Outcomes of living donor liver transplantation for hepatitis C virus-positive recipients in Japan: results of a nationwide survey

A nationwide survey of living donor liver transplantation (LDLT) for hepatitis C virus (HCV)-positive recipients was performed in Japan. A total of 514 recipients are reported and included in the study. The cumulative patient survival rate at 5 and 10 years was 72% and 63%, respectively. Of the 514 recipients, 142 patients (28%) died until the end of the observation, among which the leading cause was recurrent hepatitis C (42 cases). According to Cox regression multivariate analysis, donor age (>40), non-right liver graft, acute rejection episode, and absence of a sustained virologic response were independent prognostic factors. Of the 514 recipients, 361 underwent antiviral treatment mainly with pegylated-interferon and ribavirin (preemptive treatment in 150 patients and treatment for confirmed recurrent hepatitis in 211). The dose reduction rate and discontinuation rate were 40% and 42%, respectively, with a sustained virologic response rate of 43%. In conclusion, patient survival of HCV-positive recipients after LDLT was good, with a 10-year survival of 63%. Right liver graft might be preferable for HCV-positive recipients in an LDLT setting.

Perioperative management for pancreatoduodenectomy following severe acute pancreatitis in patients with periampullary cancer: our experience with six consecutive cases

PURPOSE

We rarely have an opportunity to perform pancreatoduodenectomy (PD) following the onset of severe acute pancreatitis (SAP) for patients with periampullary cancer. The perioperative risks and optimal timing of subsequent PD have, therefore, remained unclear.

METHODS

Between January 2006 and December 2012, we performed PD in six patients with SAP. We reviewed these six cases, and compared the perioperative risks of morbidity and mortality with those of 81 concurrent PD patients matched for primary cancer without preoperative SAP.

RESULTS

The six patients were classified as having SAP based on the Japanese criteria developed in 2008. The SAP in five patients was caused by ERCP procedures. The median interval from SAP onset to the operation was 111 days. The rate of Grade B/C postoperative pancreatic fistula formation in the SAP patients was significantly higher than that of the 81 control patients (83 vs. 26 %, P < 0.001). In addition, the median postoperative hospital stay was significantly longer in the six SAP patients relative to that of the control patients (40 vs. 30 days, P < 0.001).

CONCLUSIONS

An interval of at least 3 months after surgery may be needed to decrease the inflammation of the peripancreas region after SAP. Therefore, unnecessary and low-yield ERCP procedures should be avoided in these patients.

Establishment of a novel cell line from intraductal papillary neoplasm of the bile duct

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a novel and increasingly-occurring disease. Its characteristics remain uncertain because of the lack of an in vitro culture system. We established and characterized a novel cell line from a human IPNB.

MATERIALS AND METHODS

We obtained tumor tissue from a surgical specimen from a patient with IPNB. Cells were primary co-cultured with mouse stromal cells in serum-free medium. Tumor characteristics were compared among the primary IPNB, established cell line, and xenograft.

RESULTS

We successfully established an IPNB cell line. We temporary termed this cell line Kobe Bile Duct Cancer (KBDC)-11. Xenograft formed a tumor which had ductal structures and mucus production as the primary tumor did. Overexpression of p53, MUC staining pattern, and CD133 expression were common among the primary IPNB, KBDC-11, and the xenograft.

CONCLUSION

This novel cell line established from IPNB exhibited the same features as IPNB and might contribute to studies of IPNB and its process of malignant transformation.

Assessment of ISGLS definition of posthepatectomy liver failure and its effect on outcome in patients with hepatocellular carcinoma

BACKGROUND

Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy. As there was no standardized definition, the International Study Group of Liver Surgery (ISGLS) defined PHLF as increased international normalized ratio and hyperbilirubinemia on or after postoperative day 5 in 2010. We evaluated the impact of the ISGLS definition of PHLF on hepatocellular carcinoma (HCC) patients.

METHODS

We retrospectively analyzed 210 consecutive HCC patients who underwent curative hepatectomy at our facility from 2005 to 2010. The median follow-up period after hepatectomy was 35.2 months.

