[The features of liver metastasis of breast cancer on imaging and its response to arterial infusion chemotherapy]

Arterial infusion chemotherapy was performed in 21 patients with liver metastasis of breast cancer, which was suspected to be the limiting factor of the prognosis, and the relationship between the morphological types of liver metastases, percentage of the liver involved, their angiographic features and chemotherapeutic response was discussed. Four morphological types of liver metastases could be classified; solitary mass type, multiple nodular type, diffuse small nodular type, and mixed type. In most cases, metastatic lesions were detected as a hypoechoic area on US and as a low-density area on pre-enhanced CT scan. In their angiographic features, these lesions were revealed as hypervascular tumors in most cases. Enlargement of the common or proper hepatic artery and obstruction of the 1st or 2nd branch of the portal vein were seen in over 50% of cases. In 13 evaluable cases, the response rate was 84.6% (PR 11, NC 1, PD 1), and the 50% survival time was 13.5 months in responders and 11.0 months for all cases. With regard to the morphological type, 1, 2 and 4-type cases revealed partial response, but NC or PD cases belonged to morphological type 3. No relation between obstruction of the portal vein and the chemotherapeutic response was observed. Arterial infusion chemotherapy was thus shown to be an effective treatment for liver metastasis of breast cancer, but that the response to the treatment differed for each morphological type.

[Pathomorphological study of thorotrast-related intrahepatic cholangiocarcinoma--a comparison with non-thorotrast cases]

Thirty-five autopsy cases of Thorotrast (TH)-related intrahepatic cholangiocarcinoma were morphologically studied with a comparison to 45 non-TH cases. Latent periods ranged from 25 to 48 years, with a mean of 34.1 +/- 6.6 years. As to tumor location, the peripheral-middle type, in which the main tumor was located in the periphery to middle portion of the liver, was the most common (89.2%) in the TH-related cases, and the hilar type, in which the main tumor was located in the hepatic hilum, was the most common (78.8%) in the non-TH cases. However, there was no close relationship between the distribution of TH deposits and tumor location by soft-X ray examination of the liver slices. Grossly, the massive type with an infiltrative growth was the most common both in the TH- and non-TH cases. Histologically, there were no remarkable differences between the two groups, and tubular adenocarcinoma with varying degrees of fibrous stroma was the most common. In noncancerous areas, proliferation of the bile ducts with slight to moderate atypism and ductular proliferation around Glisson's capsule were found in 30%, and 10%, respectively, of the TH-related cases. However, such changes were also found in the non-TH cases at almost the same incidence.

[Low-dose intermittent intra-arterial infusion chemotherapy]

Arterial infusion chemotherapy is commonly-used modality for controlling cancers located in specific regions. Previously we described a new method of intra-hepatic arterial catheterization through the left subclavian artery using a subcutaneously-implanted silicone reservoir. In the present paper, we report our experience using a low dose-intermittent intraarterial (i.a.) infusion chemotherapy. Since February, 1982, 70 patients including 44 cases of metastatic liver cancer, 16 cases of primary hepatocellular carcinoma and 10 cases of other gastrointestinal malignancies, have been treated with this low dose-intermittent i.a. infusion chemotherapy, the drugs used being as follows. 1) MMC 4 mg, 5-FU 500 mg, AraC 40 mg/2w, 2) MMC 4 mg/w, 3) 5-FU 500 mg/w, MMC 4 mg/2w, ADM 30 mg/4w. Here, we briefly review the effectiveness of this modality for controlling regional diseases including liver metastases. The average hospital-free interval was 156 days and partial responses were observed in 43% (21/49) of cases. Side effects during the therapy were only mild bone marrow suppression and anorexia, which were tolerable in out-hospital care. We also studied the pharmacokinetics of i.a. infusion into the liver in comparison with i.v. infusion using 99mTc-RBC, and found that the ratio of i.a. to i.v. with regard to trans-arterial drug delivery to the liver was 10.0. From the viewpoints of first pass effect and increased local concentration theory, this ratio suggests that the effectiveness of a low-dose anti-tumor agent administered intraarterially is not so low. Accordingly, we believe that low dose-intermittent i.a. infusion chemotherapy is beneficial as an induction and maintenance chemotherapy for patients with regionally located cancers because it is effective, safer and prolongs the hospital-free interval.

Thorium dioxide-related angiosarcoma of the liver. Pathomorphologic study of 29 autopsy cases

We describe the pathomorphologic features of 29 autopsy cases of thorium dioxide-related angiosarcoma (AGS) of the liver. The average (+/- SD) latent period after thorium dioxide injection was 36.2 +/- 5.2 years. Macroscopically, thorium dioxide-related AGS was divided into four types as follows: diffuse micronodular, multinodular, massive, and mixed multinodular and massive. Diffuse-micronodular and multinodular types were the most common. Histologically, thorium dioxide-related hepatic AGS was characterized by two cell types (spindle-shaped cells and polyhedral cells) and two structural patterns (sinusoidal and solid). There was no case composed of a solid pattern only. Immunohistochemically, factor VIII-related antigen was found to be positive in the endothelial cells of normal blood vessels and in the hyperplastic endothelial cells of the sinusoids, but negative in the tumor cells. Extramedullary hematopoiesis was found in both the tumorous and nontumorous areas in four cases. Erythrophagocytosis by the tumor cells was found in three cases. In the nontumorous area, varying degrees of sinusoidal dilatation with frequent hyperplastic changes of the sinusoidal lining cells were observed in all cases. These sinusoidal changes were frequently contiguous to AGS foci and were considered as a precursor change. In addition to the dominant sinusoidal changes, nodular hepatocytic hyperplasia was observed in two cases.

