A resected case of liver metastases from extra-adrenal retroperitoneal paraganglioma with von Recklinghausen's disease 16 years after the initial surgery

The patient was a 46-year-old man who had undergone resection for a bulky retroperitoneal tumor 16 years previously during a follow-up for von Recklinghausen’s disease. Histopathological examination of the resected specimen showed that the tumor was an extra-adrenal paraganglioma. After the surgery, he had survived without any recurrence of the tumor. However, 16 years after the initial surgery, liver tumors were identified, and he was referred to our hospital for further investigation and treatment. Abdominal imaging modalities showed three masses in the left lateral segment of the liver. Fluorodeoxyglucose-positron emission tomography/computed tomography showed an abnormal uptake of fluorodeoxyglucose corresponding to the mass lesions. The patient was diagnosed with a metastatic paraganglioma based on histopathological examination of a liver mass biopsy. The patient underwent left lateral sectionectomy of the liver. Histopathological examination of the resected specimen revealed proliferating cells with basophilic cytoplasm and oval densely stained nuclei arranged in an alveolar pattern, which was similar to the findings of the initial resection specimen. Immunohistochemical staining was positive for synaptophysin and chromogranin A. Based on these findings, the resected tumors were histopathologically diagnosed with liver metastases from the retroperitoneal paraganglioma. We concluded that this is an extremely rare case of liver metastases occurring long after the initial resection of extra-adrenal peritoneal paraganglioma with von Recklinghausen’s disease.

Practices for Supporting and Confirming Decision-Making Involved in Kidney and Liver Donation by Related Living Donors in Japan: A Nationwide Survey

This nationwide survey investigated the actual practices for supporting and confirming the decision-making involved in related living-organ donations in Japan, focusing on organ type and program size differences. Answers to a questionnaire survey were collected from 89 of the 126 (71%) kidney and 30 of the 35 (86%) liver transplantation programs in Japan that were involved in living-donor transplantations in 2013. In 70% of the kidney and 90% of the liver transplantation programs, all donors underwent "third-party" interviews to confirm their voluntariness. The most common third parties were psychiatrists (90% and 83%, respectively). Many programs engaged in practices to support decision-making by donor candidates, including guaranteeing the right to withdraw consent to donate (70% and 100%, respectively) and prescribing a set "cooling-off period" (88% and 100%, respectively). Most donors were offered care by mental health specialists (86% and 93%, respectively). Third parties were designated by more of the larger kidney transplant programs compared with the smaller programs. In conclusion, the actual practices supporting and confirming the decision to donate a living organ varied depending on the organ concerned and the number of patients in the program.

[Complete Surgical Resection of a Huge Hepatocellular Carcinoma Invading the Diaphragm and Lung after Transcatheter Arterial Chemoembolization (TACE) and Sorafenib--A Case Report]

We report a case of locally advanced huge hepatocellular carcinoma (HCC) invading the diaphragm and the right lung, which was controlled by sorafenib, thereby allowing curative resection. A 72-year-old man was diagnosed with advanced HCC invading the diaphragm and the right lung. At the time of diagnosis, his tumor was considered unresectable and he underwent transarterial embolization (TAE)/transcatheter arterial chemoembolization (TACE) 3 times. Assessment with enhanced CT after TAE/TACE showed that a viable lesion remained. Subsequently, he was treated with sorafenib for 15 months. Reassessment showed that the main tumor remained stable in size, and he was admitted to our hospital for surgery. Preoperative evaluation by enhanced CT and MRI detected an intrahepatic metastasis in segment 4 of the liver. After TACE was performed for this nodule, extended right hemihepatectomy with right diaphragmatic and right lung partial resection was performed. He had no postoperative complications and was discharged 27 days after surgery. He remains alive without recurrence 10 months after surgery.

[A Successful Curative Resection Including Replacement with a Ringed Gore-Tex Tube Graft for Local Recurrence after Right Adrenalectomy and Liver Metastasis of Colon Cancer with Inferior Vena Cava Invasion]

A 65-year-old woman underwent sigmoidectomy for colon cancer in January 2002. She had multiple liver metastases and received systemic chemotherapy (UFT-E plus CPT-11) for 6 months. She underwent partial hepatectomy of S7 and S3 and cholecystectomy in July 2003. After 4 years without recurrence, right adrenal and para-aortic lymph nodes metastases were detected and she underwent right adrenalectomy and para-aortic lymphadenectomy in July 2007. In July 2008, local recurrence (1 cm in size) was identified in the cavity of the right adrenal gland. She received chemotherapy (mFOLFOX6 plus bevacizumab) for 5 years. In May 2013, PET-CT showed abnormal accumulation of FDG in S7 of the liver (SUVmax 6.7). The enhanced EOB-MRI showed a mass lesion in S7 (3 cm in size) and 2 nodules (1 cm in size) in S3 and S4. We scheduled for liver surgery with reconstruction of the inferior vena cava (IVC) after systemic chemotherapy (FOLFIRI plus cetuximab). The patient underwent partial hepatectomy of the tumor in S7 combined with resection of the diaphragm and IVC. Reconstruction of the IVC was performed using a ringed Gore-Tex tube graft in February 2014. The patient is still alive without recurrence 18 months after surgery.

Effect of graft size matching on pediatric living-donor liver transplantation in Japan

OBJECTIVES

The Japanese Liver Transplantation Society is a cooperative research consortium, established in 1980 to characterize and follow trends in patient and graft survival in all liver transplants in Japan. This study evaluated the effect of graft size matching on survival in pediatric recipients of living donor liver transplant.

MATERIALS AND METHODS

Between November 1989 and December 2010, there were 2224 patients aged < 18 years who received living-donor liver transplant in Japan. Survival was evaluated according to graft size matching.

RESULTS

There were 998 male and 1226 female donors (median age, 35.2 y). There was no donor mortality associated with surgery. The median age of recipients was 4.0 years (range, 13 d to 17.9 y) and body weight was 16.6 kg (range, 2.6 to 90 kg). The survival of living-donor liver transplant recipients was greater for pediatric than adult recipients at 1 year (adult, 81%; pediatric, 88%), 5 years (adult, 72%; pediatric, 85%), 10 years (adult, 66%; pediatric, 83%), and 15 years (adult, 57%; pediatric, 80%) after transplant (difference between adult and pediatric recipients: P ≤ .0001). In the 2224 recipients aged < 18 years, the graft types included left lateral segment in 1549 recipients (70%), left lobe in 500 recipients (23%), reduced left lateral segment in 96 recipients (4%), right lobe in 76 recipients (3%), and posterior segment in 3 recipients (0.1%). There was no significant difference in survival between recipients that had different graft types. However, recipients aged < 1 year (296 recipients) who received grafts with graft-to-recipient body weight ratio > 4.0% had significantly worse patient survival because of problems associated with large-for-size grafts.

CONCLUSIONS

Living-donor liver transplant had greater survival in children than adult recipients. Graft-to-recipient body weight ratio was a significant prognostic factor in recipients aged < 1 year.

Perceptions of transplant surgery among living liver donors in Japan

CONTEXT

To minimize impaired psychosocial outcomes among living liver donors, it may be useful to obtain their views about being a donor with respect to their specific backgrounds.

OBJECTIVE

To describe the perceptions of living liver donors with respect to transplant surgery and to determine whether any differences in perceptions were related to the recipient's age or prognosis.

DESIGN, SETTING, AND PATIENTS

In total, 240 living liver donors (mean age, 44.4 years) openly and freely described their views on transplant.