RESULTS

Thirty-nine (18.6%) patients fulfilled the ISGLS definition of PHLF. Overall survival (OS) rates at 1, 3, and 5 years in patients with/without PHLF were 69.1/93.5, 45.1/72.5, and 45.1/57.8%, respectively (P = 0.002). Recurrence-free survival (RFS) rates at 1, 3, and 5 years in patients with/without PHLF were 40.9/65.9, 15.7/38.3, and 15.7/20.3%, respectively (P = 0.003). Multivariate analysis revealed that PHLF was significantly associated with both OS (P = 0.047) and RFS (P = 0.019). Extent of resection (P < 0.001), intraoperative blood loss (P = 0.002), and fibrosis stage (P = 0.040) were identified as independent risk factors for developing PHLF.

CONCLUSION

The ISGLS definition of PHLF was associated with OS and RFS in HCC patients, and long-term survival will be improved by reducing the incidence of PHLF.

Role of the protein tyrosine phosphatase Shp2 in homeostasis of the intestinal epithelium

Protein tyrosine phosphorylation is thought to be important for regulation of the proliferation, differentiation, and rapid turnover of intestinal epithelial cells (IECs). The role of protein tyrosine phosphatases in such homeostatic regulation of IECs has remained largely unknown, however. Src homology 2-containing protein tyrosine phosphatase (Shp2) is a ubiquitously expressed cytoplasmic protein tyrosine phosphatase that functions as a positive regulator of the Ras-mitogen-activated protein kinase (MAPK) signaling pathway operative downstream of the receptors for various growth factors and cytokines, and it is thereby thought to contribute to the regulation of cell proliferation and differentiation. We now show that mice lacking Shp2 specifically in IECs (Shp2 CKO mice) develop severe colitis and die as early as 3 to 4 weeks after birth. The number of goblet cells in both the small intestine and colon of Shp2 CKO mice was markedly reduced compared with that for control mice. Furthermore, Shp2 CKO mice showed marked impairment of both IEC migration along the crypt-villus axis in the small intestine and the development of intestinal organoids from isolated crypts. The colitis as well as the reduction in the number of goblet cells apparent in Shp2 CKO mice were normalized by expression of an activated form of K-Ras in IECs. Our results thus suggest that Shp2 regulates IEC homeostasis through activation of Ras and thereby protects against the development of colitis.

Two-layer challenge test as an assessment to predict islet graft function

BACKGROUND/AIMS

To investigate graft viability assessment before transplantation using 31P-Nuclear Magnetic Resonance (NMR) spectroscopy combining a two-layer old storage method (TLM).

METHODOLOGY

Rat pancreases were divided into three groups and respectively subjected to 0 (group 1), and 30 minutes (group 2) of warm ischemia (WI) before procurement. Pancreases were digested and pancreatic digest tissues were preserved for 3 h using TLM. 31P-NMR spectroscopy was used to measure ATP levels of digest tissue. After TLM, the ratio of beta-adenosine triphosphate to phosphate monoester (betaATP/PME) obtained by 31P-NMR spectroscopy was evaluated. Isolated islets were assessed for yield and in vivo function separately using nude mice.

RESULTS

The betaATP/PME ratios were 0.11 +/- 0.04, and 0.03 +/- 0.01 in groups 1 and 2, respectively (P < 0.05). Islet yields (IEQ/pancreas) were significantly less in group 3 (P < 0.05) and the cure rate after transplantation of 200 islets to athymic nude mice were 100% (7/7), and 0% (0/7) in groups 1 and 2, respectively. We regard groups 1 as viable group and group 2 as non-viable group. The viable groups and the non-viable group were clearly distinguished by betaATP/PME ratios.

CONCLUSION

31P-NMR spectroscopy combining TLM provided an objective and rapid means to assess severity of islet graft damage prior to transplantation in the rat model.

Factors affecting survival after resection of intrahepatic cholangiocarcinoma

PURPOSE

This study aimed at assessing the prognostic factors of resection of intrahepatic cholangiocarcinoma (IHCC), which remain unclear.

METHODS

Among 70 patients with IHCC, who were admitted to our hospital between 1998 and 2011, 45 (64 %) underwent resection and 25 had unresectable tumors. Univariate and multivariate analyses were conducted retrospectively to assess the factors influencing survival of the patients who underwent resection.

