Serum levels of des-gamma-carboxy prothrombin measured using the revised enzyme immunoassay kit with increased sensitivity in relation to clinicopathologic features of solitary hepatocellular carcinoma

BACKGROUND

Des-gamma-carboxy prothrombin (DCP) is an established marker for hepatocellular carcinoma (HCC), but the conventional enzyme immunoassay (EIA) kit lacks adequate sensitivity. Thus, a revised EIA kit with increased sensitivity has been developed. In this kit, the sensitivity has increased while high specificity to HCC has been maintained. The authors have already reported the clinical usefulness of this revised EIA kit. In this study, they examined the serum levels of DCP measured by this revised EIA kit in relation to the clinicopathologic features of solitary HCC.

METHODS

Fifty-six patients with solitary HCC who underwent hepatectomy were studied. The relation between the greatest dimension and the histologic differentiation of HCC was investigated in these 56 patients, as were the serum levels of DCP measured by the revised EIA kit (Sensitive DCP), alpha-fetoprotein (AFP), and DCP measured by the conventional EIA kit (DCP). The cutoff value for Sensitive DCP was set at 40 mAU/mL, and the values for AFP and DCP were 20 ng/mL and 100 mAU/mL (0.1 AU/mL), respectively.

RESULTS

The positivity rates for Sensitive DCP, AFP, and DCP (n = 56) were 53.6%, 53.6%, and 35.7%, respectively, and the rate was 73.2% when Sensitive DCP was used in combination with AFP (Sensitive DCP + AFP). The positivity rates for these markers were as follows: 1) When the greatest dimension of HCC was more than 3 cm (n = 16) and less than 2 cm (n = 23), the rates were 81.3% and 30.4% for Sensitive DCP, 68. 8% and 39.1% for AFP, 56.3% and 13.0% for DCP, and 93.8% and 56.5% for Sensitive DCP + AFP. 2) When HCC was moderately to poorly differentiated (n = 41) and well differentiated (n = 15), the rates were 68.3% and 13.3% for Sensitive DCP, 61.0% and 33.3% for AFP, 48. 8% and 0% for DCP, and 85.4% and 40% for Sensitive DCP + AFP. 3) When HCC was either more than 3 cm or moderately to poorly differentiated (n = 42) and either less than 2 cm or well differentiated (n = 27), the rates were 69.0% and 29.6% for Sensitive DCP, 61.9% and 37.0% for AFP, 47.6% and 11.1% for DCP, and 85.7% and 51.9% for Sensitive DCP + AFP.

CONCLUSIONS

DCP measured by the revised EIA kit with increased sensitivity has a stronger correlation than AFP with size and histologic differentiation of HCC. This Sensitive DCP is a very useful marker for HCC and should be used in combination with AFP.

[Is it able to simplify the classifications of staging and curability for pancreatic cancer?]

This study was undertaken to simplify the classifications of the staging and curability of pancreatic cancer by the Japan Pancreas Society (JPS). A total of 461 patients who underwent surgical resection from 1968 to 1997 were analyzed in this study in accordance with our new classification of staging and curability. This staging mainly consists of three factors based on tumor extent:invasion to the retroperitoneum (rp); invasion to the extrapancreatic nerve plexus (pl); and lymph node metastasis (n). Each factor is simply judged as + (positive) or - (negative). Curability is also judged simply based on whether the presence of tumor is detected or not, and the degree of lymph node dissection is not included in curability. Our staging and curability assessment is strongly associated with survival rates after surgery. The 5-year survival rate of stage I patients is 50% and curability of A is > or = 50%. It is concluded that it is possible to simplify the classification of the staging and curability of pancreatic cancer by the JPS.