RESULTS

Content analysis of the descriptions revealed 4 categories: grateful for the benefits of living donor liver transplant (n = 143, 59.6%), facing the limitations of living liver transplant (n = 125, 52.1%), donor stress (n = 105, 43.8%), and crucial preoperative period (n = 75, 31.2%). The frequency of descriptions of gratitude for the benefits of transplant differed significantly between adult-to-adult and adult-to-child transplants: donors to children (ie, recipients <18 years old) were more grateful than were donors to adults (ie, recipients ≥18 years old). In addition, descriptions of gratitude differed significantly depending on the recipient's prognosis: donors with recipients who survived were more grateful and experienced fewer difficulties than did donors with recipients who died.

CONCLUSIONS

In general, living liver donors were satisfied with transplant surgery but experienced living donor liver transplant as a burden, which was affected by the transplant outcome and the age of the recipient.

[A case of surgical resection for liver metastasis of gastric cancer with portal vein tumor thrombus]

A 58-year-old man presented with anorexia and weight loss in April 2010. Endoscopic examination revealed a type 3 tumor extending from the gastric cardia to the antrum. Preoperative imaging showed liver metastasis (S8; 2 cm) and direct invasion of the cancer into the pancreas. We administered 4 courses of chemotherapy (DCS) for the unresectable tumor; the impact of the therapy was partial response (PR). We performed total gastrectomy, D2 dissection, splenectomy, distal pancreatectomy, and partial hepatectomy (S8) in April 2011. The patient was treated with 8 courses of adjuvant chemotherapy with S-1. In April 2012, abdominal computed tomography (CT) revealed a solitary recurrent lesion in the liver (S2). After 7 courses of chemotherapy(weekly paclitaxel), abdominal CT and magnetic resonance imaging (MRI) revealed a tumor thrombus in the portal vein extending from P2 to the umbilical portion (UP). We performed left hepatectomy and cholecystectomy due to the absence of new lesions. Histopathological findings revealed that the poorly differentiated adenocarcinoma had metastasized to the liver. Abdominal CT revealed the presence of multiple recurrent metastases in the liver, 4 months after the surgery. The patient died 27 months after the initial surgery and 7 months after the last operation.

[A case of curatively resected intrahepatic cholangiocarcinoma with hepatic artery and portal vein reconstruction]

We report a case of curatively resected intrahepatic cholangiocarcinoma (ICC) with hepatic artery (HA) and portal vein (PV) reconstruction. A 25-year-old man was diagnosed with ICC. Computed tomography (CT) showed that the tumor had invaded the left and common hepatic duct, the right and left HA, and the main branch of the PV. Because the posterior HA was tumor free, we performed a left trisegmentectomy, PV and HA resection and reconstruction, and a hepatocholangiojejunostomy. Pathological examination revealed a tumor classification of T3, N1, M0, Stage IVB. The patient was discharged on postoperative day 59 and gemcitabine (1,000 mg/m²) was administered as adjuvant chemotherapy. However, abdominal CT revealed peritoneal metastasis 8 months after the surgery. A gemcitabine, cisplatin, and TS-1 (GCS) regimen was selected as treatment, and the patient is alive 13 months after surgery.

[A case of hepatic resection after chemotherapy for metastatic colon cancer of the liver with invasion of the inferior vena cava and hepatic vein]

A 61-year-old man presented with lower abdominal pain. Further examination revealed descending colon cancer and multiple liver metastases (S1, S2, and S5). The largest metastatic lesion in S1 showed massive invasion to the inferior vena cava (IVC) and was considered unresectable. Resection of the primary colon cancer was performed in January 2011, followed by several types of systemic chemotherapy(12 courses of capecitabine plus oxaliplatin [XELOX] + bevacizumab[Response Evaluation Criteria In Solid Tumors{RECIST}: PD], 5 courses of folinic acid, fluorouracil, and irinotecan [FOLFIRI] + bevacizumab[RECIST: SD], and 13 courses of FOLFIRI+ panitumumab). After these regimens, the lesions in S1 and S2 substantially decreased in size (RECIST: PR), and the lesion in S5 was no longer visible. The extent of invasion to the IVC significantly reduced, and liver resection(extended left lobectomy)and partial IVC resection were performed in November 2013 without reconstruction of the IVC by using a vascular prosthesis. The patient was discharged uneventfully on postoperative day 16, and administration of tegafur-uracil-Leucovorin (UFT/UZEL) was initiated. After 4 months, a recurrent lesion was found in S5, and partial liver resection was performed. In addition, FOLFIRI+panitumumab was reinitiated for the multiple lung metastases. The patient is alive without progression of disease 3 years and 4 months after colectomy.

Neoadjuvant gemcitabine-based accelerated hyperfractionation chemoradiotherapy for patients with borderline resectable pancreatic adenocarcinoma

OBJECTIVE

We report the response to pre-operative gemcitabine-based chemoradiotherapy for pancreatic adenocarcinoma.

METHODS

Thirty-five consecutive patients with borderline resectable pancreatic adenocarcinoma of UICC Stage II or III with portal vein invasion or tumor abutment of artery received radiotherapy (twice daily fractions of 1.5 Gy, 5 days/week, total dose: 36 Gy; 30 Gy for Phase I Level 1) with weekly intravenous infusions of gemcitabine (400, 600 and 800 mg/m(2)) at Days 1 and 8 for Phase I and 800 mg/m(2) for Phase II. Restaging was repeated after completion of chemoradiotherapy.

RESULTS

Twenty-six of the 35 (74.3%) patients underwent resection. The dose-limiting toxicities were Grade 4 neutropenia and thrombocytopenia. The recommended regimen was total radiation dose of 36 Gy with gemcitabine 800 mg/m(2). Surgical resection was conducted in 11 of the 15 (73.3%) patients in Phase I study and 15 of the 20 (75.0%) in Phase II. After recommended dose chemoradiotherapy and surgical resection, the median disease-free survival was 17.4 months (5-year survival rate = 14.3%). The median overall survival time and 5-year survival rate were 41.2 months and 28.6%, respectively, for the 21 patients who underwent resection and 10.0 months and 0%, respectively, for those 5 who did not (P = 0.004).

CONCLUSION

Our pre-operative gemcitabine-based chemoradiotherapy was well tolerated and safe.

Interferon-α acts on the S/G2/M phases to induce apoptosis in the G1 phase of an IFNAR2-expressing hepatocellular carcinoma cell line

Interferon-α (IFN-α) is used clinically to treat hepatocellular carcinoma (HCC), although the detailed therapeutic mechanisms remain elusive. In particular, IFN-α has long been implicated in control of the cell cycle, but its actual point of action has not been clarified. Here, using time lapse imaging analyses of the human HCC cell line HuH7 carrying a fluorescence ubiquitination-based cell cycle indicator (Fucci), we found that IFN-α induced cell cycle arrest in the G0/G1 phases, leading to apoptosis through an IFN-α type-2 receptor (IFNAR2)-dependent signaling pathway. Detailed analyses by time lapse imaging and biochemical assays demonstrated that the IFN-α/IFNAR2 axis sensitizes cells to apoptosis in the S/G2/M phases in preparation for cell death in the G0/G1 phases. In summary, this study is the first to demonstrate the detailed mechanism of IFN-α as an anticancer drug, using Fucci-based time lapse imaging, which will be informative for treating HCC with IFN-α in clinical practice.

