Quantitative, dynamic 18F-FDG-PET for the evaluation of soft tissue sarcomas: relation to differential diagnosis, tumor grading and prediction of prognosis

The purpose of this study was to evaluate soft tissue sarcomas by dynamic (18)F-FDG-PET studies, and to establish an index of kinetic parameters for evaluation of their malignancy, histological grade and prognosis, after surgical resection. One hundred and seventeen patients including 79 with histologically proven soft tissue malignancies, 14 with primary benign soft tissue tumors and 24 with postoperative scar tissues were examined. The (18)F-FDG studies were accomplished as a dynamic series for 60 min. The evaluation of the (18)F-FDG kinetics was performed using the following parameters: standardized uptake value (SUV), global influx (Ki), computation of transport constants (k1-k4) with consideration of the vascular fraction (VB) according to a two tissue compartment model, and fractal dimension (FD) based on the box-counting procedure (non-compartmental model). Discriminant analysis (DA) was used for data evaluation. Multivariate analysis was performed to assess the predictive value of each kinetic parameter on survival. Our results showed that in the primary cases (n=46), SUV, k1, Ki and FD were higher in sarcomas than benign tumors. The diagnostic sensitivity of 62.50%, a specificity of 92.86%, and an accuracy of 71.74% were achieved by using the combination of k1 and SUV as input variables for DA. In the postoperative cases (n=71), SUV, VB, k3, Ki, and FD were higher in recurrent lesions than in scar tissues. DA revealed a sensitivity of 80.85%, a specificity of 87.50%, and an accuracy of 83.10% by using the combination of SUV, Ki and FD. In liposarcoma patients (n=32), SUV and FD were higher in GII,III tumors as compared with GI. DA led to a sensitivity of 86.96%, a specificity of 55.56%, and an accuracy of 78.13% by using the combination of SUV and FD. By multivariate analysis of primary soft tissue sarcomas (n=26) after surgical resection, groups with k3>0.025 (P<0.0026) or FD>1.25 (P<0.0162) had significantly poor prognosis. In conclusion, the evaluation of full (18)F-FDG kinetics provides important information for the diagnosis of malignant lesions, histological grading and prognosis of soft tissue sarcomas.

Quantitative measurement of blood flow using perfusion CT for assessing clinicopathologic features and prognosis in patients with rectal cancer

PURPOSE

The ability to evaluate clinicopathologic features and prognosis before surgery by contrast-enhanced CT would be valuable for managing rectal cancer. This study was designed to evaluate the clinical usefulness of perfusion CT in patients with rectal cancer before surgery.

METHODS

Forty-four consecutive patients (27 men, 17 women; median age, 63.6 years) with rectal cancer underwent perfusion CT before surgery. We retrospectively investigated the correlations between tumor blood flow generated by perfusion CT and clinicopathologic features.

RESULTS

There was a significant correlation between blood flow and wall invasion (P = 0.04). Well-differentiated tumors showed significantly higher blood flow than moderately differentiated tumors (P = 0.03). There was a significant tendency for tumors with low blood flow to show lymph node metastasis (P = 0.0005), vascular invasion (P = 0.004), lymphatic invasion (P = 0.04), and distant metastasis (P = 0.0005). For blood flow, accuracy was 75% for detection of tumors with lymph node metastasis if the cutoff point was set at 55 ml/100 g per minute. Patients with high blood flow tumors survived significantly longer than those with low blood flow tumors (P = 0.002).

CONCLUSIONS

Blood flow of rectal cancers may be useful to evaluate pathologic features and prognosis before surgery.

Impact of lymph node involvement in T2 or T3 thoracic esophageal squamous cell carcinoma

BACKGROUND/AIMS

Treatment strategy for T2/ T3 esophageal carcinoma has become controversial because of recent improvements in chemoradiation therapy. Only a few study analyzed the prognostic impact of clinicopathological factors for surgical outcome of patients with esophageal carcinoma focused on T2/T3 tumors.

METHODOLOGY

Subjects of this study were 187 patients with pathological T2 (n = 46) or pathological T3 (n = 141) thoracic esophageal squamous cell carcinoma who received surgical treatment without neoadjuvant therapy. The impact of clinicopathological factors on survival was evaluated by univariate and multivariate analysis.

RESULTS

Overall 5-year survival rate of all patients was 38%. Dismal 5-year overall survival rates were observed in patients with 5 or more positive nodes (11%). Multivariate analysis indicated that lymph node metastases (hazard ratio; 2.07, 95%IC, 1.20-3.56, p < 0.01) and the number of metastatic nodes (hazard ratio; 1.77, 95%IC, 1.11-2.82, p = 0.02) were independent risk factors for poor survival. However, tumor depth itself was not an independent risk factor for survival.

CONCLUSIONS

Although survival of patients with pathological T2 or T3 was partly dependent on tumor depth, it was mainly dependent on lymph node status. Multiple positive nodes were independent risk factors for poor survival.

[Regulation of perioperative immunological changes following laparotomy--effects of PSK on surgical stress]

Immune responses have been reported to decline following surgical stress, leading to an increased susceptibility to infection or to the growth of tumors. We report that preoperative treatment with PSK can inhibit the decline of immunocompetence during the perioperative period. BALB/c mice were laparotomized, and then the abdomens were closed. The concentrations of IL-6 and of IFN-gamma and IL-4 were measured. PSK treatment controlled the stress induced elevation. It was lower in the group with surgical stress than in the cultures derived from the non-treated group. The IFN-gamma concentration in the group with PSK was significantly higher than the level in the group with surgical stress alone. The IL-4 concentration was significantly lower in the surgical stress group than the control group. However, the concentration tended to be higher in the surgical stress + PSK treatment group than the group with surgical stress alone. The IFN-gamma/IL-4 ratio in the group with surgical stress was lower than the ratio in the non-treated group. The ratio in the group with PSK treatment was significantly higher than the ratio in the group with surgical stress alone. These results suggest that PSK restores the abnormality of the biological responses induced by surgical stress and corrects the reduced Th1/Th2 cytokine balance to a normal level.

