Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 187 (2015) 72–77
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that, if it was measured in this study, AEC intervals might have found altered in patients with preeclampsia. Thus, considering all the data about AEC, the study might have completely shed light on the effect of preeclampsia on electrical heterogeneity of atrial myocardium in many respects. References [1] Kirbas O, Biberoglu EH, Kirbas A, et al. P-wave duration changes and dispersion in preeclampsia. Eur J Obstet Gynecol Reprod Biol 2014;183:141–5. [2] Nussinovitch U. Meta-analysis of P wave dispersion values in healthy individuals: the influence of clinical characteristics. Ann Noninvasive Electrocardiol 2012;17:28–35. [3] Acar G, Sayarlioglu M, Akcay A, et al. Assessment of atrial electromechanical coupling characteristics in patients with ankylosing spondylitis. Echocardiography 2009;26:549–57. [4] Yildiz A, Ucmak D, Oylumlu M, et al. Assessment of atrial electromechanical delay and P-wave dispersion in patients with psoriasis. Echocardiography 2014;31:1071–6. [5] Ayhan S, Ozturk S, Dikbas O, et al. Detection of subclinical atrial dysfunction by two-dimensional echocardiography in patients with overt hyperthyroidism. Arch Cardiovasc Dis 2012;105:631–8.
Alptug Tokatli* Golcuk Military Hospital, Department of Cardiology, Kocaeli, Turkey Omer Yiginer Namık Ozmen Mehmet Uzun GATA Haydarpasa Hospital, Department of Cardiology, Istanbul, Turkey *Corresponding author at: Golcuk asker hastanesi, Kardiyoloji servisi, Golcuk 41910, Kocaeli, Turkey. Tel.: +90 262 426 0271; fax: +90 262 414 2020 E-mail address: [email protected] (A. Tokatli). 9 January 2015 http://dx.doi.org/10.1016/j.ejogrb.2015.02.013
Mixed hepatocellular carcinoma and cholangiocarcinoma during pregnancy: a case report Dear Editors, We found a 30-year-old Caucasian patient, gravid 1 at 30 weeks’ gestation in July 2011 with abdominal pain and a recent occurrence of hepatic hemoangioma bleeding. Her family history was negative for hepatocellular carcinoma (HCC) and personal history was negative for oral contraceptive administration. Clinical conditions were stable, routine infectious screening and liver function tests were within normal limits. Abdominal ultrasound showed a lesion of the right hepatic lobe measuring 10.5 cm 8.5 cm, with undefinable margins. A magnetic resonance confirmed the lesion measuring 13 cm 9 cm of the right hepatic lobe (V–VI segment), with hypointense signal in T1 sequences (Fig. 1), and moderately hyperintense signal in T2 sequences, with a peripheral area of 5 cm 3 cm, and non-homogenous signal. Because of increasing pain, at 31 weeks’ gestation a cesarean section was performed and a healthy male newborn of 2200 g was delivered with an Apgar score 7-8. During the surgery a right hepatectomy was performed. Histology confirmed a mixed carcinoma with morphological and immunohistochemistry positivity for both hepatocellular and
Fig. 1. a lesion measuring 13 cm 9 cm of the right hepatic lobe with hypointense signal in T1 sequences.
cholangiocarcinomatous pattern, with focal aspects of stem cells. Two different elements were recognized: the first, more widespread, showed a growth as trabecular- and pseudoglandular-like pattern, with big cells with cytoplasmic inclusions, pleomorfism and high mitotic index (more than 20 mitosis/10 HPF); the second part showed a glandular growth pattern, with multiple differentiations degrees, associated with sclerosis areas and focal areas with intracellular and luminal mucus production. The two elements were combined and of difficult detachment, both macroscopically and microscopically. The patient was then referred to chemotherapy administration and she died 6 months later. Sadoon and Hodgett [1] in 2008 reported a case of cholangiocarcinoma (CC) in pregnancy characterized by pruritis of the soles of feet and of palms of hands initially confused with obstetrics cholestasis. Prognosis of patients with cholangiocarcinoma in general population is highly unfavorable and the clinical course of the malignancy may be worsened during gestation. The largest review of HCC during pregnancy was reported by Choi et al. [2] in 2011. The rarity of this condition may be caused by the fact that the HCC is uncommon in females and in reproductive age. Moreover liver cirrhosis, associated to HCC, may cause infertility. This report represents the first case of a mixed hepatocellular and cholangiocarcinomatous pattern during gestation. It has been suggested that pregnancy could negatively influence the prognosis of HCC [3]. Gestational immune suppression may be an enabling factor in tumor progression. It has been postulated that some HCCs or CC (subtypes) can originate from hepatic progenitor cells (HPCs). HPCs can differentiate into hepatocytes and cholangiocytes and tumors can arise, on their way to differentiation. HPC features have a worse prognosis, a faster progression and more frequent recurrences after surgical treatment compared to tumors without HPC features [4]. The case we describe could probably be ascribed to HPC carcinoma, with morphological and immunohistochemistry positivity for both hepatocellular and cholangiocarcinomatous pattern. As a result of poor prognosis of HCC in pregnancy, past reports have emphasized the need for termination of pregnancy as part of treatment [3]. In our case right upper quadrant pain was the only symptom, liver function was well-preserved, and this data is consistent with previous report on HCC in young patient [5]. In conclusion, although liver cancer is a rare pathology, mostly in pregnancy, a possible diagnosis should be always considered when hepatic masses are visible and not completed detected. The presence of a mixed carcinoma (HCC and CC), as described in this case, makes the prognosis highly unfavorable. Conflict of interest The authors report no conflict of interest.