Postnatal development of eustachian tube cartilage. A study of normal and cleft palate cases

Infants with cleft palate (CP) display eustachian tube (ET) dysfunction. This study compared the postnatal development of the volume of ET cartilage in 34 normal cases and 10 CP cases using a personal computer. In cases with age under 1 month old, the total volume of ET cartilage was 61.94+/-20.89 mm(3) (mean+/-S.D.) in 16 normal control cases and 50.07+/-24.69 mm(3) in nine CP cases (t-test, not significantly different from normal). The ratio of lateral lamina (LL) to medial lamina (ML) volume (LL/ML) was reduced significantly (t-test, P<0.001) from 0.23+/-0.07 in 16 normal control cases to 0.09+/-0.05 in nine CP cases under 1 month old. In 34 normal ET cases whose ages were under 20 years, statistically significant positive correlations were found between the total volume of ET cartilage (y1) and age (x), volume of LL (y2) and age, and volume of ML (y3) and age (P<0.01, r=0.731, 0.614, 0.719). The regression lines were y1=20.37x+95.57, y2=2.02x+15.60, and y3=18. 35x+79.97. With the result obtained from this study, it is assumed that immaturity of the ET cartilage in infants, especially that of LL of the ET cartilage in CP infants, may be a significant risk factor for developing otitis media with effusion.

The significance of hepatectomy for primary intrahepatic stones

The objective of this study was to evaluate the significance of performing hepatectomy for primary intrahepatic stones. Observations on the morphology of the bile ducts, histopathological findings of the excised liver, and treatment results were reviewed in 29 of 35 patients with primary intrahepatic stones. The remaining 6 patients (17.1%) were excluded because they had intrahepatic cholangiocarcinoma. The subjects were classified into two groups according to the morphological characteristics of the bile ducts; one group comprised 25 patients having strictures in the central bile duct, and another group comprised 4 patients having no biliary stricture, but a localized dilatation in the distal bile duct. Calcium bilirubinate stones were found in all the patients with a biliary stricture, whereas cholesterol stones were found in those without a biliary stricture. Hepatectomy was performed in 25 of the 29 patients (86.2%), the results of which were excellent. In fact, during the past 10 years, no postoperative complications have occurred, nor have there been any retained or recurrent stones. Moreover, the postoperative hospitalization period was as short as 15.3 days. The findings of this study indicate that hepatectomy allows treatment for primary intrahepatic stones to be completed within a short period of time without incurring serious postoperative complications, and serves as a useful prophylactic technique for recurrent stones.

Changes in neoplastic cell features and sensitivity to mitotane during mitotane-induced remission in a patient with recurrent, metastatic adrenocortical carcinoma

A 58-year-old man had adrenocortical carcinoma in the right adrenal gland. The tumour secreted excessive cortisol and dehydroepiandrosterone-sulphate (DHEA-S), and had invaded the right hepatic lobe and vena cava. Eleven months after surgical tumour resection, the serum DHEA-S levels again increased. Local tumour recurrence and a metastasis was found in the lung. Eleven months after surgery chemotherapy with mitotane (o,p'-DDD) was initiated. Twelve weeks of mitotane reduced serum DHEA-S levels and caused these tumours to disappear. The patient was then treated with low-dose mitotane (1.5-2.0 g/day) for 2 years. Serum levels of mitotane remained at less than 10 microg/ml. Although such low serum levels of mitotane and delayed initiation of mitotane after surgery have been proposed to weaken the antineoplastic effect of mitotane, the patient had a remission for 2 years. However, there was then local re-recurrence with an increase in serum DHEA-S and death 4 months later. The histological features of neoplastic cells were quite different comparing tumour resected at surgery and tumour at autopsy. The latter had more frequent mitotic nuclei. This tumour was initially sensitive to mitotane, but later became insensitive.

Left hepatic trisegmentectomy for intraductal papillary cholangiocarcinoma: report of a case

We present a rare case of intraductal papillary cholangiocarcinoma in a 69 year-old man which was treated with left hepatic trisegmentectomy. The hepatic bile ducts were dilated by intraductal masses, which had extended into the intrahepatic bile ducts without involvement of the posterior inferior segmental duct (B6). The patient underwent left hepatic trisegmentectomy with hilar duct resection. The tumors in the posterior superior segmental duct (B7) were resected and biliary reconstruction was performed with a jejunal loop. Post-operative recovery was good, and the patient survived for 7 months after surgery.