[Expression of toll-like receptor 4 in colorectal cancer]

Toll-like receptors (TLRs) play an essential role in innate immunity by recognizing various pathogens and by activating acquired immunity. Based on the hypothesis that abnormalities of innate immune responses are involved in carcinogenesis, we examined the presence or absence of the expression of Toll-like receptor 4 (TLR4), comprising one of the TLR families, in colorectal cancer tissues. TLR4 expression in cancerous and non-cancerous colorectal tissue specimens obtained at surgery was investigated by reverse-transcription polymerase chain reaction (RT-PCR). Then, TLR4 expression levels were quantified by real-time PCR and compared between the 2 groups. TLR4 expression was significantly higher in non-cancerous tissues than in cancerous tissues. Interestingly, these results suggested that TLR4 expression was up-regulated in non-cancerous tissues or down-regulated in cancerous tissues in patients with colorectal cancer.

Histological diversity in basaloid squamous cell carcinoma of the esophagus

Basaloid squamous cell carcinoma of the esophagus (BSCCE) is a distinct variant of esophageal cancer. This study investigated histopathological variations of BSCCE. Thirty-eight surgical and two endoscopically resected specimens of BSCCE were examined. Histological features were classified into five components: solid nest (SN), microcyst and/or trabecular nest (MT), ductal differentiation (DD), cribriform pattern (CP), and an invasive squamous cell carcinoma (SCC) component. The immunohistochemical phenotypes of each component were examined using antibodies against cytokeratin (CK) 7, CK14, and alpha smooth muscle actin (SMA). SN, MT, DD, CP, and SCC were present in 95.0, 97.5, 27.5, 32.5, and 82.5% of the cases, respectively, and combinations of SN & MT, SN & DD, SN, MT & DD, SN, MT & CP, and SN, MT, DD & CP were found in 50.0, 2.5, 10.0, 17.5, and 15.0%, respectively. All the intraepithelial lesions observed in 18 (45.0%) cases were SCC. Immunoreactivity for CK7, CK14, and SMA was seen in 10.5, 86.8, and 18.4% of SN; 30.8, 97.4, and 38.5% of MT; 54.5, 100.0, and 54.5% of DD; 7.7, 76.9, and 23.1% of CP; and 6.1, 97.0, and 0.0% of SCC, respectively. CK14 immunoreactivity was seen in the periphery of most of the SN component. CK7, CK14, and SMA immunoreactivity was seen in the inner layer, all layers, and the outer layer of DD, respectively. MT and CP showed partial peripheral positivity for CK14 and SMA in microcystic, trabecular, and cribriform-like pseudoglandular structures. BSCCE demonstrates various histopathological and immunohistochemical features including a ductal and cribriform growth pattern.

Impact of preoperative dental plaque culture for predicting postoperative pneumonia in esophageal cancer patients

BACKGROUND/AIMS

In esophageal cancer patients, postoperative pneumonia frequently occurs. In the oral cavity, dental plaque is a major reservoir of bacteria, and it is possible that oral bacteria are aspirated into the upper respiratory tract after esophagectomy. We evaluated the interaction between preoperative dental plaque and postoperative pneumonia in patients undergoing esophagectomy.

PATIENTS AND METHODS

Thirty-nine patients with thoracic esophageal cancer who underwent esophagectomy were investigated. Preoperatively, dental plaque was collected and the bacterial flora investigated. If postoperative pneumonia occurred, the sputum was harvested and the pathogens were evaluated.

RESULT

Postoperative pneumonia was observed in 14 patients (35.9%): 5 (71.4%) of 7 patients in the pathogen-positive group and 9 (28.1%) of 32 patients in the pathogen-negative group. In 2 (40.0%) of 5 patients with postoperative pneumonia, who had pathogenic bacteria in the preoperative dental plaque, the same pathogenic bacteria were also identified in the postoperative sputum.

CONCLUSION

Pathogens in preoperative dental plaque are risk factors for postoperative pneumonia following thoracotomy in patients with thoracic esophageal cancer.

Improved surgical results in thoracic esophageal squamous cell carcinoma: a 40-year analysis of 792 patients

Extensive lymphadenectomy, including upper mediastinum, for thoracic esophageal carcinoma was introduced at the beginning of 1980s. However, the efficacy has not been analyzed in large series at a single institute. We evaluated factors potentially related to improved surgical results in patients with thoracic esophageal squamous cell carcinoma (SCC). From 1959 to 1998, a total of 792 patients with thoracic esophageal SCC underwent R0 surgery. A variety of clinicopathological factors were compared among patients treated from 1990 to 1998 (recent group, n=164) and 1959 to 1989 (former group, n=628). The recent group showed significantly better survival than the former group (5-year survival rates: 51 versus 17%, P<0.01), partly because earlier stage disease was included in the recent group than in the former group. Multivariable analysis, using the Cox regression analysis, indicated the time period of surgery, age, tumor location, the number of positive nodes (>5), venous invasion, and tumor-node-metastasis stage. Upper mediastinum lymphadenectomy was also an independent factor to improve survival of patients with thoracic esophageal SCC.

Ventral pancreatectomy associated with segmental duodenectomy including the major papilla

During embryonic development, the head of the pancreas comprises ventral and dorsal primordia. The embryological fusion plane between the ventral and dorsal primordia reportedly separates the adult pancreas into the ventral and dorsal pancreas. The duct of Wirsung drains the ventral pancreas and terminates in the major papilla, while the duct of Santorini drains the dorsal pancreas and terminates in the minor papilla. However, complete resection of the ventral pancreas is difficult and impractical because the lower bile duct is buried in ventral pancreatic parenchyma and resection may lead to postoperative ischemic necrosis of the duodenum, particularly around the major papilla. We have therefore performed ventral pancreatectomy associated with segmental duodenectomy including the major papilla in 3 cases with intraductal papillary mucinous neoplasm that involved only the duct of Wirsung.