RESULTS

The median survival times of the patients who underwent resection versus those who did not were 16 months versus 9 months, respectively (P < 0.001). Multivariate analysis identified residual tumor status (relative risk 4.12, P = 0.04) and pathological differentiation (relative risk 5.55, P = 0.04) as independent factors predicting survival. Patients who underwent R1 resection had a significantly higher rate of local recurrence than those who underwent R0 resection (P = 0.008). With R0 resection, there were no significant differences in patterns and rates of recurrence between patients with narrow (≤ 5 mm) versus wide (>5 mm) surgical margins.

CONCLUSIONS

R0/1 resection and a well-differentiated tumor were found to be independent prognostic factors for long-term survival after IHCC resection. If R0 resection was achieved, the width of the negative surgical margin did not affect the patterns and rates of recurrence.

Long-term outcomes and prognostic factors with reductive hepatectomy and sequential percutaneous isolated hepatic perfusion for multiple bilobar hepatocellular carcinoma

BACKGROUND

Sorafenib is currently recommended as first-line therapy for patients with intermediate or advanced hepatocellular carcinoma (HCC) per Barcelona Clinic Liver Cancer staging. However, the median overall survival (OS) with sorafenib in these patients is 10.7 months with an overall response rate of 2 %. We retrospectively investigated the long-term outcomes and prognostic factors with reductive hepatectomy and sequential percutaneous isolated hepatic perfusion (PIHP) for refractory intermediate or advanced HCC.

METHODS

A total of 68 patients who had intermediate or advanced stage HCC without extrahepatic metastases were scheduled for reductive hepatectomy plus PIHP. All patients underwent reductive hepatectomy and PIHP with mitomycin C 20-40 mg/m(2) and/or doxorubicin 60-120 mg/m(2) 1-3 months after surgery (mean, 1.51 times/patient).

RESULTS

The objective response rate of PIHP was 70.6 % (complete plus partial response). The median OS of all 68 patients was 25 months, and the 5-year OS rate was 27.6 %. Univariate and multivariate analyses indicated that tumor response to PIHP and normalization of serum des-γ-carboxy prothrombin concentrations after PIHP were independent prognostic factors for OS.

CONCLUSIONS

The median OS of the study population treated by reductive hepatectomy and sequential PIHP was 25 months. This treatment strategy can offer a possible curative treatment to patients with refractory intermediate and advanced HCC.

Gallbladder bed pocket score as a preoperative measure for assessing the difficulty of laparoscopic cholecystectomy

INTRODUCTION

Laparoscopic cholecystectomy (Lap-C) is a standard surgery for symptomatic gallbladder stones and acute or chronic cholecystitis. Resident surgeons often perform this operation early in their training, but they sometimes encounter difficulties for various technical reasons. Although encountering a gallbladder buried deep within the gallbladder bed is a common operative difficulty, literature on the subject scarcely exists.

METHODS

Forty-two patients underwent Lap-C at our hospitals and were analyzed retrospectively. We defined the gallbladder bed pocket score (GBPS) as the maximum ratio between the height and width of the gallbladder bed measured based on multi-detector computed tomography (MDCT) images. GBPS and clinical factors were assessed in terms of their correlation with the time required for gallbladder dissection from the gallbladder bed.

RESULTS

Of the 42 patients, 20 had histories of acute or chronic cholecystitis. The mean gallbladder dissection time was 14.9 min, and the mean GBPS was 0.43 in the coronal MDCT section and 0.56 in the sagittal section. The correlation coefficient between the GBPS and gallbladder dissection time was 0.40 (P = 0.01) in the coronal section and 0.38 (P = 0.02) in the sagittal section of the MDCT images. There was no statistically significant correlation between gallbladder dissection time and the surgeon's experience, patient's history of cholecystitis, gallstone size, or blood loss. However, GBPS > 0.4 predicted more difficult and prolonged dissection.

CONCLUSION

GBPS is a useful tool for preoperatively predicting the time needed to dissect the gallbladder from the gallbladder bed during Lap-C. Cases with GBPS < 0.4 seem more suitable for resident surgeons who are performing gallbladder dissection early in their Lap-C training.