[Local complications of the intestinal tract in patients with ulcerative colitis]

Various types of local complication of the intestinal tract are recognized in patients with ulcerative colitis. Among those local complications, massive bleeding, perforation and toxic megacolon require emergent operation in order to avoid fetal condition. Stricture of the colon, fustura formation and intra-abdominal abscess are rare complication in patients with ulcerative colitis, but sometimes require surgical treatment. Colitic cancer is another serious complication which develops highly advanced stage. Surveillance of the colon by endoscopy is necessary to obtain early diagnosis of the colitic cancer.

Analysis of postoperative complications after esophagectomy for esophageal cancer in patients receiving neoadjuvant therapy

Postoperative complications were investigated in 72 patients who received neoadjuvant therapy with esophagectomy. Preoperative chemotherapy consisted of 5-fluorouracil (700 mg/m2/day, on days 1 to 5), cisplatinum (70 mg/m2/day, on day 1) and leucovorin (20 mg/m2/day, on days 1 to 5). Preoperative chemoradiotherapy consisted of cisplatinum combined chemotherapy and radiotherapy (total dosage of 30-70 Gy). The incidence of postoperative pneumonia (16%) and anastomotic leakage (24%) in the preoperative chemotherapy group was slightly higher than that in the control group (n = 506), and mortality (6.0%) after esophagectomy in the preoperative chemotherapy group was higher than that (2.4%) of the control group. Postoperative morbidity and mortality were observed more frequently in patients who received two cycles of the chemotherapy than those receiving only one cycle. Postoperative complications occurred more frequently in patients suffering high grade toxicities due to the preoperative chemotherapy. The highest preoperative serum creatinine value correlated to that of postoperative period (r = 0.6494). The use of the preoperative chemoradiotherapy with a total exposure dosage of 60 Gy or more significantly increased the postoperative pneumonia rate (67%; p < 0.05) compared to the group receiving 40 Gy or less. The mortality rate (33%) also increased. The second cycle of the preoperative chemotherapy should be cancelled if patients suffer high grade toxicities during or after the first cycle, and the total exposure dosage of the preoperative chemoradiotherapy should be limited to 40 Gy or less.

Intraoperative evaluation of the depth of invasion of gallbladder cancer

BACKGROUND

It is sometimes very difficult to diagnose the depth of invasion of gallbladder cancer preoperatively. Therefore, we investigated intraoperative examinations to diagnose the depth of invasion.

METHODS

A total of 104 patients were included in this study. The relation between macroscopic morphology and the depth of invasion and evaluation of the depth of invasion by intraoperative ultrasonography and frozen section examination were investigated.

RESULTS

In all cases of a pedunculated type and a subpedunculated type with thin base, invasion remained within the mucosa. In other types, the depth of invasion was various. The accuracy of diagnosing the depth of invasion by intraoperative ultrasonography and frozen section examination was 73.9% and 85.7%, respectively.

CONCLUSIONS

The cancer classified as a pedunculated type or a subpedunculated type with thin base can be diagnosed to remain within the mucosa. In other types, intraoperative ultrasonography and frozen section examination are useful in the diagnosis of the depth of invasion.

Determination of serum hepatitis C virus (HCV) core protein using a novel approach for quantitative evaluation of HCV viraemia in anti-HCV-positive patients

AIMS/BACKGROUND

Hepatitis C virus (HCV) infection is frequently diagnosed by detection of antibody to the HCV (anti-HCV). Recently, a method for detection of HCV core protein, "Imucheck F-HCV Ag Core Kokusai", has been developed. In this study, we evaluate the utility of this method.

METHODS

HCV core protein levels in sera were determined using this following method; anti-HCV titres were measured by particle agglutination (PA) test and then quantitative HCV-RNA values were investigated using a competitive reverse transcription-polymerase chain reaction (RT-PCR) test.