Perfusion CT can predict the response to chemoradiation therapy and survival in esophageal squamous cell carcinoma: initial clinical results

The ability to predict the response to chemoradiation therapy (CRT) by contrast-enhanced CT would be valuable for managing esophageal squamous cell carcinoma. The purpose of this study was to evaluate the usefulness of Perfusion CT to predict the response to CRT in patients with esophageal squamous cell carcinoma. Thirty-one consecutive patients with esophageal squamous cell carcinoma underwent Perfusion CT before CRT. We retrospectively investigated the correlations between Perfusion parameters and the response to CRT. Clinicopathological markers and blood flow were compared in terms of survival. There were 21 clinical responders and 10 non-responders. Clinical responders showed significantly higher pre-CRT blood flow (P=0.0004), significantly higher pre-CRT blood volume (P=0.03) and a significantly shorter pre-CRT mean transit time (P=0.002) than non-responders. For pre-CRT blood flow, accuracy was 90.3% for detection of clinical responders when the cut-off point was set at 50 ml/100 g/min. Patients with high blood flow tumors survived significantly longer than those with low blood flow tumors (P=0.006). Multivariate analysis identified blood flow as a significant independent prognostic factor (P=0.01). Therefore, Perfusion CT may help to identify patients with advanced esophageal squamous cell carcinoma who will benefit from CRT.

Perfusion CT can predict the response to chemoradiation therapy and survival in esophageal squamous cell carcinoma: initial clinical results

The ability to predict the response to chemoradiation therapy (CRT) by contrast-enhanced CT would be valuable for managing esophageal squamous cell carcinoma. The purpose of this study was to evaluate the usefulness of Perfusion CT to predict the response to CRT in patients with esophageal squamous cell carcinoma. Thirty-one consecutive patients with esophageal squamous cell carcinoma underwent Perfusion CT before CRT. We retrospectively investigated the correlations between Perfusion parameters and the response to CRT. Clinicopathological markers and blood flow were compared in terms of survival. There were 21 clinical responders and 10 non-responders. Clinical responders showed significantly higher pre-CRT blood flow (P=0.0004), significantly higher pre-CRT blood volume (P=0.03) and a significantly shorter pre-CRT mean transit time (P=0.002) than non-responders. For pre-CRT blood flow, accuracy was 90.3% for detection of clinical responders when the cut-off point was set at 50 ml/100 g/min. Patients with high blood flow tumors survived significantly longer than those with low blood flow tumors (P=0.006). Multivariate analysis identified blood flow as a significant independent prognostic factor (P=0.01). Therefore, Perfusion CT may help to identify patients with advanced esophageal squamous cell carcinoma who will benefit from CRT.

Have surgical outcomes of pathologic T4 esophageal squamous cell carcinoma really improved? Analysis of 268 cases during 45 years of experience

BACKGROUND

Because invasion to an adjacent organ (T4) indicates highly advanced disease, and most surgeons avoid esophagectomy, the prognostic impact of clinicopathologic factors for survival of these patients after esophagectomy has rarely been analyzed.

STUDY DESIGN

From 1960 to 2005, a total of 268 patients with esophageal squamous cell carcinoma underwent esophagectomy for pathologic T4 disease (pT4). The impact of clinicopathologic factors on survival was evaluated by univariate and multivariate analysis. Changes in surgical outcomes and longterm survival between the earlier period (1960 to 1989) and the later period (1990 to 2005) were analyzed.

RESULTS

Overall survival rates of all patients were 25% at 1 year, 10% at 3 years, and 5% at 5 years. The survival curve of the later group was significantly better than that of the earlier group (p < 0.01). Multivariate analysis indicated that venous invasion (hazards ratio, 1.76; 95% CI, 1.33 to 2.33, p < 0.01) and presence of a postoperative complication (hazards ratio, 2.62; 95% CI, 1.96 to 3.51, p < 0.01) were independent risk factors for poor overall survival. Presence of residual cancer was also an independent risk factor for poor cause-specific survival (hazards ratio, 2.40; 95% CI, 1.23 to 4.69, p=0.01). Venous invasion and intramural metastasis were risk factors for residual cancer. A total of 38 (14%) patients, 15 in the early period and 23 in the later period, underwent complete resection (R0). Although overall survival after R0 resection in the later period improved slightly, cancer-related survival rates were similar in both periods.

CONCLUSIONS

Although overall survival of patients with pT4 improved after 1990, this improvement might be mainly dependent on curability of the resection.

Intersegmental arterial communication between the medial and left lateral segments of the liver

BACKGROUND/AIMS

Although the interlobar arterial collateral of the liver has been thoroughly analyzed, few reports have described the intersegmental arterial collateral between the medial and left lateral segments.

METHODS

The hepatic arterial system of the left liver was evaluated using 12 latex resin cast specimens in which latex resin was injected into the left hepatic artery after ligation of the right hepatic artery.

RESULTS

In all 12 livers, an intersegmental collateral between the medial and left lateral segments was detected. These collaterals were extrahepatically located in the umbilical plate and gave rise to branches traveling to the bile duct of the left liver.

CONCLUSIONS

The present study showed that the communicating arcade between the middle and left lateral hepatic arteries was consistently present in the umbilical plate and played an important role not only in the intersegmental arterial collateral system of the left liver but also in the blood supply to the bile ducts.

Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection

Although many reports have described laparoscopic minor liver resections, major hepatic resection, including right or left lobectomy, has not been widely developed because of technical difficulties. This article describes a new technique for performing laparoscopy-assisted right or left hepatic lobectomy using hilar Glissonean pedicle transection. Laparoscopic mobilization of the right or left hepatic lobe is performed, including dissection of the round, faliciform, triangular, and coronary ligaments. The right or left Glissonean pedicle is encircled and divided laparoscopically. A parenchymal dissection is then performed though the upper median or right subcostal incision, through which the resected liver is removed. We successfully performed this procedure in 6 patients without blood transfusion or serious complications. Laparoscopy-assisted hepatic lobectomy using hilar Glissonean pedicle transection can be feasible and safe in highly selected patients.