Association between ephrin-A1 mRNA expression and poor prognosis after hepatectomy to treat hepatocellular carcinoma

Hypoxia regulates the expression of genes that promote tumor growth, angiogenesis and invasion. We previously studied hypoxic tumor cells in vitro and from hepatic metastases of colorectal cancer and determined several potential prognostic factors for hepatocellular carcinoma (HCC). In this study, we evaluated the prognostic impact of the expression of ephrin-A1 (EFNA1) and its receptor, EPHA2, in patients with HCC after curative resection. Samples from a total of 139 HCC patients were analyzed by either microarray alone (n=86) or by microarray and quantitative PCR (n=53). There was no correlation between EFNA1 expression and clinicopathological factors. EPHA2 expression was not significantly correlated with any clinicopathological factors, except for microscopic portal invasion. EFNA1 was an independent prognostic factor for HCC (p=0.0277). These findings suggest that EFNA1 expression may be a useful marker for predicting high risk of recurrence in patients who have undergone curative resection for HCC.

Pregnancy outcomes after living donor liver transplantation: results from a Japanese survey

A national survey of pregnancy outcomes after living donor liver transplantation (LDLT) was performed in Japan. Thirty-eight pregnancies in 30 recipients resulted in 31 live births (25 recipients), 3 artificial abortions in the first trimester (3 recipients), 1 spontaneous abortion (1 recipient), and 3 fetal deaths (3 recipients). After the exclusion of the 3 artificial abortions, there were 35 pregnancies in 27 recipients: pregnancy-induced hypertension developed during 6 pregnancies (5 recipients), fetal growth restriction developed during 7 pregnancies (6 recipients), acute rejection developed during 2 pregnancies (2 recipients), and ileus developed during 1 pregnancy (1 recipient). Preterm delivery (<37 weeks) occurred for 10 pregnancies (10 recipients), and cesarean delivery was performed for 12 pregnancies (12 recipients). After delivery, acute rejection developed in 3 recipients. Twelve neonates were born with low birth weights (<2500 g), and 4 of these 12 neonates had extremely low birth weights (<1500 g). Two neonates had congenital malformations. The pregnancy outcomes after LDLT were similar to those reported for cadaveric liver transplantation (LT). The incidence of pregnancy-induced hypertension in recipients who were 33 years old or older at the diagnosis of pregnancy was significantly higher than the incidence in recipients who were less than 33 years old at the diagnosis of pregnancy. The incidences of fetal growth restriction, pregnancy-induced hypertension, and extremely low birth weight were significantly higher in the early group (<3 years after transplantation) versus the late group (≥3 years after transplantation). In conclusion, it is necessary to pay careful attention to complications during pregnancy in recipients who become pregnant within 3 years of LT, particularly if the age at the diagnosis of pregnancy is ≥33 years.

Reprogramming using microRNA-302 improves drug sensitivity in hepatocellular carcinoma cells

BACKGROUND

Although studies have shown that Oct4, Sox2, Klf4, and c-Myc (OKSM)-mediated induced pluripotent stem cell (iPSC) technology sensitizes cancer cells to drugs, the potential risk of inserting c-Myc and random insertions of exogenous sequences into the genome persists. Several authors, including us, have presented microRNA (miRNA)-mediated reprogramming as an alternative approach. Herein, we evaluated the efficacy of miRNA-mediated reprogramming on hepatocellular carcinoma (HCC) cells.

METHODS

Among three miRNAs (miR-200c, miR-302s, and miR-369s) that were previously presented for miRNA-mediated reprogramming, miR-302 was expressed at low levels in HCC cells. After transfecting three times with miR-302, the cells were incubated in ES medium for 3 weeks and then characterized.

RESULTS

iPSC-like spheres were obtained after the 3-week incubation. Spheres presented high NANOG and OCT4 expression, low proliferation, high apoptosis, low epithelial-mesenchymal transition marker expression (N-cadherin, TGFBR2), and sensitization to drugs. Several miRNAs were changed (e.g., low oncomiR miR-21, high miR-29b). cMyc was decreased, and methylation was elevated on histone 3 at lysine 4 (H3K4). Differentiated cells expressed markers of each germ layer (GFAP, FABP4, and ALB). AOF2 (also known as LSD1 or KDM1), one of the targets for miR-302, was repressed in iPSC-like-spheres. Silencing of AOF2 resulted in similar features of iPSC-like-spheres, including cMyc down-regulation and H3K4 methylation. In drug-resistant cells, sensitization was achieved through miR-302-mediated reprogramming.

CONCLUSIONS

miR-302-mediated iPSC technology reprogrammed HCC cells and improved drug sensitivity through AOF2 down-regulation, which caused H3K4 methylation and c-Myc repression.

Nationwide survey of the outcomes of living donor liver transplantation for hepatoblastoma in Japan

Recently, liver transplantation (LT) has been increasingly performed for unresectable hepatoblastoma (HB) with acceptable results. We conducted a national survey of cases undergoing living donor liver transplantation (LDLT) for HB to evaluate their outcomes. Thirty-nine patients (28 males and 11 females with a median age at LDLT of 3.6 years) who had undergone LDLT for HB by the end of 2009 were enrolled in this study. The clinical data were collected from their medical records via a questionnaire survey in 2011 (median follow-up = 4.6 years). Thirteen patients (33.3%) had extrahepatic lesions before LDLT. Thirty-eight patients (97.4%) received chemotherapy, and 15 (38.5%) underwent hepatectomy before LDLT. Twenty-seven patients (69.2%) were alive without recurrence after LDLT, and 12 patients (30.8%) suffered from recurrence. The most common site of recurrence was the lung (9 cases), which was followed by the graft liver (6 cases). The median interval from LDLT to recurrence was 5.5 months. Four of the 9 cases (44.4%) with lung metastasis underwent surgical resection, and 3 were alive without any tumor recurrence. Eight patients died because of tumor recurrence. The multivariate landmark analysis revealed that the independent recurrence risk factors were a high alpha-fetoprotein (AFP) level at diagnosis [≥ 500,000 ng/mL; hazard ratio (HR) = 7.86, P = 0.010], the presence of extrahepatic lesions before LDLT (HR = 3.82, P = 0.042), and a high AFP level at LDLT (≥ 4000 ng/mL; HR = 9.19, P = 0.036). The actuarial 3- and 5-year patient survival rates were 84.3% and 77.3%, respectively. In conclusion, with appropriate timing for scheduled LT, LDLT provides a valuable alternative treatment with excellent results for children with HB.

Risk factors for alcohol relapse after liver transplantation for alcoholic cirrhosis in Japan

Alcoholic liver cirrhosis (ALC) is an established indication for liver transplantation (LT). Most LT procedures in Japan are living donor liver transplantation (LDLT) because of an extreme shortage of deceased donors. Social circumstances enabling LDLT could be favorable for preventing relapse. The aims of this retrospective study were to analyze the outcomes of LDLT for ALC and to evaluate risk factors for relapse in this cohort. One hundred ninety-five subjects underwent LT [LDLT (n = 187), deceased donor LT (n = 5), or domino LT (n = 3)] for ALC in Japan from November 1997 to December 2011. Risk factors for alcohol relapse and the impact of relapse on outcomes were analyzed for 140 patients after the exclusion of 26 patients who died in the hospital and 29 patients without information about alcohol relapse. The incidence of alcohol consumption after LT was 22.9%. The risk factors for patient survival were a donor age ≥ 50 years (P < 0.01) and a Model for End-Stage Liver Disease score ≥ 19 (P = 0.03). The 10-year patient survival rates were 21.9% and 73.8% for patients who had relapsed and patients who had not relapsed 18 months after LT, respectively (P = 0.01). The relapse rates were 50.0%, 34.5%, 13.3%, 19.7%, and 14.3% for patients who had received livers from parents, siblings, spouses, sons/daughters, and deceased or domino donors, respectively. A history of treatment for psychological diseases other than alcoholism before LT was a significant indicator for the risk of recidivism (P = 0.02), and noncompliance with clinic visits after LT and smoking after transplantation were promising indicators for the risk of recidivism (P = 0.06, and P = 0.05, respectively). Preoperative alcohol consumption was not a risk factor. In conclusion, rather than selecting patients on the basis of preoperative alcohol use, we should provide sociomedical support to improve adherence after LT for ALC in Japan.