[A case of metachronous pancreatic cancer that developed 4 years after initial pancreatectomy]

A 55-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy for pancreatic ductal adenocarcinoma( PDAC) in July 2008. The final diagnosis was Stage I PDAC according to the Union for International Cancer Control( UICC) TNM classification. After the operation, adjuvant chemotherapy with gemcitabine was administered for 6 months. The tumor marker level increased at 49 months after the operation, and 18-fluoro-deoxyglucose (FDG)-positron emission tomography( PET) showed FDG accumulation in the remnant pancreas. A hypovascular tumor was revealed in the remnant pancreas on computed tomography( CT). As PDAC was diagnosed without distant metastasis, completion pancreatectomy was performed. Histopathological investigation revealed PDAC with invasion into the muscularis propria of the anastomosed jejunum and splenic plexus. The final diagnosis was T3N0M0 UICC Stage IIA metachronous PDAC. The postoperative course was uneventful. However, multiple liver metastases and local recurrence were detected on CT 2 months after resection, and the patient died 3 months after resection. Most reported cases of metachronous PDACs were diagnosed at an advanced stage despite regular follow-ups after the initial resection. Further investigation is needed to determine the adequate surveillance time and novel therapeutic strategies.

[A case involving long-term survival following bile duct cancer with para-aortic lymph node metastasis that was treated by multidisciplinary therapy]

Complete resection of advanced bile duct cancer is difficult due to the anatomical location of the tumor and invasion into other organs. Even if a complete resection is achieved, the survival rates of patients with bile duct cancer after surgery are lower as compared to those associated with other gastrointestinal tumors. Certain cases with para-aortic lymph node metastasis have a poor prognosis. In the present report, we describe a case involving long-term survival following bile duct cancer that was treated by multidisciplinary therapy (particle radiotherapy, surgical resection, chemotherapy). In the present case, we detected lymph node (LN) metastasis only in LN#16, but not in LN#13 or LN#17. We believe that particle radiotherapy, consisting of proton and carbon-ion, can be used to control the lymphatic metastasis around the pancreas head and hepatoduodenal ligament. Our findings suggest that particle radiotherapy can be a standard neoadjuvant therapy for bile duct cancer.

[Analysis of the safety and efficacy of percutaneous isolated hepatic perfusion after particle therapy for advanced hepatocellular carcinoma]

Here, we report the efficacy of dual treatment with hepatic resection and percutaneous isolated hepatic perfusion (PIHP) for advanced hepatocellular carcinoma( HCC). Recently, we introduced treatment with combined particle therapy and PIHP for unresectable HCC in cases of insufficient liver function. The purpose of this study was to evaluate the safety and efficacy of PIHP for local control in the liver after particle therapy. From 2006 to 2013, 6 patients underwent particle therapy for the main lesion and subsequent PIHP for remnant liver lesions. Their mean age was 64 years, and the mean size of the main lesion was 6.2 cm (range, 2.0-10.8 cm). All patients had liver cirrhosis. After particle therapy, PIHP was performed by hepatic arterial infusion of 100 mg/m2 of doxorubicin and 30 mg/m2 of mitomycin C. With regard to side effects, neutropenia occurred in all patients but no serious hepatobiliary injury was observed. The response rate for PIHP was 50% (partial response: 3 and stable disease: 3). The mean overall survival time was 26.9 months after particle therapy. In conclusion, even after particle therapy, PIHP is a safe treatment and is associated with a good local control rate for remnant HCCs. Further accumulation of data is needed to evaluate the efficacy of this treatment strategy in terms of prognosis.

Three-dimensional computed tomographic cholangiography as a novel diagnostic tool for evaluation of bile duct invasion of perihilar cholangiocarcinoma

BACKGROUND/AIMS

This study assessed the results of preoperative evaluation of ductal invasion by perihilar cholangiocarcinoma, imaged using 3-dimensional (3D) CT cholangiography compared to conventional endoscopic retrograde cholangiography (ERC) and magnetic resonance cholangiopancreatography (MRCP).

METHODOLOGY

ERC, MRCP and 3D-CT cholangiography were planned in 24 patients with preoperatively diagnosed perihilar cholangiocarcinoma. Evaluations of bile duct images using each of 3 modalities were classified into 2 groups (the Visualization uncertain (VU) group and the Visualization certain and clear (VCC) group) according to the quality of biliary images. The results of pathological assessments and preoperative radiological evaluations were compared.