Extrahepatic control of the middle hepatic vein with inflow control by pedicle clamping in major liver surgery

Surgical techniques commonly used for controlling bleeding during major liver surgery are hepatic inflow occlusion (Pringle maneuver) or total hepatic vascular exclusion (THVE), which are effective procedures of diminishing intraoperative blood loss. However, it is difficult to control retrograde bleeding from the hepatic veins using Pringle maneuver and some patients do not tolerate hemodynamic changes caused by THVE. We isolated the left and middle hepatic veins separately using Arantius' ligament approach to these hepatic veins, and extrahepatic control of the relevant to the liver segment to be resected hepatic veins with inflow control by Glissonian pedicle clamping was successfully performed.

Concurrent chemoradiation for patients with squamous cell carcinoma of the cervical esophagus

Little is known concerning the role of concurrent chemoradiation (CCRT) in the management of carcinoma of the cervical esophagus. We retrospectively evaluated our treatment approach for patients with cervical esophageal cancer with special emphasis on CCRT with or without surgery. Medical records of 21 consecutive patients with cervical esophageal carcinoma treated mainly with CCRT (1997-2004) were reviewed, and factors that influenced patient survival were analyzed retrospectively. Nineteen received CCRT with cisplatin/5-fluorouracil and five underwent curative surgery. Two patients who were deemed unfit for CCRT received radiation therapy alone. All had three-dimensional treatment planning (median total dose, 40 Gy with surgery, 64 Gy without surgery). Of the 19 patients who received CCRT, 11 patients including five who underwent curative surgery achieved initial local control. Neither of the two patients who received radiation therapy alone achieved local control. Among 19 patients who underwent CCRT, 9/11 with T1-3 grade tumors achieved initial local control, but only 2/8 patients with T4 tumors (P = 0.011, chi(2) test) achieved initial local control. No patient without initial local control survived > 20 months compared with 2-year and 5-year survival rates of 60% and 40% in those who achieved initial local control (P = 0.038). No patient with T4 tumors survived > 18 months, whereas 2- and 5-year survival rates were 62% and 41%, respectively, in those with T1-3 tumors (P = 0.006). The significant effect of T-classification on survival was maintained when analyzed among 19 patients who received CCRT. CCRT shows promise for cervical esophageal carcinoma. T-classification and initial local control had significant impact on survival.

Relationship between right portal and biliary systems based on reclassification of the liver

BACKGROUND

Although the anatomy of the right portal and biliary systems and their interrelationships must be understood to safely and satisfactorily perform left-sided resection of hilar cholangiocarcinoma or right-lobe living donor liver transplantation, the anatomies of the right portal and biliary systems are extremely difficult to understand.

METHODS

A total of 60 patients with normal liver underwent computed tomography during both portography and cholangiography to evaluate relationships between the right biliary and portal systems based on reclassification of the liver to divide the right liver into 3 segments.

RESULTS

All ventral and posterior ducts constantly join medially to the anterior portal trunk. In contrast, some dorsal ducts join the ventral duct medially and others join the posterior duct lateral to the anterior trunk.

CONCLUSIONS

Reclassification of the liver to divide the right liver into 3 segments facilitates an understanding of relationships between the right portal and biliary systems.

Anatomy of the middle hepatic vein: applications to living donor liver transplantation

BACKGROUND/AIMS

In living donor liver transplantation, right lobe graft without a middle hepatic vein (MHV) results in potential venous congestion in the anterior segment, while transplantation with MHV represents an important ethical issue from the perspective of donor safety. The present study assessed ramification patterns of the MHV and relationships between hepatic venous drainage of the anterior and medial segments, to plan optimal harvesting of the right lobe as a graft.

METHODOLOGY

The authors reviewed 102 patients with normal livers who underwent contrast-enhanced multi-detector row CT.

RESULTS

The hepatic vein that drained S4sup (V4sup) joined only the left hepatic vein (LHV) in 60 patients (58%), only the MHV in 25 (25%), and both LHV and MHV in 17 (17%). Both V4sup and the hepatic vein that drained S8 (V8) joined the MHV in 42 patients (42%), and V8 joined proximal to V4sup in 18 of these 42 patients.

CONCLUSIONS

In donation of a right lobe graft including MHV, preservation of V4sup in the remnant donor liver seems possible in most donors.

The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries

BACKGROUND

There is an increasing demand for living donor liver transplants. However, the biliary complication rates are still high.

METHODS

The anatomy of the communicating arcade (CA) between the right and left livers and its relevance to the blood supply of the hilar bile duct was evaluated using adult cadaveric livers and cast specimens.

RESULTS

In all specimens that were of sufficient quality for evaluation, the CA was found to be located extrahepatically in the hilar plate with thin tributaries branching to the hilar bile duct. On the left side, 55% of the CA originated from a segment IV artery. On the right side, 73% of the CA originated from the right anterior hepatic artery.

CONCLUSIONS

To maintain an adequate blood supply for the hilar bile duct of the donor graft during living donor liver transplantation, the branching point of the CA should be preserved.

Endoscope-assisted thoracoscopic technique for esophageal bronchogenic cyst which presented elevated CA125

A 26-year-old male was admitted to our hospital with a complaint of mild dysphagia. Preoperative examinations revealed a cystic lesion at the lower esophagus, thought to be a bronchogenic cyst. The patient underwent successful thoracoscopic tumor extirpation, assisted by endoscopy, without undergoing major thoracotomy. Thoracoscopic surgery is recommended for this entity, but the muscle layer is often injured. Endoscopic ultrasonography was very useful, as it could detect damage to the proper muscle layer of the esophagus near the tumor. Thus, we could predict preoperatively that the defect in the muscle layer, which must be closed, would be caused by the surgery. Additionally, endoscopy easily facilitated the detection of the regional defect and the border of the proper muscle layer, and also could be used as a stent during wall suturing. This technique enabled us to avoid postoperative stenosis of the esophagus. Furthermore, our case presented a high level of CA125. The preoperative serum CA125 value was 93.8 U/ml and intratumoral CA125 concentration was 1,690,000 U/ml. Serum CA125 decreased to 16.5 U/ml after surgery. In this paper, we present a new strategy of the treatment for bronchogenic cyst and a review the literature.

