that HPC marker-positive cancer cells would be important for vascular invasion and metastasis and suggested that HPC marker-positive cancer cells are an important target in HCC treatment

Down-regulation of hepatic AMP-activated protein kinase and up-regulation of CREB coactivator CRTC2 for gluconeogenesis under calorie-restricted conditions at a young age

AMP-activated protein kinase (AMPK) is a key molecule that controls energy homeostasis at cellular and whole body levels. Calorie restriction (CR) may exhibit the anti-aging effect through modulation of AMPK activity. We investigated the hepatic AMPK pathways for gluconeogenesis (the transducer of regulated cyclic adenosine monophosphate response element-binding protein (CREB) 2; CRTC2) and cell growth (mammalian target of rapamycin, mTOR). Male F344 rats at 2.5 months (mo) and 18 mo of age were subjected to 4-mo-long 30% CR; control rats were fed ad libitum (AL) throughout the experiment. Rats were killed 15 min after saline or glucose injection to evaluate activation of signal molecules under transient hyperglycemic and subsequent hyperinsulinemic conditions. Western blot analyses demonstrated a modest reduction of threonine-172-phosphorylated (p)-AMPKα levels and an increment of nuclear CRTC2 in the young CR group as compared with the agematched AL group. We also confirmed the increased binding of CRTC2 and CREB and up-regulation of gluconeogenic genes (PGC-1α and PEPCK) in the CR group. However, there was no CR-specific alteration in total or phosphorylated mTOR levels. The results suggest down-regulation of hepatic AMPK activity by CR for metabolic adaptation that promotes gluconeogenesis. The effect of CR on mTOR remains elusive

Diverse perspectives to address for the future treatment of heterogeneous hepatocellular carcinoma

Hepatocellular carcinomas (HCCs), which often arise from chronic liver damage, have poor conditional 5-year survival and are recognized as heterogeneous tumors. Considering the heterogeneity of HCCs, diverse perspectives need to be addressed for treating such tumors, besides the findings of conventional imaging modalities and tumor markers. Data from the latest technologies, such as liquid biopsy, and the detection of the presence of cancer cells with stem/progenitor cell markers, gene mutations and diverse pathways, crosstalk with immune cells and cancer-associated fibroblasts, and mechanisms of epithelial–mesenchymal transition provide diverse lines of information. Integration of these data with clinical data might be necessary to develop effective therapies for precision medicine. Here, we review several aspects of dealing with the complexity of heterogeneous HCCs