Glutamine synthetase immunostaining correlates with pathologic features of hepatocellular carcinoma and better survival after radiofrequency thermal ablation

Purpose: Activation of the wnt pathway identifies a subgroup of hepatocellular carcinomas (HCC) with specific epidemiologic and genetic profiles. Wnt activation is predicted by mutation and/or nuclear translocation of β-catenin and by glutamine synthetase (GS) immunoreactivity. We investigated whether GS staining associates with specific pathologic features of HCC and with survival after radiofrequency thermal ablation. Experimental Design: Monoistitutional retrospective-prospective study in a tertiary hospital setting. Two hundred and seven cirrhotics (mean age, 70 years; 63% males, 82.1% hepatitis C virus positive) with early HCC were consecutively treated with radiofrequency thermal ablation (RFTA). Mean tumor size was 2.7 cm; 20.3% of patients had multiple nodules; and median follow-up was 36 months with 54.6% overall mortality. Tumor samples were mainly obtained by biopsy (92,5%) and examined by H&E and immunostaining for β-catenin and GS. Main outcome measures were overall and tumor-specific mortality by Kaplan-Meier analysis and Cox proportional hazard models corrected for competing risks. Results: Ninety-one patients (43.9%) had GS-positive HCCs by immunostaining. These tumors had larger size (P = 0.012) and characteristic histology (low grade, pseudoacini, hydropic changes, bile staining, lack of steatosis, and fibrosis). Other clinical or treatment variables were similar between groups. Variables correlating with tumor-specific and overall mortality by univariate analysis were tumor recurrence, advanced disease, posttreatment α-fetoprotein levels, and GS staining. Yearly, overall mortality rate was lower in GS-positive patients (12.4 versus 20% yearly; P = 0.006). By multivariate analysis, GS immunostaining correlated with reduced specific (hazard ratio, 0.58; 95% confidence interval, 0.34-0.97) and overall mortality (hazard ratio, 0.62; 95% confidence interval, 0.40-0.96). Conclusions: Standard histology and GS status identify a HCC subset with distinct clinical and pathologic features

Abdominal spilled stones: ultrasound findings

Laparoscopic cholecystectomy (LC) is the treatment of choice for uncomplicated symptomatic gallstones. Spillage of stones due to gallbladder rupture has been reported in up to 33% of all LCs, but clinical sequelae caused by dropped gallstones are uncommon. We recently observed two patients with retained stones after LC. Correct diagnosis was made by abdominal ultrasonography (US) in both cases. In the first patient, who presented with fever, malaise, and weight loss 18 months after LC, abdominal US revealed hypoechoic focal lesions containing hyperechoic images with posterior shadowing of the liver and spleen. US-guided aspiration biopsies of these lesions yielded purulent material, and the injection and aspiration of saline solution provoked rolling movements of the hyperechoic images. Laparotomy confirmed the diagnosis of abscess-containing spilled gallstones. In the second patient, multiple hyperechoic images with posterior shadowing were observed in the Morison pouch during a routine US examination. The diagnosis of retained stones was consistent with the history of gallstone spillage during LC performed 2 months previously and was confirmed by computed tomographic findings of hyperdense images in the Morison pouch. The patient was asymptomatic, and treatment was thus deferred. Our experience suggests that US can be very useful in the detection of gallstones spilled during LC

Rabeprazole is equivalent to omeprazole in the treatment of erosive gastro-oesophageal reflux disease. A randomised, double-blind, comparative study of rabeprazole and omeprazole 20 mg in acute treatment of reflux oesophagitis, followed by a maintenance open-label, low-dose therapy with rabeprazole

Background.: Previous studies have shown similar effects of rabeprazole and omeprazole, when used at the same dose in the treatment of reflux oesophagitis. However, such studies have been conducted as superiority studies but interpreted as equivalence ones. Aim.: To properly assess the comparative efficacy of rabeprazole and omeprazole in inducing complete endoscopic healing and symptom relief in patients with reflux oesophagitis. Methods.: Patients (n = 560) with Savary-Miller grade I-III reflux oesophagitis were randomised in a double-blind, double-dummy fashion to rabeprazole or omeprazole 20 mg once daily for 4-8 weeks. Then, patients endoscopically healed and symptomatically relieved were openly maintained with rabeprazole 10 mg or 2 × 10 mg once daily (in the event of clinical and/or endoscopic relapse) for a maximum of 48 weeks. Results.: After 4-8 weeks of treatment, healing (primary end-point) was observed in 228/233 (97.9%) patients in the rabeprazole group and in 231/237 (97.5%) in the omeprazole one (equivalence effect demonstrated by p < 0.0001 at Blackwelder test and an upper confidence limit at 97.5% of 0.023). However, rabeprazole was faster in inducing heartburn relief than omeprazole (2.8 ± 0.2 versus 4.7 ± 0.5 days of therapy to reach the first day with satisfactory heartburn relief, p = 0.0045 at log-rank test). In the maintenance phase, 15.2% of patients had an endoscopic and/or clinical relapse. Conclusion.: Rabeprazole is equivalent to omeprazole in healing reflux oesophagitis, but shows a faster activity on reflux symptoms in the early treatment phase. © 2005 Editrice Gastroenterologica Italiana S.r.l