RESULTS

In the bile duct evaluation, the rates between the 2 groups were not significantly different across the three modalities. 3D-CT cholangiography evaluated tumour involvement most clearly in patients with obstructive jaundice (p = 0.044), and ERC evaluated biliary tree more clearly compared to MRCP or 3D-CT cholangiography in patients without obstructive jaundice (p = 0.051). For evaluation of pathological tumor invasion in the VCC group, 3D-CT cholangiography enabled a correct diagnosis in 7 of 11 patients, and R0 resection was achieved in 8 of 11 patients.

CONCLUSIONS

3D-CT cholangiography offers accurate preoperative assessment of bile duct invasion by perihilar cholangiocarcinoma, especially in patients with obstructive jaundice.

[The role of preoperative percutaneous isolated hepatic perfusion and hepatectomy in multidisciplinary treatment]

We report a case of multiple bilobar hepatocellular carcinoma( HCC) that was successfully treated with a multidisciplinary treatment including preoperative percutaneous isolated hepatic perfusion and hepatectomy. The patient was a 61- year-old man who was detected as having HCC mainly in segment 4 and 8 of the liver and multiple bilobar intrahepatic metastasis during follow-up evaluation for chronic hepatitis B. Curative resection was difficult because the patient had insufficient liver function and because of the location of the tumor. Hence, we performed preoperative percutaneous isolated hepatic perfusion (PIHP) to control the multiple HCC. Seven weeks after the PIHP, the tumor size had reduced, and therefore we performed an extended left hepatic lobectomy. In addition to these treatment modalities, we performed transcatheter arterial chemoembolization (TACE) 3 times owing to recurrent HCC in the right liver lobe. Considering that HCC in segment 8 can be treated with TACE, we performed partial hepatectomy. As of the last follow-up visit, the patient was alive without disease recurrence. Thus, preoperative PIHP may improve the resectability rate in patients with multiple bilobar HCC for which curative resection is difficult to perform.

[A case of initially unresectable gallbladder cancer with surgical resection after chemotherapy with gemcitabine]

A 75-year-old woman was admitted to our hospital with elevated serum hepatic enzyme levels. After evaluation with imaging studies, she was diagnosed as having gallbladder cancer, which had invaded the liver and hepatic artery, with lymph node metastases. The tumor was considered unresectable, and the patient received chemotherapy with gemcitabine (GEM)alone. Six months later, computed tomography(CT)indicated shrinkage of the gallbladder tumor and disappearance of lymph node metastases. Surgical resection was planned. However, liver metastasis was suspected on the basis of macroscopic findings, and the patient underwent gallbladder bed resection. Pathological examination indicated that almost all of the tumor cells in the gallbladder were viable; however, there were no tumor cells in the liver nodule and lymph node. The postoperative course was uneventful. The patient received adjuvant chemotherapy with GEM and was alive without recurrence 17 months after tumor resection. Immunohistochemical analysis showed that 80.9% of the tumor cells were positive for CD133, a cancer stem cell marker. This case illustrates a possible relationship between cancer stem cells and chemoresistance.

Wnt5a signaling promotes apical and basolateral polarization of single epithelial cells

Wnt signal plays important roles in polarization. Here intestinal epithelial cells are shown to form apicobasal polarization at a single-cell level in an extracellular matrix adhesion–dependent manner. Wnt5a signaling promotes single-cell polarization through balanced control between Rac1 and RhoA activities spatially.

Single epithelial-derived tumor cells have been shown to induce apical and basolateral (AB) polarity by expression of polarization-related proteins. However, physiological cues and molecular mechanisms for AB polarization of single normal epithelial cells are unclear. When intestinal epithelial cells 6 (IEC6 cells) were seeded on basement membrane proteins (Matrigel), single cells formed an F-actin cap on the upper cell surface, where apical markers accumulated, and a basolateral marker was localized to the rest of the cell surface region, in a Wnt5a signaling–dependent manner. However, these phenotypes were not induced by type I collagen. Rac1 activity in the noncap region was higher than that in the cap region, whereas Rho activity increased toward the cap region. Wnt5a signaling activated and inhibited Rac1 and RhoA, respectively, independently through Tiam1 and p190RhoGAP-A, which formed a tertiary complex with Dishevelled. Furthermore, Wnt5a signaling through Rac1 and RhoA was required for cystogenesis of IEC6 cells. These results suggest that Wnt5a promotes the AB polarization of IEC6 cells through regulation of Rac and Rho activities in a manner dependent on adhesion to specific extracellular matrix proteins.