Phase I/II adenoviral p53 gene therapy for chemoradiation resistant advanced esophageal squamous cell carcinoma

We investigated the feasibility, safety, biological activity and therapeutic efficacy of adenovirus-mediated p53 gene transfer in patients with chemoradiation resistant advanced esophageal carcinoma. Eligible patients were not surgical candidates and had measurable, advanced squamous cell carcinoma of the esophagus that was resistant to chemoradiation therapy. On a 28-day cycle, intratumoral injections of Ad5CMV-p53 (INGN 201; ADVEXIN) were administered on days 1 and 3 at four dose levels (10 x 10(11) particles to 25 x 10(11) particles) and treated for up to five cycles. Ten patients received a total of 26 cycles with no dose-limiting toxicity. Administration of multiple courses was feasible and well-tolerated. Local tumor responses revealed stable disease in nine cases and progressive disease in one case. The overall responses were stable in six and progressive in four cases. Using polymerase chain reaction (PCR) analyses, gene transfer and p53 specific transgene expression were detected in tumor biopsy tissue from all patients. mRNA levels of p53, p21 and MDM2 increased in all but one case. Three patients showed absence of disease upon repeat biopsies. Substantial improvement in swallowing was observed in one patient with stenotic lesions. Intratumoral injection of Ad5CMV-p53 is safe, feasible and biologically active when administered in multiple doses to patients with esophageal cancer. Observations from this study indicate that this treatment results in local antitumor effects in chemoradiation resistant esophageal squamous cell carcinoma.

Evaluation of CT during arterial portography for preoperative diagnosis of intrahepatic cholangiocarcinoma

BACKGROUND/AIMS

To evaluate computed tomography during arterial portography for preoperative evaluation in patients with intrahepatic cholangiocarcinoma.

METHODOLOGY

Computed tomography during arterial portography was performed in 11 intrahepatic cholangiocarcinoma patients undergoing hepatectomy. Segmental perfusion defect, sensitivity of the main tumor, and sensitivity of intrahepatic metastasis on computed tomography during arterial portography were retrospectively evaluated.

RESULTS

In 9 of 11 patients (81.8%), a segmental perfusion defect was seen. The sensitivities for detecting the main tumor and intrahepatic metastasis were 81.8% and 20%, respectively. In 2 patients, the main tumors existed in segmental perfusion defects and thus were not depicted. In 4 false-negative cases, intrahepatic metastatic lesions existed in the segments that were the counterparts of segmental perfusion defects on computed tomography during arterial portography.

CONCLUSIONS

The sensitivity of computed tomography during arterial portography for diagnosing intrahepatic cholangiocarcinoma and its intrahepatic metastasis was low due to segmental perfusion defect. It is necessary for intrahepatic cholangiocarcinoma to be subjected to systematic segmentectomy including all areas corresponding to the segmental perfusion defect.

Neoadjuvant chemoradiotherapy followed by esophagectomy for initially resectable squamous cell carcinoma of the esophagus with multiple lymph node metastasis

Neoadjuvant chemoradiotherapy (CRT) was expected to improve surgical curability and prognosis for advanced esophageal cancer. However, the clinical efficacy of neoadjuvant CRT followed by esophagectomy with three-field lymphadenectomy (3FL) for initially resectable esophageal squamous cell carcinoma (SCC) remains unclear. Since 1998, we have defined the status of metastases to five or more nodes, or nodal metastases present in all three fields as multiple lymph node metastasis, which was previously shown to be associated with poor prognosis. Between 1998 and 2002, 83 patients with initially resectable esophageal SCC were prospectively allocated into two groups, according to the clinical status of nodal metastasis. Nineteen patients clinically accompanied by multiple lymph node metastasis initially underwent neoadjuvant CRT followed by curative esophagectomy with 3FL (CRT group). The other 64 patients clinically without multiple lymph node metastasis immediately received curative esophagectomy with 3FL (control group). Although the overall morbidity rate was significantly higher in the CRT group, no in-hospital death occurred in either group. Patients without pathologic multiple lymph node metastasis in the CRT group showed a significantly better disease-free survival rate than either patients pathologically with multiple lymph node metastasis in the control group or those in the CRT group. However, the differences in the overall survival rate among the groups were not significant. Thus, the significant survival benefit by neoadjuvant CRT in addition to esophagectomy with 3FL was not confirmed, although it may have been advantageous, without increase in mortality, to at least some patients who responded well to neoadjuvant CRT. Therefore, neoadjuvant CRT can be an initial treatment of choice for resectable esophageal SCC clinically with multiple lymph node metastasis. The prediction of response to CRT and the development of alternative treatment for hematogenous recurrence could achieve a further survival benefit of this trimodality treatment.

Two-staged hepato-pancreatoduodenectomy and interventional pancreaticojejunostomy

Two-staged pancreatoduodenectomy, including exteriorization of the pancreatic juice and second-look pancreaticojejunostomy, has been recommended for high-risk patients to avoid pancreatic leakage, which often causes intra-abdominal hemorrhage. We present a new technique of interventional pancreaticojejunostomy under both fluoroscopy and endoscopy without second-look laparotomy. A 77-year-old woman with local recurrence and liver metastasis from colon cancer underwent hepato-pancreatoduodenectomy with the external drainage of pancreatic juice via the pancreatic duct tube without pancreaticojejunostomy. Two months later, the jejunum was punctured with the insertion of a 5-F needle-knife into the pancreatic fistula during endoscopic observation of jejunal lumen, followed by the insertion of two 0.35-inch guidewires into the jejunum and the pancreatic fistula. Finally, a 10-Fr stenting tube was placed between the jejunum and the pancreatic fistula. No complications developed.

Communicating arcade between the right and left hepatic arteries: evaluation with CT and angiography during temporary balloon occlusion of the right or left hepatic artery

PURPOSE

To evaluate prospectively the relationship between the arterial collateral system at the hepatic hilum and the blood supply to the hilar bile duct by using computed tomography (CT) and angiography during temporary balloon occlusion of the right or left hepatic artery.