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 187 (2015) 72–77
References [1] Sadoon S, Hodgett S. Unusual cause of itching in a pregnancy (cholangiocarcinoma). J Obstet Gynaecol 2008;28(February (2)):230–1. [2] Choi KK, Hong YJ, Choi SB, et al. Hepatocellular carcinoma during pregnancy: is hepatocellular carcinoma more aggressive in pregnant patients. J Hepatobiliary Pancreat Sci 2011;18:422–31. [3] Jeng LB, Lee WC, Wang CC, Chen MF, Hsieh TT. Hepatocellular carcinoma in a pregnant woman detected by routine screening of maternal alpha-fetoprotein. Am J Obstet Gynecol 1995;172:219–20. [4] Fujii T, Zen Y, Harada K, et al. Participation of liver cancer stem/progenitor cells in tumorigenesis of scirrhous hepatocellular carcinoma-human and cell culture study. Hum Pathol 2008;39:1185–96. [5] Chang P, Ong W, Lui H, Tan C. Is the prognosis of young patients with hepatocellular carcinoma poorer than the prognosis of older patients? A comparative analysis of clinical characteristics, prognostic features, and survival outcome. J Gastroenterol 2008;43:881–8.
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Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy Annibale Donini Department of General and Emergency Surgery, University of Perugia, Perugia, Italy Gian Carlo Di Renzo Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy *Corresponding author at: Department of Obstetrics and Gynecology, University of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy. Tel.: +39 075 5783231; fax: +39 075 5783829 E-mail address: [email protected] (S. Gerli).
Sandro Gerli* Alessandro Favilli Claudia Giordano
21 September 2014 http://dx.doi.org/10.1016/j.ejogrb.2015.02.010
76
that, if it was measured in this study, AEC intervals might have found altered in patients with preeclampsia. Thus, considering all the data about AEC, the study might have completely shed light on the effect of preeclampsia on electrical heterogeneity of atrial myocardium in many respects. References [1] Kirbas O, Biberoglu EH, Kirbas A, et al. P-wave duration changes and dispersion in preeclampsia. Eur J Obstet Gynecol Reprod Biol 2014;183:141–5. [2] Nussinovitch U. Meta-analysis of P wave dispersion values in healthy individuals: the influence of clinical characteristics. Ann Noninvasive Electrocardiol 2012;17:28–35. [3] Acar G, Sayarlioglu M, Akcay A, et al. Assessment of atrial electromechanical coupling characteristics in patients with ankylosing spondylitis. Echocardiography 2009;26:549–57. [4] Yildiz A, Ucmak D, Oylumlu M, et al. Assessment of atrial electromechanical delay and P-wave dispersion in patients with psoriasis. Echocardiography 2014;31:1071–6. [5] Ayhan S, Ozturk S, Dikbas O, et al. Detection of subclinical atrial dysfunction by two-dimensional echocardiography in patients with overt hyperthyroidism. Arch Cardiovasc Dis 2012;105:631–8.
Alptug Tokatli* Golcuk Military Hospital, Department of Cardiology, Kocaeli, Turkey Omer Yiginer Namık Ozmen Mehmet Uzun GATA Haydarpasa Hospital, Department of Cardiology, Istanbul, Turkey *Corresponding author at: Golcuk asker hastanesi, Kardiyoloji servisi, Golcuk 41910, Kocaeli, Turkey. Tel.: +90 262 426 0271; fax: +90 262 414 2020 E-mail address: [email protected] (A. Tokatli). 9 January 2015 http://dx.doi.org/10.1016/j.ejogrb.2015.02.013
Mixed hepatocellular carcinoma and cholangiocarcinoma during pregnancy: a case report Dear Editors, We found a 30-year-old Caucasian patient, gravid 1 at 30 weeks’ gestation in July 2011 with abdominal pain and a recent occurrence of hepatic hemoangioma bleeding. Her family history was negative for hepatocellular carcinoma (HCC) and personal history was negative for oral contraceptive administration. Clinical conditions were stable, routine infectious screening and liver function tests were within normal limits. Abdominal ultrasound showed a lesion of the right hepatic lobe measuring 10.5 cm 8.5 cm, with undefinable margins. A magnetic resonance confirmed the lesion measuring 13 cm 9 cm of the right hepatic lobe (V–VI segment), with hypointense signal in T1 sequences (Fig. 1), and moderately hyperintense signal in T2 sequences, with a peripheral area of 5 cm 3 cm, and non-homogenous signal. Because of increasing pain, at 31 weeks’ gestation a cesarean section was performed and a healthy male newborn of 2200 g was delivered with an Apgar score 7-8. During the surgery a right hepatectomy was performed. Histology confirmed a mixed carcinoma with morphological and immunohistochemistry positivity for both hepatocellular and
Fig. 1. a lesion measuring 13 cm 9 cm of the right hepatic lobe with hypointense signal in T1 sequences.
