Early Detection of Metastases by Bone Scintigraphy in Patients with Hepatocellular Carcinoma

Introduction

Although bone involvement is reported as uncommon in hepatocellular carcinoma (HCC), its incidence has significantly increased in the last decade due to novel imaging techniques and multidisciplinary treatment approaches and the overall survival in HCC patients has prolonged.

Bone metastases were most frequently found in the pelvis (20%), followed by the lumbar spine (14%) and long bones (13%) , and bone metastasis is discovered as the first symptoms in about 5%-7% of the HCC patients, which would cause clinical misdiagnosis easily. We ever reported a patient with a half year history of right hip pain, who was diagnosed as primary femoral benign tumor initially. A single photon emission computed tomography (SPECT) of total skeletal bones showed abnormal radioactive tracer uptake widely in acetabulum, femoral head, neck of femur, large rotor and the third right frontal rib, while CT scan only showed lesions in the right side of the femoral head and the large rotor).

Bone scintigraphy (BS) can be an option for patients to reduce the misdiagnosis rate and to rule out the possibility of bone metastasis from HCC, which could give a comprehensive assessment to whole body bones. 99mTc-MDP (Technetium-99m-methylene diphosphonate) is usually used as imaging agent. The kidneys, bladder and sometimes the ureter can be seen in the imaging, due to that the imaging tracer is typically excreted by urinary system. Hence the right renal abnormality (reached the pelvis and with irregular shape) was detected by bone scintigraphy in the reported case. Subsequently, non-enhanced and then contrast-enhanced CT of abdomen was taken, which demonstrated a huge enhanced mass in the right lobe of the liver (showed increased contrast enhancement within the lesion during the arterial phase). The patient was given right hip joint replacement, and the pathology diagnosis was liver metastasis carcinoma.

Aberrant Canal Configuration of the Maxillary First Molar: A Case Report

Knowledge of both the normal and abnormal anatomies of theroot canal system dictates the parameters for the execution ofroot canal therapy and this can directly affect the outcome ofthe endodontic therapy . Many unusual canalconfigurations and anomalies in the maxillary first molarshave been documented in case reports and several studies.There are numerous variations in the canal number andconfiguration in maxillary molars . In maxillary firstmolars, mesiobuccal roots tend to have more variations in thecanal system followed by the distobuccal root, whereas thepalatal root has the least.

The maxillary first molar most commonly has three or fourcanals, with one canal in both the palatal and distobuccal rootsand one or two in the mesiobuccal root. Most of theclinical literature on the fourth canal in maxillary molarsreports an additional mesiobuccal canal (MB2). In addition tothese studies, the literature cites the variation in the palatalroot of the maxillary molars as a single root with 2 separateorifices, 2 separate canals, and 2 separate foramina; 2 separateroots, each with 1 orifice, 1 canal, and 1 foramen; and a singleroot with 1 orifice, a bifurcated canal, and 2 separate foramen,with a trifurcation at the apical third in the palatal canal. Theincidence of two root canals in the palatal root of maxillarymolars has been reported to be 2- 5.1%.This case report intensifies the complexity of maxillarymolar variation and is intended to reinforce the clinician’sawareness of the rare morphology of root canals. It presentsendodontic therapy of a permanent maxillary, first molar with2 canals in a single palatal root.

A 23-year-old male presented to the Department ofConservative Dentistry and Endodontics, with the chiefcomplaint of pain on chewing associated with the leftmaxillary first molar. On clinical examination revealed a deepcarious lesion in the same tooth. The tooth was painful onpercussion and gave exaggerated response to thermal and theelectric pulp tests. The preoperative radiographic evaluationof the involved tooth indicated caries, which approximated thepulp with the normal root canal anatomy and the widening ofthe periodontal ligament space . After thoroughclinical and radiographic examination, a diagnosis of chronicirreversible pulpitis with apical periodontitis was made andthe patient was prepared for endodontic treatment. Thepatient’s medical history was found to be non-contributory.The tooth was anaesthetized by using 2% lidocaine with1:100,000 adrenaline. After isolation by using a rubber dam, aconventional endodontic access opening was made.

Short-term Survival in Acutely Decompensated Cirrhotic Patients

ADS: Acute Decompensation Score; AST: Aspartate Aminotransferase; ALT: Alanine Aminotransferase; AUROC: Area Under the ROC Curve; GGT: Gamma-Glutamyl Transpeptidase; iMELD: Integrated Model for End-stage Liver Disease Model; INR: International Normalized Ratio for Prothrombin Time; LR: Likelihood Ratio; MARS: Molecular Adsorbent Recirculating System; MELD: Model for End-stage Liver Disease; MELD-Na: Model for End-stage Liver Disease-sodium score; MESO Index: Model for End-stage Liver Disease to Sodium; NPV: Negative Predictive Value; OLT: Orthotopic Liver Transplantation; PPV: Positive Predictive Value; ROC: Receiver Operating Characteristic; S: Sensitivity; SMT: Standard Medical Therapy; SOFA: Sepsis-related Organ Failure Assessment; Sp: Specificity

Introduction

Patients with previously stable chronic liver disease often develop an acute deterioration in their liver function following a precipitating event, liver-related or not. This clinical pattern is often reported as Acute-on-Chronic Liver Failure : ACLF : 2. The most frequent and severe consequences of the acute decompensation are: hepatorenal syndrome : HRS, severe hepatic encephalopathy : HE, grade II or more, organ failure : other than the liver and, finally, multiple organ dysfunction; leading to death in 50 to 90% of these population.

Up to now, orthotopic liver transplantation: OLT provides the only possible curative therapy for patients achieving this extremely severe liver dysfunction. Unfortunately, the precipitants leading to the acute deterioration: infection, acute bleeding, acute renal failure, surgical procedures, etc. often contraindicate an emergency liver transplantation.

Artificial liver support has been postulated as an effective therapy to bridge patients developing acute deterioration of cirrhosis to OLT in safe conditions. Unfortunately, studies on the efficacy of albumin dialysis failed to demonstrate a beneficial effect of this therapy in the survival of the overall population of cirrhotic patients studied. However, it seems plausible that some selected populations of ACLF patients, such as those at high-risk of death, would benefit from these new and expensive liver-support therapies.