Impact of rituximab desensitization on blood-type-incompatible adult living donor liver transplantation: a Japanese multicenter study

We evaluated the effects of rituximab prophylaxis on outcomes of ABO-blood-type-incompatible living donor liver transplantation (ABO-I LDLT) in 381 adult patients in the Japanese registry of ABO-I LDLT. Patients underwent dual or triple immunosuppression with or without B cell desensitization therapies such as plasmapheresis, splenectomy, local infusion, intravenous immunoglobulin and rituximab. Era before 2005, intensive care unit-bound status, high Model for End-Stage Liver Disease score and absence of rituximab prophylaxis were significant risk factors for overall survival and antibody-mediated rejection (AMR) in the univariate analysis. After adjustment for era effects in the multivariate analysis, only absence of rituximab prophylaxis was a significant risk factor for AMR, and there were no significant risk factors for survival. Rituximab prophylaxis significantly decreased the incidence of AMR, especially hepatic necrosis (p < 0.001). In the rituximab group, other B cell desensitization therapies had no add-on effects. Multiple or large rituximab doses significantly increased the incidence of infection, and early administration had no advantage. In conclusion, outcomes in adult ABO-I LDLT have significantly improved in the latest era coincident with the introduction of rituximab.

Predicting the necessity of autologous blood collection and storage before surgery for hepatocellular carcinoma

BACKGROUND AND OBJECTIVES

It remains unclear what kinds of patients undergoing hepatectomy for hepatocellular carcinoma (HCC) actually need autologous blood storage/transfusion.

METHODS

Prior to surgery, autologous blood storage was prospectively performed in 245 patients with HCC, whereas it was not performed in 40 patients. Based on the use of the deposited autologous blood and the estimated postoperative hemoglobin (Hb) level when blood was not deposited, they were divided into necessary group and unnecessary group. By comparing the two groups, a scoring system to predict the need for autologous blood was established.

RESULTS

The 245 patients from whom blood was collected and stored were categorized into necessary group (32 patients with homologous blood transfusion and 11 with estimated postoperative Hb of <8.0 g/dl) and unnecessary group (30 patients with autologous blood discarded and 172 with estimated Hb ≥ 8.0 g/dl). Using factors that were significantly different between the two groups, a scoring system to predict the need for autologous blood was developed; preoperative Hb level, tumor size, and tumor thrombus. The area under the receiver-operator characteristic curve of the score was 0.836.

CONCLUSIONS

The established scoring system was found useful in identifying those HCC patients who need autologous blood storage/transfusion during hepatectomy.

Plasma miR-21 is a novel diagnostic biomarker for biliary tract cancer

Biliary tract cancer (BTC) has a generally poor prognosis. Furthermore, it is difficult to distinguish BTC from benign biliary disease (BBD) with commonly used modalities. Therefore, a novel biomarker to facilitate cancer detection is highly desirable. Recent studies have reported the use of circulating microRNAs (miRNAs) as biomarkers for cancers. The purpose of this study was to evaluate whether circulating miRNA-21 (miR-21) could be used as a biomarker for BTC. Plasma samples were obtained from 94 BTC patients, 50 healthy volunteers (HVs), and 23 BBD patients. miR-21 levels in the samples were measured by qRT-PCR. Plasma miR-21 levels in patients with BTC were significantly higher than in HVs or in patients with BBD (P < 0.0001 for both). Receiver-operator curve (ROC) curve analysis in differentiating BTC patients from HVs indicated that area under the curve (AUC), optimal sensitivity and specificity was 0.93, 85.1% and 100%, respectively, and those in differentiating BTC patients from BBD patients was 0.83, 72.3%, 91.3%, respectively. Validation of these results indicated that the negative predictive value, positive predictive value, sensitivity, specificity, and accuracy in differentiating BTC patients from HVs was 76.6%, 98.6%, 84.0%, 98.0%, and 88.9%, respectively, and those in differentiating BTC patients from BBD patients was 42.2%, 93.0%, 71.2%, 82.6%, and 72.6%, respectively. These sets of values were improved by combining miR-21 and CA19-9 measurements. Plasma miR-21 is a novel diagnostic biomarker for BTC, and may be useful in distinguishing between BTC and BBD patients.

[Successful liver resection of a rapidly growing hepatic angiosarcoma-a case report]

An 82-year-old man without any complaint was shown to have a hypoechoic lesion, 2 cm in diameter, in segment 5 of the liver by ultrasonography. After 3 months, an abdominal computed tomographic (CT) scan revealed a tumor lesion, 5.5 cm in diameter, with irregular peripheral enhancement. Positron emission tomography (PET)-CT revealed abnormal accumulation of fluorodeoxyglucose in the liver tumor, but no accumulation in other lesions. Based on the diagnosis of primary malignant liver tumor, we performed S5 subsegmentectomy of the liver. Histopathological examination showed spindle tumor cells forming hemorrhagic and focal necrosis. On immunohistochemistry, the tumor cells weakly expressed CD31. We diagnosed the tumor as hepatic angiosarcoma. The patient was discharged from the hospital 17 days after the surgery and survived without evidence of recurrence for 12 postoperative months.

[A case of a patient with hepatocellular carcinoma who achieved long-term survival after repeated transcatheter arterial chemoembolization and sorafenib therapy]

We report a case of multiple intrahepatic recurrence of hepatocellular carcinoma( HCC) that was successfully treated with transcatheter arterial chemoembolization( TACE) and sorafenib therapy. A 73-year-old man was diagnosed as having multiple intrahepatic recurrence in segment 2 (S2) and segment 7 (S7) of the liver on abdominal computed tomography (CT) scans 4 years after he underwent liver resection. He was treated with 5 cycles of TACE. Two years and 6 months after the initial TACE, we found that the patient had become refractory to TACE, and therefore, we initiated sorafenib therapy. The response to treatment was stable disease (SD) for 9 months, but the patient's tumor marker levels increased and the tumor gradually increased. Therefore, he underwent additional TACE for the intrahepatic lesions. The patient is still alive with recurrences 4 years and 8 months after the initial recurrence.

[Long-term survival of a patient with multiple advanced hepatocellular carcinomas with portal vein tumor thrombus]

A 59-year-old man was diagnosed as having hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) from the left branch to the main trunk and multiple liver tumors in the right lobe. He first underwent 8 courses of fluorouracil arterial infusion and interferon therapy( FAIT).The PVTT shrunk following combination therapy; however, the liver tumors were enlarged and metastasis was noted in the right adrenal gland. Treatment with sorafenib was initiated. Ten months later, additional reduction of PVTT was noted with no changes in the multiple liver tumors. After confirmation of sufficient portal flow, we performed transcatheter arterial chemoembolization (TACE).After having undergone, in total, 4 rounds of TACE with sorafenib, the patient underwent radiofrequency ablation( RFA) for the right adrenal gland metastasis. The patient is still alive, in good health. Our findings from this case suggest that, in some patients having advanced HCC with PVTT, long- term survival can be achieved when the intrahepatic lesions are controlled by various adequate therapies.