RESULTS

The HCV core protein was detected only in anti-HCV-positive sera. Of 490 anti-HCV-positive sera, 130 (26.5%) were positive by this method. Of 144 anti-HCV-positive/HCV-RNA-positive sera, 130 (90.3%) were positive by it. A significant correlation between the HCV core protein levels and quantitative HCV-RNA values was recognized (n= 110, r=0.86, p<0.01). A significant correlation between the HCV core protein levels and alanine aminotransferase titres was also observed (n=67, r=0.72, p<0.05). All 71 patients with chronic active hepatitis, cirrhosis and hepatocellular carcinoma were positive with this method, whereas 18 of 32 patients with chronic inactive hepatitis were positive. Twenty-three patients with chronic active hepatitis were treated with interferon-alpha. During therapy, some patients showed a negative conversion of HCV core protein. One (7.7%) of 13 patients with HCV genotype 1 and 5 (62.8%) of 8 patients with genotype 2 remained negative for 6 months after the therapy.

CONCLUSION

This method may be useful for quantitative evaluation of HCV viraemia in anti-HCV-positive patients.

Histopathological changes of the eustachian tube cartilage and the tensor veli palatini muscle with aging

OBJECTIVES

The eustachian tube (ET) and the tensor veli palatini muscle (TVPM) are thought to play an important role in ventilatory function. Calcification of the ET cartilage and the replacement of TVPM by fat tissue are often observed histologically in elderly patients. To our knowledge, however, there are no quantitative studies of these pathological findings in relation to age.

STUDY DESIGN

The calcification of the ET cartilage and the atrophy of the TVPM in 36 normal human temporal bones obtained from 36 individuals with ages ranging from 2 days to 88 years were investigated.

METHODS

The number of calcified chondrocytes in the midportion of the ET cartilage was quantified as the average number of cells per square millimeter. Atrophy of the TVPM was evaluated at the midportion of the site where the TVPM is attached to the tip of lateral lamina of ET cartilage. A grade of 0, 1, 2, 3, or 4 was assessed for each section, which indicated approximately 0% to 5%, 5% to 30%, 30% to 70%, 70% to 95%, or 95% to 100% of the TVPM replacement by fat tissue, respectively.

RESULTS

A statistically significant correlation was found between the number of the calcified cells and aging (P < .001). A statistically significant correlation was also found between the degree of the atrophy of TVPM and aging (P < .001).

CONCLUSIONS

The calcification of the ET cartilage and the atrophy of the TVPM are closely associated with aging. Therefore, it is suggested that these two findings may be a predisposing factor for ET dysfunction in elderly adults.

Liver regeneration and restoration of liver function after partial hepatectomy: the relation of fibrosis of the liver parenchyma

BACKGROUND/AIMS

Patients who survive partial hepatectomy sometimes have unsatisfactory liver regeneration and restoration of liver function. Although the extent of resection should be adjusted to attain favorable liver regeneration and restoration of liver function, a guiding principle for this has not been established.

METHODOLOGY

Seventy patients with hepatic tumors associated with liver disorders of various severity who underwent hepatectomy were studied. We calculated the removal rate of the liver and the regeneration rate of the remnant liver using computed tomography. The liver function was investigated using ICG R-15 (retention rate of indocyanine green). Liver disorder was classified into 4 groups, according to the severity of fibrosis.

RESULTS

The regeneration rates of the remnant liver indicated a significant decline in patients with severe fibrosis. In the no fibrosis and mild fibrosis groups, an increased removal rate was associated with increased regeneration rate, and post-operative ICG R-15 improved with time. However, in the moderate fibrosis and severe fibrosis groups, an increased removal rate was not associated with increased regeneration rate, and post-operative ICG R-15 showed no change or became worse with time.