cholangiocarcinomatous pattern, with focal aspects of stem cells. Two different elements were recognized: the first, more widespread, showed a growth as trabecular- and pseudoglandular-like pattern, with big cells with cytoplasmic inclusions, pleomorfism and high mitotic index (more than 20 mitosis/10 HPF); the second part showed a glandular growth pattern, with multiple differentiations degrees, associated with sclerosis areas and focal areas with intracellular and luminal mucus production. The two elements were combined and of difficult detachment, both macroscopically and microscopically. The patient was then referred to chemotherapy administration and she died 6 months later. Sadoon and Hodgett [1] in 2008 reported a case of cholangiocarcinoma (CC) in pregnancy characterized by pruritis of the soles of feet and of palms of hands initially confused with obstetrics cholestasis. Prognosis of patients with cholangiocarcinoma in general population is highly unfavorable and the clinical course of the malignancy may be worsened during gestation. The largest review of HCC during pregnancy was reported by Choi et al. [2] in 2011. The rarity of this condition may be caused by the fact that the HCC is uncommon in females and in reproductive age. Moreover liver cirrhosis, associated to HCC, may cause infertility. This report represents the first case of a mixed hepatocellular and cholangiocarcinomatous pattern during gestation. It has been suggested that pregnancy could negatively influence the prognosis of HCC [3]. Gestational immune suppression may be an enabling factor in tumor progression. It has been postulated that some HCCs or CC (subtypes) can originate from hepatic progenitor cells (HPCs). HPCs can differentiate into hepatocytes and cholangiocytes and tumors can arise, on their way to differentiation. HPC features have a worse prognosis, a faster progression and more frequent recurrences after surgical treatment compared to tumors without HPC features [4]. The case we describe could probably be ascribed to HPC carcinoma, with morphological and immunohistochemistry positivity for both hepatocellular and cholangiocarcinomatous pattern. As a result of poor prognosis of HCC in pregnancy, past reports have emphasized the need for termination of pregnancy as part of treatment [3]. In our case right upper quadrant pain was the only symptom, liver function was well-preserved, and this data is consistent with previous report on HCC in young patient [5]. In conclusion, although liver cancer is a rare pathology, mostly in pregnancy, a possible diagnosis should be always considered when hepatic masses are visible and not completed detected. The presence of a mixed carcinoma (HCC and CC), as described in this case, makes the prognosis highly unfavorable. Conflict of interest The authors report no conflict of interest.
Letters to the Editor—Brief Communications / European Journal of Obstetrics & Gynecology and Reproductive Biology 187 (2015) 72–77
References [1] Sadoon S, Hodgett S. Unusual cause of itching in a pregnancy (cholangiocarcinoma). J Obstet Gynaecol 2008;28(February (2)):230–1. [2] Choi KK, Hong YJ, Choi SB, et al. Hepatocellular carcinoma during pregnancy: is hepatocellular carcinoma more aggressive in pregnant patients. J Hepatobiliary Pancreat Sci 2011;18:422–31. [3] Jeng LB, Lee WC, Wang CC, Chen MF, Hsieh TT. Hepatocellular carcinoma in a pregnant woman detected by routine screening of maternal alpha-fetoprotein. Am J Obstet Gynecol 1995;172:219–20. [4] Fujii T, Zen Y, Harada K, et al. Participation of liver cancer stem/progenitor cells in tumorigenesis of scirrhous hepatocellular carcinoma-human and cell culture study. Hum Pathol 2008;39:1185–96. [5] Chang P, Ong W, Lui H, Tan C. Is the prognosis of young patients with hepatocellular carcinoma poorer than the prognosis of older patients? A comparative analysis of clinical characteristics, prognostic features, and survival outcome. J Gastroenterol 2008;43:881–8.
77
Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy Annibale Donini Department of General and Emergency Surgery, University of Perugia, Perugia, Italy Gian Carlo Di Renzo Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy *Corresponding author at: Department of Obstetrics and Gynecology, University of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy. Tel.: +39 075 5783231; fax: +39 075 5783829 E-mail address: [email protected] (S. Gerli).
Sandro Gerli* Alessandro Favilli Claudia Giordano
21 September 2014 http://dx.doi.org/10.1016/j.ejogrb.2015.02.010