[Long-term survival of a patient with hepatocellular carcinoma with portal vein tumor thrombus treated with interferon-α and 5-fluorouracil combination therapy]

We report a case of long-term survival of a patient with hepatocellular carcinoma( HCC) with portal vein tumor thrombus (PVTT) treated with fluorouracil arterial infusion and interferon therapy (FAIT). A 54-year-old man with severe liver cirrhosis was diagnosed as having HCC in segment 1 and 4 of the liver, with PVTT in the left branch. After 7 courses of FAIT, the main tumor and PVTT were no longer visible on enhanced computed tomography scans. However, recurrent HCC was detected in segment 4. Subsequently, the patient was treated with transarterial chemoembolization (TACE) after confirmation of portal blood flow. At 5 years after the initial treatment, the patient is alive without further recurrence of HCC. Therefore, even if patients have HCC with PVTT in the main branch and severe liver cirrhosis, long-term survival is possible by administration of a combination of FAIT and TACE.

Subcuticular sutures versus staples for skin closure after open gastrointestinal surgery: a phase 3, multicentre, open-label, randomised controlled trial

BACKGROUND

Staples have been widely used for skin closure after open gastrointestinal surgery. The potential advantages of subcuticular sutures compared with staples have not been assessed. We assessed the differences in the frequency of wound complications, including superficial incisional surgical site infection and hypertrophic scar formation, depending on whether subcuticular sutures or staples are used.

METHODS

We did a multicentre, open-label, randomised controlled trial at 24 institutions between June 1, 2009, and Feb 28, 2012. Eligible patients aged 20 years or older, with adequate organ function and undergoing elective open upper or lower gastrointestinal surgery, were randomly assigned preoperatively to either staples or subcuticular sutures for skin closure. Randomisation was done via a computer-generated permuted-block sequence, and was stratified by institution, sex, and type of surgery (ie, upper or lower gastrointestinal surgery). Our primary endpoint was the incidence of wound complications within 30 days of surgery. Analysis was done by intention to treat. This study is registered with UMINCTR, UMIN000002480.

FINDINGS

1080 patients were enrolled and randomly assigned in a one to one ratio: 562 to subcuticular sutures and 518 to staples. 1072 were eligible for the primary endpoint and 1058 for the secondary endpoint. Of the 558 patients who received subcuticular sutures, 382 underwent upper gastrointestinal surgery and 176 underwent lower gastrointestinal surgery. Wound complications occurred in 47 of 558 patients (8·4%, 95% CI 6·3-11·0). Of the 514 who received staples, 413 underwent upper gastrointestinal surgery and 101 underwent lower gastrointestinal surgery. Wound complications occurred in 59 of 514 (11·5%, 95% CI 8·9-14·6). Overall, the rate of wound complications did not differ significantly between the subcuticular sutures and staples groups (odds ratio 0·709, 95% CI 0·474-1·062; p=0·12).

INTERPRETATION

The efficacy of subcuticular sutures was not validated as an improvement over a standard procedure for skin closure to reduce the incidence of wound complications after open gastrointestinal surgery.

FUNDING

Johnson & Johnson.

Long-term outcomes of pediatric living donor liver transplantation in Japan: an analysis of more than 2200 cases listed in the registry of the Japanese Liver Transplantation Society

The Japanese Liver Transplantation Society (JLTS) was established in 1980 in order to characterize and follow trends in patient characteristics and graft survival among all liver transplant patients in Japan. This study analyzed the comprehensive factors that may influence the outcomes of pediatric patients who undergo living donor liver transplantation (LDLT) by evaluating the largest cohort in the world. Between November 1989 and December 2010, 2224 pediatric patients underwent LDLT in Japan. There were 998 male (44.9%) and 1226 female donors (55.1%) without donor mortalities related to transplant surgery. There were 946 male (42.5%) and 1278 female (57.5%) recipients with a median age of 4.0 years (range: 13 days to 17.9 years). Cholestatic liver disease was the leading indication for LDLT (n = 1649; 76.2%), followed by metabolic disorders (n = 194; 8.7%), acute liver failure (n = 192; 8.6%) and neoplastic liver disease (n = 66; 3.0%). The 1-, 5-, 10- and 20-year patient survival rates were 88.3%, 85.4%, 82.8% and 79.6%, respectively. Blood-type incompatibility, recipient age, etiology of liver disease and transplant era were found to be significant predictors of overall survival. We are able to achieve satisfactory long-term pediatric patient survival outcomes in the JLTS series without compromising the living donors.

PTK787/ZK222584 combined with interferon alpha and 5-fluorouracil synergistically inhibits VEGF signaling pathway in hepatocellular carcinoma

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus remains poor. We previously reported the beneficial effects of interferon alpha (IFN) and 5-fluorouracil (5-FU) combination therapy for these patients. We showed that the mechanism of therapy was regulation of vascular endothelial growth factor (VEGF). Here, we combined IFN/5-FU therapy with the VEGF receptor-selective inhibitor PTK787/ZK222584 (PTK/ZK) and examined the antitumor effects and the mechanism of action.

METHODS

We studied two HCC cell lines, PLC/PRF/5 and HuH7, and a human umbilical vein endothelial cell line, HUVEC. We studied the effects of IFN/5-FU with or without PTK/ZK in growth inhibition assays, immunohistochemistry, Western blot analysis, and immunocytochemistry.

RESULTS

In a HuH7 xenograft model, the combination of PTK/ZK and IFN/5-FU significantly inhibited proliferation, induced apoptosis, decreased microvessel density, reduced the number of tumor cells that expressed VEGF receptor 2 (VEGFR-2), and repressed the phosphorylation of Akt in vivo. In HCC cells and HUVECs in vitro, IFN/5-FU plus PTK/ZK repressed the expression of VEGFR-2 and repressed the phosphorylation of VEGFR, Akt, Erk, and p38MAPK.

CONCLUSIONS

VEGF signaling inhibition enhanced the antitumor effects of IFN/5-FU therapy on HCC cells and endothelial cells via Erk, Akt, and p38MAPK pathways.

Clinicopathological features of long-term survivors for advanced biliary tract cancer and impact of the number of lymph nodes involved

BACKGROUND & AIM

To investigate the characteristics of long-term survivors after surgery for advanced biliary tract cancer (BTC), especially those with local invasion and/or lymph node involvement.

METHODS

We analyzed the features of long-term survivors using a prospectively collected database and verified the results using recent patients' data which have been well-described, especially in relation to lymph node dissection and metastasis. We used classification by the Japanese Society of Biliary Surgery (JSBS).

RESULTS

Among 170 patients with advanced BTC (Stage III or IV in JSBS), 25 (10 bile duct cancer, 9 gall bladder cancer, and 6 cancer of the papilla of Vater) survived for more than 5 years. Twenty-four patients had undergone fCurA/B (R0) surgery in these 25 patients. In comparison with the patients who did not survive for 5 years, the long-term survivors had fewer metastatic lymph nodes, that is, up to three (p = 0.0028). In regard to the impact of lymph node metastasis, the prognostic factor was the number of lymph nodes (3-year overall survival, 0 or 1: 68.1% vs >2: 40.0%, p = 0.0304).

CONCLUSION

For obtaining long-term survival, curative resection would be necessary in patients with no more than one lymph node metastasis.

[A case of advanced multiple hepatocellular carcinomas in both lobes that achieved long-term survival after repeated transcatheter arterial chemoembolization and surgical resection]

A 73-year-old man with advanced multiple hepatocellular carcinoma(HCC) in both lobes(S2, S3, S4, S8, and S1) was admitted to our hospital. Abdominal computed tomography revealed neither vascular invasion nor distant metastasis. Because 3 attempts of transcatheter arterial chemoembolization (TACE) resulted in successful control of the tumors in the right lobe, a left hepatic lobectomy was performed. Although postoperative recurrences were observed, they were controllable by repeated TACE, and the patient remains in a relatively good general condition 3 years and 8 months since the operation.