[Intra-arterial infusion chemotherapy using a subcutaneously implanted silicone reservoir--with reference to the chemotherapy protocol]

Sixty patients with advanced cancers were treated with intraarterial infusion chemotherapy using a subcutaneously implanted silicone reservoir. Forty-five patients received a low dose-intermittent intraarterial infusion chemotherapy employing either combination MFC (MMC 4 mg, 5-FU 500 mg, Ara-C 40 mg) at intervals of two weeks or MMC 4 mg weekly. The results were as follows. (1) Among 30 cases, where objective evaluation of the initial response was possible, partial responses (PR) were observed in 15 cases (50%). (2) No severe complication was observed using this protocol. Only one case out of the 45 needed to discontinue the medication because of bone marrow suppression. (3) Among 28 cases, where follow-up data were available, the average hospital-free interval was 207 days. The average ratio of hospital-free interval to survival period was 56.4%. The results indicate that our method is beneficial as a maintenance chemotherapy for patients with advanced cancers, because it is effective, safer and improves the quality of life.

[Intra-arterial infusion chemotherapy using a subcutaneously implanted silicone reservoir--with special reference to the method]

Sixty patients with advanced cancers were treated with intraarterial infusion chemotherapy using a subcutaneously implanted silicone reservoir. Forty-nine patients were catheterized from a branch of the left subclavian artery. The results were as follows. (1) In spite of some technical difficulties, catheterization from a branch of the left subclavian artery was minimally invasive, and catheter trouble using this route was less frequent than that occurring when the profound femoral arterial route was employed. (2) Implantation of the catheter end using a silicone reservoir liberated the patients from restrictions in their daily lives, and with this method, intraarterial infusion chemotherapy could be carried out easily when required without hospitalization. We conclude that this procedure is a beneficial method of intraarterial infusion chemotherapy for patients with advanced cancers.

[Total pelvic exenteration for primary and locally recurrent rectal cancer]

Thirteen patients with advanced carcinoma of the lower colon and no evidence of extrapelvic metastasis were submitted to total pelvic exenteration with urinary diversion. The operative mortality rate was 7.7%. Determinate 5-year survival rate of 40% was achieved. Local recurrence of rectal cancer following abdominoperineal resection is rarely amenable to limited resection. Six patients with deeply invading recurrent lesions had pelvic exenteration combined with sacral resection. This procedure seems a reasonable treatment for palliation and the chance of cure in selected patients. CT examination of the pelvis is very valuable for the early detection and localization of recurrence.

Surgical treatment of cavernous hemangioma of the liver

This report describes our experiences with 12 cases of cavernous hemangioma of the liver. Eight patients were submitted to surgical procedures. Five out of eight underwent liver resections that ranged from simple excision to hepatic lobectomy. Three patients underwent hepatic artery ligation. There were no surgical deaths or any late deaths. Four more asymptomatic patients have been observed for up to 11 years (mean 4.0 years). None of the patients in this group has evidenced intensification of symptoms or any remarkable change of the size of lesions.

[Proliferative lesions in thorotrast-deposited livers pertaining to the development of primary cancers]

We obtained human cadavers livers with thorotrast deposits and examined them light microscopically. The bile ducts of the large portal tract exhibited many foci of intraductal papillary hyperplasia including some severe atypical foci. The proliferation of bile ductules at the periportal zone was more marked in cases with cholangiocarcinoma than in those with other diseases. Micro-peliosis, in which the number of lining endothelial cells was significantly increased, was prominent in angiosarcoma cases. We suggest that advanced micro-peliosis represents a specific proliferative lesion pertaining to the development of angiosarcoma. There were many hyperplastic lesions of hepatocytes with structural deformity that often proceeded to vague nodular growth.

Ligation and catheterization of the hepatic artery for palliative treatment of malignant hepatic tumors

Eleven unresectable hepatoma patients and three metastatic tumor patients with colonic cancer underwent ligation and/or catheterization of the hepatic artery of the main tumor-bearing zone. Mitomycin C (liquid or microcapsulated) or Adriamycin were administered via the catheter intermittently or continuously with a portable pump device. In follow-up study the tumor size was frequently visualized by arteriography via the cannula. Some tumors became smaller with calcification. The levels of alpha-Fetoprotein of CEA in some cases dropped remarkably and stayed low for a fairly long period. There was no immediate postoperative death. Six of 11 unresectable hepatoma patients survived longer than 8 months with a maximum survival of 17.5 months. Two of three metastatic patients have survived more than 11 months at this writing. This method seems effective for prolongation of patient survival.