Prognostic significance of surgical margin in hepatocellular carcinoma resection: an analysis of 165 Childs' A patients

BACKGROUND AND OBJECTIVES

The clinical significance of the width of the surgical margin in the resection of hepatocellular carcinoma (HCC) has yet to be clarified.

METHODS

Childs' A patients (165) who underwent resections of HCC were studied. Patients were divided into a wide margin group (1.0 cm or more, group W, n = 85), and a narrow margin group (< 1.0 cm, group N, n = 80).

RESULTS

Multivariate analysis showed that preoperative alpha-fetoprotein level (P = 0.0202), venous invasion (P = 0.0226), surgical margin (P = 0.0012), and TNM stage (P = 0.0023) were significant predictors of disease-free survival. By the log-rank test, the disease-free survival rate of the group W patients was significantly higher than that of the group N patients (P = 0.0007). Group N had a higher percentage of patients undergoing minor resection (wedge resection or subsegmentectomy) (44% vs. 26%, P = 0.016) and had a higher percentage of patients with centrally located tumor (62% vs. 29%, P = 0.000) than group W.

CONCLUSIONS

The results of this study indicated the significant influence of surgical margin on HCC recurrence after resection. Minor resection and centrally located tumor are factors related to a narrow surgical margin.

Selection of invasive and metastatic subpopulations from a human lung adenocarcinoma cell line

To better understand the mechanism(s) underlying lung cancer invasion and metastasis, a Transwell invasion chamber was used to select progressively more invasive cancer cell populations from a clonal cell line of human lung adenocarcinoma, CL1. Five sublines with progressive invasiveness, designated CL1-1, CL1-2, CL1-3, CL1-4, and CL1-5, were obtained through this in vitro selection process. Their invasive abilities through basement membrane matrix showed a 4- to 6-fold increase over that of the parental cells. Moreover, the sublines manifested an increase in their colony-forming ability on soft agar, tumorigenicity, and metastatic potency in severe combined immunodeficiency (SCID) mice. Examining the phenotypes of the cell lines revealed increased expression of 92 kD gelatinase and an increase in the cell population stained with anti-keratin-8 and -18 antibodies. Clonal isolation of anti-keratin-18-antibody-positive and -negative cell populations demonstrated a correlated enhancement of the invasiveness of these cells and their expression of keratin-18. These results support the notion that the metastatic behavior of lung cancer cells can be characterized with this in vitro system, and that the properties of these progressively invasive cancer cells can be clonally studied.

Effect of hepatocyte growth factor on cell cycle and c-met expression in human gastric cancer cells

Hepatocyte growth factor (HGF) was found to stimulate the growth and progression of gastric cancer cells through hepatocyte growth factor receptor (HGFR). In the present study, the effects of HGF on the expression of HGFR in relation to cell cycle progression of human gastric cancer cells were investigated by two-parameter flow cytometric analysis. We found that the expression of HGFR in SC-M1 and KATO-III gastric cancer cells was cycle dependent, the level of HGFR increased from GO-G1 to S phase and the highest level of HGFR was found in G2-M phases. The level of HGFR was higher in KATO-III than SC-M1 cells. However, HGF treatment induced a dose-dependent stimulation of growth as well as down-regulation of HGFR in SC-M1 cells but not in KATO-III cells. These results suggest that functional HGFR rather than overexpressed HGFR may be more important for the growth of gastric cancer cells.

Quality of life of patients with gastric adenocarcinoma after curative gastrectomy

Quality of life (QOL) was evaluated in 162 patients having radical gastrectomy for cancer. The results showed that more than half of the patients had a good appetite; they consumed a normal diet and a normal volume of food. Approximately 60% of the patients had weight loss of more than 5 kg. Patients who underwent a total gastrectomy had poor tolerance of normal food and frequent eating and body weight loss versus those who had a subtotal gastrectomy. Patients who underwent Billroth II reconstruction after a distal subtotal gastrectomy lost more body weight than those with a Billroth I anastomosis. The extent of lymphadenectomy did not influence the QOL. Patients under 65 years of age had a better QOL. Nearly all patients had normal work and daily living activities. Some patients appeared to lack energy or had a period of anxiety or depression. These data indicate that radical gastrectomy can be performed with an acceptable QOL for a potentially curable gastric carcinoma.

Intestinal obstruction after laparoscopic herniorrhaphy

Laparoscopic herniorrhaphy is still a controversial procedure. Two cases of intestinal obstruction after laparoscopic herniorrhaphy are reported. The clinical features, possible mechanisms, managements, and outcomes were analyzed. The results showed that preexisting mesenteric defect, fibrin depositions, and longer operation time were predisposing factors for post-laparoscopic herniorrhaphy intestinal obstruction. These findings suggest that cleansing of fibrin deposition and shorter operation times may be important to avoid postoperative intestinal obstruction.