CONCLUSIONS

Severe fibrosis of the liver parenchyma is associated with poorer regeneration of the remnant liver leading to poor restoration of post-operative liver function. The severity of fibrosis is useful as a predictive factor for liver regeneration and restoration of liver function after partial hepatectomy.

Extended resection for intrahepatic cholangiocarcinoma in Japan

To elucidate surgical outcome after extended surgery for intrahepatic cholangiocarcinoma (ICC), we retrospectively allocated 83 patients who had undergone resection to a standard surgery group (n = 56), in which the patients had undergone hepatectomy alone or hepatectomy with bile duct resection, and an extended surgery group (n = 27), in which the patients had undergone the standard operation combined with vessel resection and/or pancreatectomy. The incidence of mass-forming plus periductal-infiltrating type lesions (P = 0. 0129), lymph node metastasis (P = 0.0005), noncurative resection (P < 0.0001), mortality within 30 days and within 1 year after surgery (P = 0.0392, P = 0.0010), local recurrence (P = 0.0439), and peritoneal disseminated recurrence (P = 0.0241) was significantly higher in the extended surgery group than in the standard surgery group. The 5-year survival rate was significantly higher in the standard surgery group (30%) than in the extended surgery group (10%; P = 0.0061). The mortality rate within 1 year after extended surgery was significantly higher in the patients with infiltrating-spread type tumors than in the patients with non-infiltrating spread type tumors (P = 0.0032), and long-term (5-year) survival in the extended surgery group was significantly lower in the patients with infiltrating-spread type tumors than in the patients with non-infiltrating spread type tumors (P = 0.0253). We conclude that extended surgery does not improve the curative resection rate or the surgical outcome of ICC, and that extended surgery is not indicated for patients with infiltrating-spread type tumors.

Lymph node metastasis in intrahepatic cholangiocarcinoma

BACKGROUND

Lymph node metastasis is a significant prognostic factor in intrahepatic cholangiocarcinoma. This study was aimed at investigating lymph node metastasis in intrahepatic cholangiocarcinoma and to examine whether the extent of metastasis affects outcomes after surgery.

METHODS

From 1980 through 1996, 70 patients with intrahepatic cholangiocarcinoma underwent hepatectomy, with a 50% curative resection rate. Lymph node dissection was performed in 51 patients, and the presence of lymph node metastasis was examined microscopically. The metastatic nodes were divided into groups N1, N2 or N3 using the classification proposed by the Liver Cancer Study Group of Japan.

RESULTS

Twenty-three patients had lymph node metastasis. Metastasis was to N1 nodes in 10 patients, to N2 nodes in nine patients and to N3 nodes in four patients. Nineteen patients had metastatic nodes in the hepatoduodenal ligament, which was the most common metastatic site regardless of tumor location. The five-year survival rate in patients with lymph node metastasis (0%) was significantly lower (p < 0.0001) than that in patients without lymph node metastasis (51 %); however, five-year survival rates did not differ between patients with metastases to N1, N2 and N3 nodes.

CONCLUSIONS

Lymph nodes in the hepatoduodenal ligament may be sentinel nodes for intrahepatic cholangiocarcinoma, and outcomes after surgery for patients with lymph node metastasis are poor regardless of the sites of nodal metastasis.

Successful cytokine treatment of aplastic anemia following living-related orthotopic liver transplantation for non-A, non-B, non-C hepatitis

The relationship between aplastic anemia and viral hepatitis is well recognized, and such patients usually have a high mortality. We successfully treated a case of aplastic anemia following living-related orthotopic liver transplantation (LROLT) for non-A, non-B, non-C hepatitis. A 2-yr-old boy with fulminant hepatic failure from non-A, non-B, non-C hepatitis received LROLT. Before transplantation, he had pancytopenia which was probably hepatitis associated, and viral suppression was suspected after bone marrow (BM) biopsy. After the transplantation, he developed progressive pancytopenia and a diagnosis of aplastic anemia was made via BM biopsy. With immunosuppressant agents (cyclosporine, methylprednisolone), cytokine therapy (granulocyte-colony stimulating factor (G-CSF), macrophage-colony stimulating factor (M-CSF), recombinant human erythropoietin (rhEPO)) was effectual and the patient recovered from pancytopenia. He was discharged from the hospital 57 d after the liver transplantation and remains well 1 yr after LROLT. Combined cytokine therapy with high doses of G-CSF, M-CSF and rhEPO appeared to be effective in the treatment of aplastic anemia following liver transplantation for non-A, non-B, non-C hepatitis. Since M-CSF activates macrophages, it may have contributed to the graft rejection. Careful consideration should be given to the use of high-dose M-CSF in liver transplant patients.