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. The study included 13 patients with no lesions at the hepatic hilum (eight men and five women; age range, 41-78 years; mean, 65.8 years). After serial angiographic studies were performed for preoperative evaluation or transcatheter arterial chemoembolization, a 5.5-F catheter with an occlusion balloon was positioned in the right or left hepatic artery. Eleven patients underwent angiography of the left hepatic artery with temporary occlusion of the right hepatic artery, and two patients underwent angiography of the right hepatic artery with temporary occlusion of the left hepatic artery. In addition, 11 patients underwent single-level dynamic CT during hepatic arteriography (CTHA) with temporary occlusion of the right or left hepatic artery. The images from angiography and CTHA were interpreted by two authors who assessed the existence of the arterial communication and its branching points, location, and relationship to the hilar bile duct and caudate lobe.

RESULTS

During temporary occlusion of the right or left hepatic artery, the communicating arcade (CA) between the right and left hepatic arteries was immediately evident in all patients. On the left side, the CA originated from the segment IV artery in eight patients (62%) and from the left hepatic artery in five (38%). On the right side, the CA originated from the right anterior hepatic artery in six patients (46%), the right hepatic artery in two (15%), and both arteries in five (38%). The CA was extrahepatically located close to the hilar bile duct and forked into a few branches to the caudate lobe.

CONCLUSION

The CA may play an important role not only in the interlobar arterial collateral system but also in the blood supplies to the caudate lobe and hilar bile duct.

Overexpression of glucose transporter 1 in esophageal squamous cell carcinomas: a marker for poor prognosis

Recently, Glut1 (human erythrocyte glucose transporter) expression has been demonstrated in various tumors. The aim of this study is to evaluate the prognostic utility of Glut1 expression in esophageal carcinomas. We studied Glut1 expression by immunohistochemistry of paraffin sections from 63 esophageal squamous cell carcinomas. All 63 carcinomas expressed Glut1. The mean percentage of positively stained tumor cells was 77.8% (median, 84.7%). There were two staining patterns in positive cells: 'strongly positive' and 'weakly positive'. The percentage of 'strongly positive' cells (%Glut1-SP) ranged from 0% to 95.6% (mean, 32.3%; median, 27.4%). The 5-year survival rate for patients with a high %Glut1-SP (> 30%) was significantly lower than that for patients with a low %Glut1-SP (< 30%) (P < 0.01). Statistical analysis revealed that the relative risk of death for patients with high %Glut1-SP was 2.02 times that for patients with low %Glut1-SP (P = 0.064), suggesting a possible independent predictive value for %Glut1-SP.

Anterior fissure of the right liver--the third door of the liver

BACKGROUND/PURPOSE

Although the anterior segment of the liver has been divided into segments 8 and 5, we have, during surgical or interventional procedures, occasionally encountered patients in whom the right anterior portal vein does not bifurcate into the superior and inferior branches. Thus, the in vivo anatomy of the right liver was reevaluated to clarify the segmental anatomy.

METHODS

We evaluated the hepatic venous and portal ramification patterns, using three-dimensional images reconstructed from computed tomography. In addition, liver volumetry was performed.

RESULTS

All branches arising from the anterior trunk were divided into two groups: the right ventral portal branches (RVP) and the right dorsal portal branches (RDP), and the anterior fissure vein crossed between the RVP and RDP. The ventral and dorsal regions of the anterior segment were approximately equal from a volumetric point of view.

CONCLUSIONS

The anterior segment seems to be divided into the ventral and dorsal segments by the anterior fissure, and we propose a reclassification of the right liver that divides the right liver into three segments. Dissection of the parenchyma along the anterior fissure makes the third door of the liver open, resulting in the exposing of all Glissonian pedicles of the right liver. The introduction of our segmental anatomy and surgical procedure will allow more systematic and limited liver resections.

Proposal for a reclassification of liver based anatomy on portal ramifications

BACKGROUND

Portal branching patterns that differ from those previously described are occasionally encountered during liver surgery.

METHODS

A total of 60 patients with normal intrahepatic venous anatomy underwent helical computed tomography during arterial portography (CTAP). Next, 3 dimensional portograms were reconstructed to verify the locations of the portal veins. Portal branching patterns in the right hemiliver were assessed.

RESULTS

In all 60 patients examined, the right anterior portal vein bifurcated into the ventral and dorsal branches. In 42 (70%) of 60 patients, some branches arose from the right posterior portal trunk. Between 1 and 3 branches (mean 2.3 branches per patient) coursed cranially, between 2 and 5 branches (mean 3.2 branches per patient) coursed caudally, and between 1 and 2 branches (mean 1.3 branches per patient) coursed laterally.

CONCLUSIONS

We propose that the right liver should be divided into 3 segments, which are designated as the right anterior, middle, and posterior segments.

Relationship between glucose transporter, hexokinase and FDG-PET in esophageal cancer

BACKGROUND/AIMS

18F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been established as a powerful diagnosing modality in clinical oncology. FDG accumulation has been demonstrated to correlate with hexokinase activity. However, recent reports suggest that glucose transporters participate in FDG accumulation. The aim of this study is to evaluate glucose transporter and hexokinase expression and clarify the relationship between them and FDG accumulation.

METHODOLOGY

FDG-PET was performed in 72 preoperative patients with esophageal cancer. The ratios of tumor radioactivity to plasma radioactivity (Ci/Cp values) were obtained 60 minutes after administration. We studied the expressions of glucose transporter 1 (Glut1) and type-II hexokinase (HK-II) by immunohistochemical analysis of the resected specimen. The percentages of cells expressing Glut1 and HK-II were scored on a 5-point scale (1=0-20%, 2=20-40%, 3=40-60%, 4=60-80%, 5=80-100%). Then the 3 scores obtained from 3 counting trials were averaged to give the Glut-index and HK-index.

RESULTS

All esophageal cancers showed marked FDG accumulation. All 72 cancers expressed Glut1 and 71 of 72 cancers expressed HK-II. The Glut-index had a weak correlation with the Ci/Cp value (not significant). The HK-index had a close positive correlation with the Ci/Cp value (p<0.005).

CONCLUSIONS

FDG accumulation correlates more with type-II hexokinase expression than with glucose transporter 1 expression.