Effect of hepatic arterial infusion chemotherapy of 5-fluorouracil and cisplatin for advanced hepatocellular carcinoma in the Nationwide Survey of Primary Liver Cancer in Japan

BACKGROUND

The efficacy of hepatic arterial infusion chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC) remains unclear.

METHODS

The outcome of 476 patients with HCC who underwent hepatic arterial infusion chemotherapy with 5-fluorouracil and cisplatin (HAIC) were compared with 1466 patients who did not receive active therapy.

RESULTS

A survival benefit of the therapy after adjusting for known risk factors was observed (hazard ratio, 0.48; 95% CI, 0.41-0.56; P<0.0001). In propensity score-matched analysis (n=682), median survival time was longer for patients who underwent chemotherapy (14.0 months) than for patients who did not receive active treatment (5.2 months, P<0.0001).

CONCLUSION

For advanced HCC, HAIC is considered to be an effective treatment.

MUC2 expression and prevalence of high-grade dysplasia and invasive carcinoma in mixed-type intraductal papillary mucinous neoplasm of the pancreas

BACKGROUND/OBJECTIVES

Morphological types and mucin protein expressions classify intraductal papillary mucinous neoplasms (IPMNs). Main duct (MD)-IPMN mostly consists of intestinal type (I-type), which expresses MUC2. Branch duct (BD)-IPMN mostly consists of gastric type (G-type), which does not express MUC2. However, the definition of mixed-type IPMN has yet to be clarified and it contains various histological types. The aim of this study was to investigate the relationship between MUC2 expression and the presence of high-grade dysplasia (HGD) and invasive carcinoma, especially in mixed-type IPMN.

METHODS

This retrospective study included 101 consecutive patients with surgically resected IPMNs between April 2001 and October 2012. All patients were morphologically classified into four distinct types (I-type, G-type, PB-type: pancreatobilliary, O-type: oncocytic) and immunohistochemical reactivity of various anti-mucin antibodies were investigated.

RESULTS

According to the classification of the 2012 international guidelines, the numbers (and histomorphological types: I/G/PB/O) of MD, mixed-type, and BD-IPMNs were 16 (12/4/0/0), 45 (16/28/1/0), and 40 (0/38/1/1). Prevalence of MUC2 expression in MD, mixed-type, and BD-IPMNs were 75% (12/16), 36% (16/45), and 0% (0/40). In mixed-type IPMN, the prevalence of HGD and/or invasive carcinoma in MUC2-positive IPMN was significantly higher than that of MUC2-negative IPMN (HGD + invasive carcinoma: 88% vs. 38%, p = 0.0017; invasive carcinoma: 50% vs. 21%, p = 0.042). Multivariate analysis showed that MUC2 expression is an independent predictive factor of HGD and invasive carcinoma in mixed IPMN (odds ratio 14.6, 95% CI 2.5-87.4, p = 0.003).

CONCLUSIONS

In mixed-type IPMN, MUC2 expression clearly identified HGD and invasive carcinoma and may provide most appropriate surgical indication.

18-Fluorodeoxyglucose positron emission tomography does not aid in diagnosis of pancreatic ductal adenocarcinoma

BACKGROUND & AIMS

There are no accurate and reliable tools for diagnosis of early stage pancreatic ductal adenocarcinoma (PDA) or small metastatic lesions. It is also a challenge to differentiate PDA from focal mass-forming pancreatitis (FMP). There is controversy regarding the efficacy of 18-fluorodeoxyglucose positron-emission tomography (FDG-PET) in the diagnosis of PDA. We investigated whether FDG-PET provides information that, combined with data from other imaging techniques, can aid in decision making for patients with suspected PDA.

METHODS

We performed a retrospective analysis of data collected from 232 consecutive patients with suspected PDA at Kobe University Hospital from January 2006 through June 2012. All patients underwent a diagnostic imaging protocol that included multidetector row computed tomography, superparamagnetic iron oxide-enhanced magnetic resonance imaging, and FDG-PET. Based on endoscopic ultrasonography, fine-needle aspiration biopsy, or endoscopic retrograde cholangiopancreatography analyses, 218 patients had PDA (89 underwent resection and 129 did not) and 14 patients had FMP (8 had focal mass-forming chronic pancreatitis and 6 had focal mass-forming autoimmune pancreatitis).