[A case of advanced hepatocellular carcinoma with inferior vena cava tumor thrombus and multiple intrahepatic metastases treated successfully by transcatheter arterial chemoembolization and radical hepatectomy]

A 76-year-old man, who had been treated with interferon-α(IFN-α) for hepatitis C, was diagnosed with multiple hepatocellular carcinomas (HCC; S7/8, S8, S5, S2) with right hepatic vein tumor thrombus (Vv2). He initially underwent transcatheter arterial chemoembolization(TACE). One month after TACE, the hepatic vein tumor thrombi extended into the inferior vena cava(Vv3). No distant metastasis was observed, and his liver function was well-preserved. Therefore, we performed a posterior segmentectomy, partial hepatectomy(S8, S5, S2), inferior vena cava tumor thrombus excision, and cholecystectomy. Four months after the operation, intrahepatic recurrences were detected, and these lesions were controlled via TACE. Four years and 2 months after the initial treatment, the patient survived and presently, is in a good condition. This case suggested that long-term survival is possible by surgery and repeated TACE in case of good liver function by a sustained virologic response (SVR) via treatment with IFN-α for hepatitis C virus.

[A case of advanced hepatocellular carcinoma with tumor thrombosis in the main trunk of the portal vein successfully treated by multidisciplinary therapies]

We report a case of advanced hepatocellular carcinoma(HCC) with tumor thrombosis in the main trunk of the portal vein successfully treated by multidisciplinary therapies. This case is that of a 61-year-old man with loss of appetite and weight loss. The abdominal computed tomography revealed an early enhanced and late wash-out lesion in the right hepatic lobe and tumor thrombosis in the major trunk of the portal vein. We diagnosed advanced HCC related to chronic hepatitis C [T4 (Vp4) N0M0, Stage IVA] and performed extended right lobectomy and extraction of the tumor thrombosis. The patient then underwent hepatic arterial infusion of 5-fluorouracil (5-FU) combined with systemic administration of interferon (IFN)-α therapy as an adjuvant therapy. Two years have passed since these therapies were performed with no recurrence of the disease. We expected that the patient would achieve long-term survival. Therefore, we administered IFN/ribavirin (RBV) therapy for chronic hepatitis C for 48 weeks. The patient is still alive, 44 months after the initial treatment. This case suggests that some patients with advanced HCC and a tumor thrombosis can achieve long-term survival by multidisciplinary therapies, including IFN-α/5-FU combination therapy.

[A case report of total remnant pancreatectomy for ductal carcinoma after distal pancreatectomy for invasive intraductal papillary mucinous carcinoma]

Recently, the number of case reports detailing cancer recurrence in the pancreatic remnants, following surgical resection of intraductal papillary-mucinous carcinoma (IPMC) of the pancreas has increased. We report the case of a 74-year-old woman who underwent pancreatic resection twice in a 3-year period for primary IPMC and remnant pancreatic ductal carcinoma. We first performed distal pancreatectomy for branched IPMC in the pancreatic tail. Histopathological examination revealed invasive IPMC and the negative margin of the pancreatic duct. The expression of tumor markers gradually increased in the 2 years and 4 months after the initial surgery, and a tumor was detected in the remnant pancreas. We performed total remnant pancreatectomy. The recurrent tumor consisted of moderately differentiated adenocarcinoma. Currently, the patient is alive without recurrence for a year since the second resection. This experience suggests that careful surveillance is necessary for IPMC.

[A case of hepatocellular carcinoma treated by transcatheter arterial chemoembolization and hepatectomy after subtotal stomach preserving pancreaticoduodenectomy for duodenal cancer]

Treatments for hepatocellular carcinoma(HCC) including surgical resection, transcatheter arterial chemoembolization (TACE), percutaneous local therapy, and systemic chemotherapy are decided upon according to tumor progression and liver function. However, it is difficult to choose a treatment after biliary tract reconstruction. Here we report a case of successful treatment for HCC and its recurrence where there had also been subtotal stomach preserving pancreaticoduodenectomy(SSPPD) for duodenal cancer. A 65-year-old female patient who had undergone SSPPD for duodenal cancer was found to have HCC in segment 8 (S8) 12 months later. Three months after super selective TACE, S8 partial resection was performed approaching through right thoracotomy and laparotomy. 2 years after the first hepatectomy, HCC was found to have reoccurred in S7/8 and S8. Right hepatic lobectomy was then performed without blocking the hepatic hilum. Liver resection was carried out with the aim of achieving A-P point. In this case then, several radical treatments have been completed without any biliary complication.

[Surgical resection and S-1 administration for the treatment of hepatocellular carcinoma]

A 57-year-old man was admitted to our hospital for hepatocellular carcinoma (HCC). He underwent right hepatectomy with preoperative adjuvant transcatheter arterial chemoembolization. A follow-up computed tomography scan revealed a single pulmonary metastasis. After 2 courses of S-1 administration, he underwent left lower lobectomy, and a pathological specimen taken at the time was diagnosed as pulmonary metastasis of HCC. Although adjuvant chemotherapy with S-1 resulted in relapse-free survival for 2 years after pulmonary resection, he was found to have recurrence of liver cancer and underwent partial hepatectomy. This case report suggests that surgical resection and S-1 administration would be a useful treatment option for hepatocellular carcinoma with distant metastasis.

Outcomes after living donor liver transplantation for acute liver failure in Japan: results of a nationwide survey

Nationwide surveys of acute liver failure (ALF) are conducted annually in Japan, and 20% of patients with ALF undergo liver transplantation (LT). We extracted data for 212 patients who underwent LT for ALF from the nationwide survey database of the Intractable Liver Diseases Study Group of Japan. After the exclusion of 3 patients who underwent deceased donor LT, 209 recipients of living donor liver transplantation (LDLT) were analyzed. ALF patients were placed into 3 subgroups according to the time from the onset of the disease to the occurrence of encephalopathy: patients who presented with encephalopathy within 10 days of the disease's onset were classified as having acute ALF, patients who presented within 11 to 56 days were classified as having subacute ALF, and patients who presented within 9 to 24 weeks were classified as having late-onset hepatic failure (LOHF). Long-term follow-up data were obtained from the registry of the Japanese Liver Transplantation Society. The 2 data sets were merged, and descriptive and survival data were analyzed. A Cox regression analysis was performed to define factors predicting overall mortality, short-term mortality (≤90 days after LT), and long-term mortality (>90 days after LT). One hundred ninety of the analyzed patients (91%) were adults (age ≥ 18 years); 70 patients (34%) were diagnosed with acute ALF, 124 (59%) were diagnosed with subacute ALF, and 15 (7%) were diagnosed with LOHF. Hepatitis B virus was the most common cause of acute ALF (61%), whereas autoimmune hepatitis (14%) and drug allergy-induced hepatitis (14%) were more frequent in patients with subacute ALF or LOHF. The cumulative patient survival rates 1, 5, and 10 years after LT were 79%, 74%, and 73%, respectively. Patient age was associated with short- and long-term mortality after LT, whereas ABO incompatibility affected short-term mortality, and donor age affected long-term mortality. In conclusion, the long-term outcomes of LDLT for ALF in this study were excellent, regardless of the etiology or classification. The majority of the donors were living donors. Increasing the deceased donor pool might be an urgent necessity.

Once-daily prolonged-release tacrolimus in de novo liver transplantation: a single center cohort study

BACKGROUND/AIMS

The feasibility of oral administration of once-daily prolonged-release tacrolimus (TAC-PR) in de novo liver transplantation is not clear and therefore was investigated further.