Genomic deletion and p53 inactivation in cervical carcinoma

The tumor-suppressor gene p53 acts as "the guardian of the genome", sensing DNA damage and initiating protective responses. To examine the hypothesis that p53 abnormality leads to increased genomic alterations in primary tumor cells, our study utilized 51 primary tumors of cervical carcinoma and 10 microsatellite markers. These markers were mapped to the short arms of chromosomes 3 and 5, covering the regions 3p13-25 and 5p15.1-15.3. Genomic deletion on 3p and 5p was correlated with genetic or epigenetic p53 inactivation pathways, including p53 mutation, genetic deletion of p53 and cervical infection with human papillomavirus. The proportion of abnormal p53 was found to be significantly higher in the cases exhibiting loss of heterozygosity (LOH) on 5p (p < 0.001), supporting the hypothesis of the presence of a p53-dependent pathway to cervical tumorigenesis. In contrast, however, LOH on 3p was found to be independent of p53 inactivation. A common deletion region, 3p22-24, was identified in 44% of informative cases, and genomic loss at this specific region was correlated with early tumorigenic onset and poor grade of tumor differentiation. Diversity within the patterns of genomic alteration in the same form of cancer suggests different sets of risk/tumorigenic profiles, molecular pathogenesis, as well as prognosis and outcome.

Clinicopathological comparison of resectable hepatocellular carcinoma between the young and the elderly patients

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common cancers in many parts of the world. In Taiwan it is the leading cause of death in male cancer patients. The peak age of onset of HCC varies according to geographic barriers, which indicates different hepatocarcinogenesis among different age groups. This study aims to evaluate whether there exists significantly different clinicopathological features between young and elderly HCC patients.

METHODS

During a six-year period, a total of 248 patients with HCC underwent liver curative resection at Veterans General Hospital-Taipei, Taiwan. Among them, 22 patients were younger than 40 years of age, and 43 patients were older than 70 years of age. Important clinicopathological characteristics of the patients (including sex, family history of HCC, smoking habits and alcohol consumption patterns, hepatitis B or C infection, indocyanine-green retention rate at 15 minutes (ICGR-15), serum alpha-fetoprotein value, tumor size, tumor number, tumor venous invasion, capsular formation, tumor staging, cirrhosis, and tumor DNA ploidy) and postresectional prognosis were compared between young and elderly HCC patients.

RESULTS

The frequency of presence of family history (22.7% versus 4.7%), hepatitis B surface antigen carrier rate (81.8% versus 48.8%), and patients with large-sized tumors (31.8% versus 7.0%) were significantly higher in young patients than in elderly patients. The male:female ratio (4.5:1 versus 42:1), degree of liver damage (reflected by the ICGR-15 value, 5.6 +/- 5.0% versus 13.1 +/- 8.8%) and the incidences of liver cirrhosis (18.2% versus 48.8%) were significantly lower in young patients than in elderly patients. However, there were no significant differences in postresectional survival rates between these two groups.

CONCLUSIONS

There are age-related differences in clinicopathological characteristics of HCC patients. Accordingly, different mechanisms of hepatocarcinogenesis may exist between young and elderly HCC patients.

Prognostic indicators for survival after curative resection for patients with carcinoma of the stomach

This study aims to determine prognostic indicators among patient-, tumor-, and treatment-related factors of gastric cancer patients. A total of 510 patients who underwent curative gastric resection were studied. Univariate analysis of patient-related factors showed a significantly lower survival in patients with a history of obstruction, hypoalbuminemia, and anemia. Tumor-related factors including gross appearance, location, and size of tumor; depth of cancer invasion; level, number, and frequency of lymph node metastasis; stromal reaction and tumor growth pattern; and histological classification all significantly affected survival. Surgical treatment related factors such as total or distal subtotal gastrectomy, extent of lymphadenectomy, and combined resection of adjacent organ(s) showed a statistically significant adverse influence on survival. Multivariate analysis identified only four tumor-related factors-number of metastatic lymph nodes, depth of cancer invasion, stromal reaction, and gross appearance of the tumor-as independently affecting survival. These findings suggest that only four tumor-related factors were prognostic indicators in patients with gastric cancer.

Intestinal-type tumour in resected gastric remnant cancer

Lauren's intestinal type of gastric cancer was proposed to be dependent on long-term environmental factors and is always preceded by chronic premalignant change. A cohort study was performed and demonstrated an increased cancer risk of gastric remnant after gastric surgery for benign disease. It is generally believed that after gastrectomy the residual stomach has an environmental change and, thus, enters a neoplastic process. Based on the carcinogenic theory of intestinal-type tumour, it would be of interest to know whether the intestinal-type tumour is more common in gastric remnant cancer. Forty patients with gastric remnant cancer had gastrectomy in the Veterans General Hospital-Taipei. Another 683 patients with primary gastric carcinoma underwent resection and were used as controls. The clinical characteristics, tumour stage and intestinal-type tumour were analysed in gastric remnant cancer and were compared with the various portions of primary gastric carcinoma. Although the overall distribution of intestinal-type carcinoma in gastric remnant (45%) was no different to that of any other portion of stomach cancer, intestinal-type carcinoma was more common in the early stage of gastric remnant (73%) and distal stomach (73%), but not in the proximal stomach (50%), which was supposed to have the same characteristics as the gastric remnant because of identical anatomic location. More than expected, intestinal-type carcinoma in early gastric remnant cancer together with a long incubation interval between primary surgery and later tumour occurrence were compatible with the theory of carcinogenesis of intestinal-type carcinoma.