Glissonean pedicle transection method for hepatic resection: a new concept of liver segmentation

A new concept of hepatic segmentation along with the Glissonean pedicle tree, and the basis of hepatic resection by the Glissonean pedicle transection method are presented. The portal triad continues from the hepato-duodenal ligament to the intra-hepatic portion as the Glissonean pedicle. That is, the artery, portal vein and bile duct, together with connective tissue, are sheathed by the peritoneum to form a fibroid bundle. The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver and the trunks of the secondary and more peripheral branches run inside the liver. The ramification pattern of the tertiary branches which branch out from each secondary branch is different from patient to patient. The liver is nourished by the secondary branches of the Glissonean pedicle. Each secondary branch feeds one segment. The liver can thus be separated into three segments and an additional caudate area. The area fed by each one of the tertiary branches is cone-shaped; fermed a "cone unit". Each segment conists of six to eight cone units. In limited resections, the number of cone units to be respected is adjusted and the tertiary branches which feed these areas must be transected selectively through a hilar or a parenchymal approach. To date we have experienced no complications with this procedure, employed for 832 patients with hepatocellular carcinoma.

Does gross appearance indicate prognosis in intrahepatic cholangiocarcinoma?

BACKGROUND AND OBJECTIVES

Survival after surgery for intrahepatic cholangiocarcinoma (ICC) is usually poor. The objective of this study was to investigate whether the gross appearance of ICC indicates postoperative prognosis.

METHODS

Seventy patients with ICC underwent hepatectomy, with a 50% curative resection rate. Tumors were classified according to gross appearance [mass-forming (n=28), periductal-infiltrating (n=14), intraductal growth (n=10), and mass-forming plus periductal-infiltrating (n=18)], and the presence of lymph node or intrahepatic metastasis was studied microscopically.

RESULTS

The incidence of positive lymph nodes was significantly higher in the patients with mass-forming plus periductal-infiltrating tumors than in those with intraductal growth tumors (P=0.0089). The curative resection rate was significantly lower in patients with mass-forming plus periductal-infiltrating tumors than in those with either mass-forming or intraductal growth tumors (P=0.0001, P=0.0048, respectively). The 5-year survival rate after surgery in patients with mass-forming plus peri-ductal-infiltrating tumors (0%) was significantly lower than that in patients with mass-forming tumors (39%) or intraductal growth tumors (69%) (P=0.0036, P=0.0011, respectively). Multivariate analysis using Cox's hazards model revealed that lymph node metastasis (P=0.0109) and curative resection (P=0.0315) were statistically significant independent prognostic factors; however, macroscopic types were not.

CONCLUSIONS

Patients with mass-forming plus periductal-infiltrating ICCs have a poor prognosis; however, the macroscopic types may not be a statistically significant independent prognostic factor.

Analysis of postoperative liver function of donors in living-related liver transplantation: comparison of the type of donor hepatectomy

BACKGROUND

There is a potentially significant risk to the donor in living-related liver transplantation.

METHODS

We analyzed surgical risk and stress to 35 donors in living-related liver transplantation with special reference to the types of donor hepatectomy. Donor surgery was performed in one of three ways: (1) lateral segmentectomy without ligation of the middle hepatic vein (MHV) in the remnant liver (group 1, n=21); (2) lateral segmentectomy with ligation of MHV in the remnant liver (group 2, n=6); and (3) left lobectomy with MHV (group 3, n=8).