METHODOLOGY

The clinical profiles of 16 consecutive primary living donor liver transplantation (LDLT) recipients, who received oral TAC-PR once daily (TAC-PR group) between January 2009 and August 2010, were compared with those of 14 consecutive liver transplantation recipients given twice-daily tacrolimus (TAC; TAC group) between August 2006 and January 2009. Of the 14 patients in the TAC group, 9 received LDLT (TAC-L subgroup).

RESULTS

Patient characteristics were similar between groups. Trough levels of TAC during the first 3 months after liver transplantation were well-adjusted in both groups. Dose adjustment was more frequently required (31.3%) in the TAC-PR group and the total amount of TAC was significantly higher in the TAC-PR group (181.1±75.3mg) than in the TAC-L group (100.2±53.8mg, p=0.014). The incidence of biopsy-proven acute cellular rejection, renal dysfunction, other morbidities and hospital stay length were similar between groups.

CONCLUSIONS

Oral administration of TAC-PR for de novo liver transplantation recipients was well tolerated with similar safety and efficacy profiles as traditional twice-daily TAC with closely controlled adjustment of the TAC-PR dose.

Equivalent outcomes after anatomical and non-anatomical resection of small hepatocellular carcinoma in patients with preserved liver function

BACKGROUND

Although anatomical resection (AR) is considered better than non-anatomical resection (NAR) for the treatment for hepatocellular carcinoma (HCC), there is only limited evidence in support of this argument.

AIM

The aim of this study was to investigate whether AR is superior to NAR regarding postoperative outcomes in patients with small solitary HCC and preserved liver function.

METHODS

The study subjects were 92 curatively-resected patients with adequate liver function reserve (indocyanine green retention rate at 15 min <15%, prothrombin time >70%, serum albumin >3.5 g/dl) and macroscopically small (≤3.0 cm) solitary HCC without macroscopic vascular invasion; 30 patients underwent AR and 62 patients NAR. Postoperative short-term outcomes including mortality and morbidity and long-term outcomes were compared in the two groups.

RESULTS

There was no significant difference in clinicopathological background in the two groups. Although resected liver volume was significantly larger in the AR group than the NAR group (p < 0.0001), no significant differences were detected in the incidence of mortality or morbidity. For long-term outcomes, there were no significant differences between the two groups in disease-free survival or overall survival. Multivariate analysis showed that the extent of surgical procedure was not a significant prognostic factor for disease-free or overall survival.

CONCLUSIONS

AR of a solitary small HCC did not carry postoperative outcome advantages compared with NAR in patients with preserved liver function. We recommend NAR for hepatic resection of small solitary HCC in patients with preserved liver function.

Arterial stimulation and venous sampling for glucagonomas of the pancreas

BACKGROUND/AIMS

Arterial stimulation and venous sampling (ASVS) is a catheter-based diagnostic technique used to identify the localization of an insulinoma or gastrinoma. The aim of this study was to clarify the clinical significance of ASVS for glucagonomas.

METHODOLOGY

Eight patients with pancreatic hypervascular tumors and elevated serum glucagon levels in the peripheral blood were enrolled. Pancreatic angiography was performed and a bolus dose of calcium was injected into a suitable artery. Hepatic venous blood samples were then obtained to measure concentrations of glucagon and insulin. All patients underwent surgical resection, and the resected specimens were investigated immunohistochemically.

RESULTS

Compared to insulin, the glucagon levels stabilized after calcium stimulation in four patients, with a 1.2-fold increase or decrease. In the remaining four patients, there was a 1.6- to 5.8-fold increase in glucagon levels. The peak value of glucagon was observed at 90s or 120s which was slower than the insulin peak observed in patients with insulinoma. The patients with elevated glucagon levels during ASVS exhibited positive immunostaining of glucagon in resected specimens.

CONCLUSIONS

Increase in glucagon after calcium stimulation was observed in patients with glucagonomas. ASVS for glucagonomas may be useful in determining the most suitable surgical procedure.

Steroid-free living donor liver transplantation for HCV--a multicenter prospective cohort study in Japan

This prospective, non-randomized, multicenter cohort study analyzed the safety and efficacy of a steroid-free immunosuppressive (IS) protocol for hepatitis C virus (HCV)-positive living donor liver transplant (LDLT) recipients in Japan. Of 68 patients enrolled from 13 transplant centers, 56 fulfilled the inclusion/exclusion criteria; 27 were assigned the steroid-free IS protocol (Fr group) and 29 the traditional steroid-containing IS protocol (St group). Serum HCV RNA levels increased over time and were higher in the St group until postoperative day 90 (POD 14, p=0.013). Preemptive anti-HCV therapy was started in a higher percentage of recipients (59.3%) in the Fr group than in the St group (31.0%, p=0.031), mainly due to early HCV recurrence. The incidence of HCV recurrence at one yr was lower in the Fr group (22.2%) than in the St group (41.4%; p=0.066). The incidence of acute cellular rejection was similar between groups. New onset diabetes after transplant, cytomegalovirus infection, and renal dysfunction were significantly less frequent in the Fr group than in the St group (p=0.022, p<0.0001, p=0.012, respectively). The steroid-free IS protocol safely reduced postoperative morbidity and effectively suppressed both the HCV viral load in the early post-transplant period and HCV recurrence in HCV-positive LDLT recipients.

PLOD2 induced under hypoxia is a novel prognostic factor for hepatocellular carcinoma after curative resection

BACKGROUND

Under hypoxia, tumour cells undergo genetic and adaptive changes that allow their survival. Previously, we reported that high expression of hypoxia-inducible factor (HIF)-1 was a significant predictive factor for recurrence in hepatocellular carcinoma (HCC). Hypoxia also stimulates expression of procollagen-lysine, 2-oxoglutarate 5-dioxygenase (PLOD) genes via the HIF-1 pathway.

AIMS

The aim was to evaluate the relationship between hypoxia stress and expression of PLOD genes in HCC in vitro and to identify a new prognostic marker in HCC patients.

METHODS

The PLOD2 expression was assessed under hypoxia in hepatoma cell lines and characterized in 139 HCC samples following hepatic resection using microarray experiments, quantitative RT-PCR and immunohistochemistry. Prognostic factors in HCC patients were assessed using univariate and multivariate analyses.

RESULTS

The PLOD2 expression was induced under the hypoxia in vitro. Disease-free survival in the high PLOD2 expression group of HCC patients was significantly shorter when compared with the low-expression group (P = 0.002). In a subset of HCCs, we found that the PLOD2 expression of microarray was correlated with data of quantitative RT-PCR and immunohistochemistry. Of clinicopathological factors, PLOD2 expression was significantly correlated with tumour size (P = 0.022) and macroscopic intrahepatic metastasis (P = 0.049). In univariate analysis, six prognostic factors (tumour multiplicity, macroscopic intrahepatic metastasis, histological grade, microscopic portal invasion, microscopic intrahepatic metastasis and PLOD2 expression) were significant for disease-free survival. PLOD2 expression was identified as a significant, independent factor of poor prognosis (P = 0.013).

CONCLUSIONS

PLOD2 is a potential novel prognostic factor for HCC patients following surgery.

[A case of successful surgical resection followed by S-1 administration for hepatocellular carcinoma with lung metastases and a tumor thrombus into right atrium]

A case of a 68-year-old man with hepatocellular carcinoma (HCC) is presented. He underwent partial liver resection for three times and transcatheter arterial chemoembolization (TACE) for three times. Follow-up CT revealed a recurrent hepatic surface mass with malignant extended into the inferior vena cava (IVC) and right atrium (RA). CT scan also revealed multiple metastatic nodules in bilateral lungs. The tumor thrombus into the RA and the hepatic surface mass were successfully treated with surgical resection. Pathological specimen allowed the diagnosis of poorly-differentiated HCC. Adjuvant chemotherapy with S-1 resulted in complete remission of lung metastases. Tumor markers showed a significant improvement after S-1 administration. This case report suggests that a surgical resection followed by S-1 administration would be effective for a patient with lung metastases and a tumor thrombus into IVC or RA.