Serological identification of TROP2 by recombinant cDNA expression cloning using sera of patients with esophageal squamous cell carcinoma

We applied serological analysis of recombinant cDNA expression libraries (SEREX) to cases of esophageal squamous cell carcinoma (SCC) to identify tumor antigens. One of the clones identified was TROP2, which is known as calcium signal transducer. To evaluate the clinical significance of serum anti-TROP2 antibodies (s-TROP2-Abs) in patients with esophageal SCC, the presence of s-TROP2-Abs was analyzed by Western blotting using bacterially expressed TROP2 protein. We found that 23 of 75 (31%) patients were positive for s-TROP2-Abs. Positivity in terms of s-TROP2-Abs showed a significant association with tumor size but not with other clinicopathological features. The protein expression levels of TROP2 were much higher in esophageal SCC cell lines as compared to those in normal esophageal mucosa and its immortalized cells although the mRNA expression levels were not necessarily elevated in malignant cell lines and tissues. Immunohistochemical studies showed that the expression of TROP2 protein in esophageal SCC specimens was noticeably higher than that found in mild hyperplasia of esophageal mucosae. Thus, s-TROP2-Abs seemed useful in the diagnosis of SCC and may be a candidate for serum tumor markers.

Hepatoblastoma in an adult A case report and clinical review of literatures

In this paper, our aim is to report a very rare case of adult hepatoblastoma (HB) and to discover clues of diagnosis and adequate treatment by surveying collected English literatures. Our patient was a 20-year-old lady suffering from nausea and appetite loss. The main tumor measuring 18cm was located in the anterior and medial segments. Other tumors were also present in the left lobe. The tumors had cystic areas and hypervascularity. The chemotherapy based on the diagnosis of HCC by needle biopsy had failed. The tumors were resected together with the diaphragm and diagnosed as adult HB of epithelial type. The patient succumbed to cancer 3 months later. We have collected 25 cases of adult HB and discussed clinical features. Diagnostic findings are as follows: single huge tumor, located in the right lobe, having cystic change, calcification (mixed type) and hypervascularity. Preoperative needle cytology or biopsy failed to diagnose all but one case. All living cases were resected without preoperative chemotherapy. No response to chemotherapy was observed in any case. If a tumor has the above clinical features, we have concluded that an excision of the tumor should be considered, without preoperative chemotherapy and tumor puncture.

Growth suppression of esophageal squamous cell carcinoma induced by heavy carbon-ion beams combined with p53 gene transfer

Heavy carbon-ion beam therapy has revealed several potential advantages over X-rays. Heavy-ion therapy has been applied for various solid tumors including esophageal squamous cell carcinoma (SCC). Although the local control rate in carbon ion radiotherapy for esophageal cancer has revealed better rates than conventional radiotherapy, severe mucosal damage was observed in adjacent normal mucosa. A suitable treatment strategy is required to reduce irradiation dose by introducing combined local therapy. Recently, we initiated clinical p53 gene therapy for esophageal SCC. We herein evaluate the cytotoxic effects of heavy carbon-ion beams combined with p53 gene transfer on human esophageal SCC. We assessed the induction of apoptosis and growth suppression with the use of recombinant adenoviral vector Ad.p53 or heavy carbon-ion beam irradiation or both. Growth suppression was significantly potentiated by combined treatment with heavy carbon-ion beams and Ad.p53 as compared to that treated with either of them alone. Western blot analysis confirmed the expression of both exogenous p53 and p21 proteins after irradiation of Ad.p53 infected cells. Enhanced apoptotic cell death was observed with a terminal deoxynucleotidyl transferase-mediated nick end-labeling assay. These data suggest that heavy carbon-ion beam irradiation combined with Ad.p53 may be a potentially effective therapeutic strategy for locally advanced esophageal SCC.

Efficacy and toxicities of concurrent chemoradiation for elderly patients with esophageal cancer

BACKGROUND

To evaluate the efficacy and toxicity of concurrent chemoradiation in patients with esophageal cancer aged 75 and older.

PATIENTS AND METHODS

Twenty-two elderly patients were treated with concurrent chemoradiation. Seventeen received a combination of cisplatin/carboplatin and 5-fluorouracil, 5 received daily 5-fluorouracil. Total doses of radiotherapy ranged from 50 to 65 Gy.

RESULTS

Nineteen out of 22 patients completed the planned chemoradiation. Five in 8 patients (63%) with T1-2 lesion and 1 in 14 patients (7o%) with T3-4 lesion achieved complete response (p=0.011). Only 2 patients experienced grade 3 toxicities. Grade 2 or worse hematological toxicities were less frequently observed in patients who received local-field radiotherapy (p=0.006). There was no isolated lymph node recurrence. The median survival time was 9 months.

CONCLUSION

This study showed the potential for chemoradiation in elderly patients. A planning target volume of radiotherapy should include only clinically involved lesions in this setting.

Development of less invasive surgical procedures for thoracic esophageal cancer

In order to minimize the invasiveness of the operative procedure for thoracic esophageal cancer, several procedures have been introduced since January 1997. They included: (i) perioperative use of steroids; (ii) muscle-sparing thoracotomy without costectomy; (iii) preparation of the gastric tube with preservation of sufficient blood supply; (iv) reconstruction of the alimentary tract via posterior-mediastinal route; and (v) formation of anastomosis between the remaining esophagus and the gastric tube at a location between the gastroepiploic arteries of the gastric greater curvature. Twenty-one patients who did not receive preoperative chemoradiotherapy underwent the newly developed procedure, and were compared with those receiving the original procedure. Hospital mortality was zero, and postoperative systemic inflammatory response syndrome was suppressed. The mean postoperative hospital stay was 21.5 days, and the actuarial 3-year survival rate was 76.2%. From the comparison with those receiving the original procedure, it can be concluded that the newly developed procedures were effective in minimizing surgical invasiveness and were sufficiently curative in terms of cancer treatment.

Hemodynamics of intrahepatic cholangiocarcinoma: evaluation with single-level dynamic CT during hepatic arteriography

BACKGROUND

We determined the radiologic characteristics of intrahepatic cholangicarcinoma (ICC) on single-level dynamic computed tomography during hepatic arteriography (CTHA) and assessed the hemodynamics of the tumor.