RESULTS

FDG-PET detected 50% of stages 0 and I, 91.9% of stage II, 100% of stage III, and 96.8% of stage IV tumors. Detection was affected significantly by tumor size (P = .024) and T stage (P = .023) in resected tumors. Multidetector row computed tomography detected significantly more liver metastases than FDG-PET. Few para-aortic lymph node or peritoneal metastases were detected by FDG-PET. FDG-PET correctly identified 11 of the 14 patients with FMP (5 of 8 with focal mass-forming chronic pancreatitis and 6 of 6 with focal mass-forming autoimmune pancreatitis).

CONCLUSIONS

FDG-PET is not effective in detecting early stage PDA and small metastases, or in differentiating PDA from FMP. Combining FDG-PET with current diagnostic techniques for PDA did not provide any decisive information, therefore it should not be included in this analysis.

Clinical implication of hypovascular hepatocellular carcinoma studied in 4,474 patients with solitary tumour equal or less than 3 cm

BACKGROUND & AIMS

To clarify the biological behaviour of small hypovascular hepatocellular carcinoma (HCC) because of insufficient evidence even though frequently encountered.

METHODS

The study covered naïve 4,474 patients who met solitary HCC ≤ 3 cm (mean, 2.1 cm), histopathologically proven and Child Pugh A or B. Macroscopic vascular invasion and distant metastasis were excluded. The hypovascularity of tumour was defined as hypo- or iso-enhancement in arterial phase of multiple dynamic imaging techniques.

RESULTS

Of them, 802 (18%) were hypovascular. The ratio of hypovascular HCC decreased as tumour size increased (P < 0.001) and most of them developed to hypervascular type when they grew over 1.5 cm. Hypovascular group showed a significantly higher ratio of well differentiated grade (P < 0.001) and marginally less incidence of microvascular invasion and metastases compared with hypervascular group. The histologic dedifferentiation (less differentiation) developed step-by-step as tumour size increased in hyper- and even hypovascular group. The des-γ-carboxy prothrombin (DCP) value ≥ 300 mAU/ml was closely correlated with increase of tumour size in both groups. Logistic regression analysis revealed five variables were independent predictors for hypovascular HCC; tumour size ≤ 1.5 cm, alpha-fetoprotein < 200 ng/ml, DCP < 40 mAU/ml, well differentiated grade, and positivity for hepatitis C virus antibody.

CONCLUSIONS

Hypovascular HCC was biologically less aggressive and developed with stepwise dedifferentiation and transformation to hypervascular appearance along with tumour growth. These results will help in leading correct diagnosis of small hypovascular tumour and assessing optimal treatment for hypovascular HCC ≤ 3 cm.

Lymphadenectomy combined with locoregional treatment for multiple advanced hepatocellular carcinoma with lymph node metastases

Lymphadenectomy of lymph node metastasis (LNM) from hepatocellular carcinoma (HCC) may potentially improve survival of patients with intrahepatic tumors controllable by means of locolegional treatment. However, the treatment strategy has not gained wide clinical acceptance, especially in patients with multiple advanced HCC. Thus, the purpose of this study is to evaluate the role of lymphadenectomy combined with locoregional treatment for the management of multiple advanced HCC with LNM. Between January 1998 and August 2012, 15 patients underwent a selective lymphadenectomy either concurrently or sequentially after hepatectomy. Seven of 15 patients underwent reductive hepatectomy while the remaining 8 patients had hepatectomy at curative intent. In patients with reductive hepatectomy, lymphadenectomy was concurrently performed and the residual intrahepatic tumors were treated thereafter with additional locoregional treatments consisting of transcatheter arterial chemoembolization, radiofrequency ablation, and percutaneous isolated hepatic perfusion. Only 4 patients (26.6%) of 15 patients developed lymph node recurrence. However, intrahepateic recurrence was encountered in 13 of 15 patients. The median survival time after lymphadenectomy was 25.2 months with the overall survival rates at 1, 2, and 3 years being 76.9%, 52.7%, and 26.4%, respectively. Selective lymphadenectomy and multimodal locoregional treatment in patients with multiple residual tumors exhibited a similar overall survival to complete resection of LNM and intrahepatic tumors (P=0.78). Lymphadenectomy combined with an additional aggressive locoregional treatments may be justified in selected patients with multiple advanced HCC with LNM.