[A case of intrahepatic cholangiocarcinoma with invasion to right adrenal gland]

A 64-year-old woman was admitted for epigastralgia. Abdominal computed tomography demonstrated a large tumor in the right lobe of the liver to adrenal grand. An aspiration tumor biopsy was performed because of difficulty in diagnosing the tumor, and the pathological findings suggested intrahepatic cholangiocarcinoma. At surgery right hepatic lobectomy with caudate lobe combined with right adrenal glandectomy and diaphragmectomy was performed. Pathological findings showed moderately differentiated tubular adenocarcinoma with invasion to right adrenal gland, but no lymph node metastasis was involved nor invasion of lymph vessel and vein. The postoperative course was uneventful and the woman remains recurrence-free for 12 months after the surgery.

[A case of successful second look operation for hepatocellular carcinoma with right atrial tumor thrombus]

We report a case of advanced hepatocellular carcinoma (HCC) with right atrial tumor thrombus treated by interferon (IFN)-combinated chemotherapies and second look operation. A case was a 56-year-old man who had right upper abdominal and back pain. The abdominal CT revealed an early enhanced lesion in the posterior segment of the liver with right atrial tumor thrombus. The patient underwent 2 courses of IFN-β/adriamycin combination therapy and followed by surgical resection. Due to severe congestive live, we only surgically resected tumor thrombi at right atrium, inferior vena cava, and right hepatic vein. Additionally, we closed posterior branch and right hepatic vein to prevent from a tumor progression. Following 16 months of IFN/5-FU and IFN/S-1 therapy, we performed a right posterior sectionectomy of the liver. Twelve months after the second operation, liver tumor relapsed and we performed transcatheter arterial chemoembolizatin, followed by IFN-combinateted chemotherapies. Thereafter, we continued chemotherapy for 14 months. The tumor progressed into the bile duct, and he died after 3 years and 8 months from the initial treatment. The case suggests that some patients with HCC with major vascular invasion and tumor thrombus can gain a long-term survival by multifocal treatment including surgery and chemotherapy.

[A case of successful surgical resection after repeated transcatheter arterial chemoembolization for far advanced multiple hepatocellular carcinomas in both lobes associated with Vp₂ portal vein tumor thrombus]

Treatments for hepatocellular carcinoma (HCC) include surgical resection, transcatheter arteral chemoembolization (TACE), percutaneous local therapy and systemic chemotherapy. However, it is difficult to perform a curative treatment for patients with far advanced multiple hepatocellular carcinomas. Here we report a case of successful surgical resection after repeated TACE for far advanced multiple hepatocellular carcinomas in both lobes associated with Vp₂ portal vein tumor thrombus. A 54-year-old male who had multiple HCC lesions in lateral, median and right lobes with portal vein tumor thrombus was admitted to our hospital. Three attempts of TACE resulted in a successful control of the tumors in the right lobe. Left hepatic lobectomy was therefore performed, and a relapse-free survival was obtained for over 5 years after surgery.

[A case of complete response to interferon-α and S-1 combination therapy for multiple pulmonary recurrences of hepatocellular carcinoma after hepatic resection]

A 77-year-old man was diagnosed as hepatocellular carcinoma, and was referred to our hospital. After he was treated by transcatheter chemoembolization, he underwent a left hepatic lobectomy of the liver and cholecystectomy. Serum AFP and PIVKA-II remarkably elevated 7 months after surgery, and CT scan revealed multiple metastatic nodules in bilateral lungs. The nodules were diagnosed as lung metastasis of HCC. Because the lesions grew larger, S-1/IFN was administered. Diagnostic imaging and tumor markers showed a marked improvement after 4 courses of S-1/IFN therapy, and he is still alive with good condition without recurrence and progression of tumors.

[A case of successful treatment by interferon-α and 5-fluorouracil combination therapy (FAIT) and transcatheter arterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus]

We report a case of successful treatment by interferon-α (IFN) and 5-fluorouracil (5-FU) combination therapy and transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). A 70-year-old woman, who was diagnosed as unresectable HCC with PVTT in the main trunk of portal vein and multiple intrahepatic metastases, was admitted to our hospital for further treatment for HCC. First, she was treated by 3 courses of IFN and 5-FU combination therapy. Three courses after the combination therapy, PVTT was shrunken and portal flow to the liver was reperfused. Therefore, she was treated by TACE for intrahepatic tumors. She received a repeat treatment of the combination therapy and TACE. Four years after the initial treatment, she is still alive with good condition with intrahepatic tumors. This case suggested that some patient of HCC with PVTT could get a long-term survival if an initial treatment was succeeded and could apply further treatment such as TACE.

Advantage of autologous blood transfusion in surgery for hepatocellular carcinoma

AIM: To evaluate the significance of autologous blood transfusion (AT) in reducing homologous blood transfusion (HT) in surgery for hepatocellular carcinoma (HCC).

METHODS: The proportion of patients who received HT was compared between two groups determined by the time of AT introduction; period A (1991-1994, n = 93) and period B (1995-2000, n = 201). Multivariate logistic regression analysis was performed in order to identify independent significant predictors of the need for HT. We also investigated the impact of AT and HT on long-term postoperative outcome after curative surgery for HCC.

RESULTS: The proportion of patients with HT was significantly lower in period B than period A (18.9% vs 60.2%, P < 0.0001). Multivariate logistic regression analysis identified AT administration as a significant independent predictor of the need for HT (P < 0.0001). Disease-free survival in patients with AT was comparable to that without any transfusion. Multivariate analysis identified HT administration as an independent significant factor for poorer disease-free survival (P = 0.0380).

CONCLUSION: AT administration significantly decreased the need for HT. Considering the postoperative survival disadvantage of HT, AT administration could improve the long-term outcome of HCC patients.

Postoperative quality of life: development and validation of the "Dysfunction After Upper Gastrointestinal Surgery" scoring system

BACKGROUND

Although postoperative quality of life is an important outcomes measure, few tools exist to evaluate patients specifically after upper gastrointestinal surgery. The previously developed Dysfunction After Upper Gastrointestinal Surgery (DAUGS)32 scoring system has been further refined to include just 20 items. This study was undertaken to validate the refined evaluation tool.

STUDY DESIGN

The study was performed as a survey, administered to patients after upper gastrointestinal resection at 3 separate institutions.

RESULTS

The DAUGS20 score after gastrectomy (n = 662) was 27.8 and that after esophagectomy (n = 221) was 36.1, showing a significant difference (p < 0.05). The score after distal gastrectomy (n = 282) was 25.4 and that after total gastrectomy (n = 149) was 32.0, showing a significant (p < 0.05) difference. The α coefficient of all items on the DAUGS20 system was 0.904 and Cronbach's α coefficients of the subscales were 0.612 to 0.856, demonstrating high reliability of this evaluation tool. In addition, 7 factors were extracted from the 20 items using definitive factor analysis, to verify validity.

CONCLUSIONS

Patient quality of life should be evaluated as an outcomes measure after surgical resection for cancer, just as overall survival is analyzed. The DAUGS20 score is reliable, has validity in the evaluation of postoperative patients, and is a valuable tool to assess patient quality of life after upper gastrointestinal surgery for cancer.