RESULTS

No critical complications were observed in any group. The postoperative enzyme levels in group 2 were significantly higher than those in groups 1 and 3 (P<0.01). Although blood loss was covered by autologous blood transfusion in the first six cases, no banked blood was transfused in any of the cases. Surgical duration was significantly longer and blood loss was significantly greater in group 3 than in group 1 (P<0.05). Follow-up computed tomography showed atrophic changes in segment IV in groups 1 and 2. No remarkable changes were seen in segments V or VIII in any of the three groups.

CONCLUSION

Regardless of the donor hepatectomy procedure, serious complications did nor occur after surgery. Although it should be noted that the type of donor hepatectomy affects postoperative donor liver function, left lateral segmentectomy with ligation of MHV in the remnant liver is a useful method for obtaining liver grafts from living-related donors who have unusual anatomic variations of the hepatic veins.

Genotype-phenotype correlation of patients with multiple endocrine neoplasia type 2 in Japan

BACKGROUND

Multiple endocrine neoplasia type 2 (MEN 2) is a hereditary syndrome characterized by medullary thyroid carcinoma (MTC), pheochromocytoma and hyperparathyroidism. MEN 2 is caused predominantly by germ-line mutations of the RET proto-oncogene. This study aimed to clarify the genotype-phenotype correlation in MEN 2 patients in Japan in order to modify the clinical management according to the genotype.

METHODS

Constitutive DNA of 64 MEN 2 patients (48 kindreds) were searched for mutations at exons 10, 11, 13, 14 and 16 of the RET proto-oncogene using polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP), direct sequencing and restriction enzyme digestion. The clinical characteristics of the patients were obtained from a previous nationwide questionnaire survey.

RESULTS

Overall, 62 (96.9%) out of 64 patients had a germ-line point mutation at the hot spots. MTC and pheochromocytoma occurred equally in every genotype except C630S. Specific genotype had a correlation between tumor size and age at the operation for MTC or extent of MTC, i.e. C618S developed late onset type of MTC as compared with that of C634R, C634Y and M918T. Small MTC in C634R may be less aggressive than those in C634Y and M918T.

CONCLUSIONS

DNA testing has good clinical implications for the management of patients with MEN 2 and the timing and operative procedures of thyroidectomy can be modified according to the genotype.

[Indications for and operative outcome of hepato-pancreatoduodenectomy in the treatment of carcinoma of the gallbladder]

The indications for hepatopancreatoduodenectomy (HPD) are still controversial. Opinion is divided especially concerning the need to perform pancreatoduodenectomy (PD) for lymph node dissection, with some investigators claiming that the peripancreatic lymph nodes can be dissected adequately without PD. Detailed studies of resected specimens in our department have shown that preservation of the head of the pancreas carries an increased risk of leaving behind cancer cells in small lymph nodes and ducts remaining in the peripancreatic region. We therefore perform HPD in all patients at increased risk for metastasis to peripancreatic lymph nodes, as indicated by subserosal invasion with distinct evidence of lymph node involvement, tumor location at the neck or both fundus and body of the gallbladder, and serosa exposure to tumor irrespective of tumor location and lymph node involvement. When the outcome was compared between HPD and hepatic resection plus dissection of peripancreatic lymph nodes (HR), we found that the operative results of HPD were poor with extended lobectomy plus PD because of high rates of postoperative complications and operative mortality. However, the results have gradually improved with the introduction of percutaneous transehepatic portal embolization and advances in perioperative care. Although overall there is no difference between HPD and HR in long-term outcome, the outcome with HPD is significantly better in node-positive patients and patients without hepatoduodenal ligament involvement, there by demonstrating the value of performing peripancreatic lymph node dissection by PD. However, there is no difference between HPD and HR in patients with hepatoduodenal ligament involvement, and attempts to develop other new and effective means of treatment should continue.