METHODS

Eleven patients with pathologically confirmed ICC underwent single-level dynamic CTHA. After placing the catheter tip in the proper hepatic artery and running a 30-s continuous scan, scanning was performed every 15 or 30 s for 120 s. The change of contrast-enhancement pattern of the ICCs were interpreted retrospectively.

RESULTS

The pattern of enhancement was classified into two types: vascular and hypovascular. In the vascular type, the contrast enhancement gradually spread from each intratum oral artery and became mottled. It changed from a mottled and hypoattenuated pattern to an even and hyperattenuated appearance in comparison with the adjacent liver approximately 120 s after the injection of contrast agent. In the hypovascular type, the tumor was barely enhanced and remained hypoattenuated compared with the adjacent liver at 120 s after the beginning of the injection. The 11 ICCs were classified into eight vascular types and three hypovascular types. Intratumoral arteries were visualized in nine tumors: eight vascular types and one hypovascular type.

CONCLUSION

The contrast-enhancement pattern of ICC on single-level dynamic CTHA is related to the intratumoral artery.

Limited resection of the right hemiliver based on reclassification of the right anterior segment of the liver

We proposed that the anterior segment was divided into ventral and dorsal segments, and reclassified the right hemiliver into three segments; ventral, dorsal, and posterior segments. According to our classification we successfully performed limited resection of the right hemiliver.

Ruptured pancreaticoduodenal artery aneurysm treated by superselective transcatheter arterial embolization and preserving vascularity of pancreaticoduodenal arcades

We report a case of a ruptured aneurysm in the anterior superior pancreaticoduodenal artery (PDA) with hypovolemic shock managed successfully by superselective transcatheter arterial embolization of the aneurysm. A 75-year-old male presented to our hospital with hematemesis and melena. On admission, he was in shock. Angiography showed an aneurysm about 1 cm in diameter in the anterior superior PDA. However, extravasation of contrast medium was not seen owing to hypovolemic shock. A catheter was inserted into the aneurysm, and superselective microcoil embolization of the PDA aneurysm was successfully achieved. After the microcoil was inserted into the aneurysm itself, it was observed that duodenal vascularity and pancreaticoduodenal arcades were preserved and aneurysm was not present. There was no complication such as necrosis or abscess formation in the pancreas. The patient recovered and is doing well after 18 months of follow-up. Superselective transcatheter arterial embolization should be considered as the initial treatment of choice for all peripancreatic aneurysms.

Limited resection based on reclassification of segment 8 of the liver

Liver vein patterns which differ from those previously described are occasionally encountered during surgery. Therefore, we reclassified the anterosuperior segment (S8) into S8v (ventral area) and S8d (dorsal area), and the right paramedian sector into the ventral segment (S8v+S5) and the dorsal segment (S8d) based on portal and hepatic vein patterns. Using this new classification, we performed three types of limited resection of S8 in six patients with neither major nor minor procedural complications including biliary leaks, and no blood transfusion. This new classification allows development of surgical procedures where resection is limited to the portal unit and tumor.

Prognostic value of preoperative serum immunosuppressive acidic protein in patients with esophageal squamous cell carcinoma

Immunosuppressive acidic protein (IAP) is a potent biological marker of immunological surveillance in patients with malignant tumors. The aim of this study was to analyze the clinicopathologic significance of IAP in patients with esophageal carcinoma. Preoperative serum IAP concentration was measured by enzyme-linked immunosorbent assay in 115 patients with primary esophageal squamous cell carcinomas. The associations between clinicopathologic factors, C-reactive protein (CRP) values and IAP concentration were determined. Prognostic values were determined by multivariate analysis using Cox's proportional hazards model. The IAP concentration is significantly higher in patients with stage II-IV cancers than in those with stage I cancer. Significant differences in IAP concentration were observed depending upon tumor size, tumor depth, lymph node status and CRP values. A high IAP concentration, more than 500 micro g/mL, was an independent prognostic factor. Thus, a high IAP concentration is associated with tumor progression and poor survival in patients with esophageal squamous cell carcinoma.

Relation between hepatic and portal veins in the right paramedian sector: proposal for anatomical reclassification of the liver

Although a right liver graft without a middle hepatic vein resulted in potential venous congestion in the right paramedian sector, the details of the hepatic venous distribution in the right paramedian sector have not been established. In this study, the ramification patterns of the hepatic veins draining the right anterosuperior segment (S8) and the relation between the hepatic and portal veins were assessed using multislice computed tomography in 44 patients without lesions in the liver. All 52 drainage veins of the ventral area of S8 joined the middle hepatic vein, and all 48 drainage veins of the dorsal area joined the right hepatic vein. The hepatic vein crossing between the ventral and dorsal areas was observed in each patient examined. Therefore, we propose a reclassification wherein the right paramedian sector is divided into ventral and dorsal segments. This new classification may contribute to the development of new and safer surgical procedures, including more limited resection and right lobe adult living donor liver transplantation to avoid graft congestion.

Extrahepatic course of the subsegmental biliary branch of the anteroinferior area of the liver

Two cases in whom the subsegmental biliary branch of the anterio-inferior area (B5) coursed to the right laterally and inferiorly, forming a caudally convex arc, and running near the neck of the gallbladder are reported. In these two patients, the B5 branches were not aberrant, however, these branches were running near the gallbladder bed extrahepatically, which alerted us to the risk of their inadvertent division. The relationship between the cystic duct and the B5 branch is clinically important during cholecystectomy, especially laparoscopic cholecystectomy.

Use of an occlusion balloon catheter during laparotomy for control of postoperative bleeding after pancreatoduodenectomy

Pancreatoduodenectomy has become safer, but postoperative complications, including life-threatening intraperitoneal bleeding, are still relatively common. We recently treated intraperitoneal bleeding after pancreatoduodenectomy by performing a laparotomy in conjunction with the use of a large occlusion balloon catheter. Angiography had failed to identify the site of bleeding in this patient. Our experience suggests that using a large occlusion balloon catheter to control bleeding effectively maintains an adequate surgical field in patients requiring laparotomy for hemostasis.