Randomized trial of three types of gastrojejunostomy in unresectable periampullary cancer

BACKGROUND

A gastrojejunostomy with duodenal partition was designed to clarify whether so-called circulus vomiting exists and, if so, its clinical significance, by comparing it with two other types of gastrojejunostomy commonly used for gastric bypass in unresectable periampullary cancer.

METHODS

Forty-five patients with unresectable periampullary cancer complicated by gastric outlet obstruction (GOO) were recruited into this study between May 1992 and November 1995. They were randomized to receive one of the three types of gastrojejunostomy. The anastomosis in type I gastrojejunostomy was performed at the jejunum 20 cm distal to the ligament of Treitz. Type II was similar to type I except that in type II a duodenum partition was done by linear stapler 1 cm beyond the pylorus. Type III gastrojejunostomy was performed at the Roux-limb jejunum 60 cm distal to biliojejunostomy.

RESULTS

"Food reentry" was noted in three (21%) of the type I patients, as determined by upper gastrointestinal (UGI) study. Of the three, one patient had severe circulus vomiting, one had anorexia, and one had no major symptoms. When patients were evaluated immediately after oral diet intake resumed, the incidence (27%) of clinical GOO symptoms and mean value of gastric emptying time (GET1/2, 118.1 +/- 39.2 min) were significantly lower in type II patients than in types I and III patients. When evaluated I month after operation, the incidence (7% and 17%, respectively) of clinical symptoms of GOO and mean value of GET1/2 (42.0 +/- 23.0 and 35.6 +/- 5.4 min, respectively) were significantly lower in both type II and type III patients than in type I patients. The type II patients resumed oral diet after operation 3.5 days earlier than type I patients, p < 0.05.

CONCLUSIONS

Circulus vomiting induced by food reentry does exist if the gastrojejunostomy is performed as the type I gastrojejunostomy in this study. The newly designed type II gastrojejunostomy with duodenal partition is an easy, safe, and effective gastric bypass and avoids the problem of food reentry.

Peritoneal dialysis solution induces apoptosis of mesothelial cells

For better simulation of the long-dwell exchanges in conventional CAPD, we have developed a modified mesothelial cell culture system consisting of a Transwell culture apparatus. The equilibration patterns of pH, dextrose and osmolality in the present culture system were observed to be very similar to those in human CAPD. The effects of six different peritoneal dialysis solutions on the apoptosis of mesothelial cells were evaluated using this modified culture system. The results imply that peritoneal dialysis solution per se may incite apoptosis of mesothelial cells, and also that low calcium peritoneal dialysis solution is a milder apoptosis stimulant as compared to the conventional peritoneal dialysis solution. Moreover, varying concentrations of dextrose in the peritoneal dialysis solution were not observed to significantly affect the apoptosis rate. The roles of ambient high concentrations of calcium and dextrose, low pH, as well as high osmolality in the apoptosis are also discussed.

The interaction between human cytomegalovirus immediate-early gene 2 (IE2) protein and heterogeneous ribonucleoprotein A1

Human cytomegalovirus (HCMV) is an ubiquitous pathogen which causes significant illness in immunocompromised individuals. The immediate-early gene 2 (IE2) protein of HCMV plays an important role in the regulation of virus replication. Previous studies have shown that the IE2 protein is able to interact with several cellular proteins, but many of the IE2 interacting partners remain unidentified. By utilizing the yeast two-hybrid system, the heterogeneous ribonucleoprotein A1 (hnRNP A1) was identified as an IE2 interacting protein. The interaction was confirmed via the in vitro binding of bacterial expressed glutathione S-transferase (GST) IE2 fusion protein with the in vitro translated hnRNP A1. The mutational analysis showed that both the N-terminal half (1-290 residues) and C-terminal half (291-579 residues) of IE2 protein can interact with the hnRNP A1, indicating that more than one region of IE2 protein are involved in the binding with hnRNP A1.

Human stomach alcohol and aldehyde dehydrogenases: comparison of expression pattern and activities in alimentary tract

BACKGROUND & AIMS

Alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) are the major enzymes responsible for ethanol metabolism in humans. The human stomach has been documented to be involved in the metabolism of first-passed alcohol. The aim of this study was to determine ethanol-metabolizing activities in the stomach with regard to sex, age, enzyme pattern, and polymorphism.

METHODS

A total of 209 surgical gastric mucosal specimens were investigated. The expression patterns of ADH and ALDH were identified by isoelectric focusing, and the activities were assayed spectrophotometrically.

RESULTS

At 33 or 500 mmol/L ethanol, pH 7.5, the activities in the ADH3 1-1 phenotypic and mu-ADH-expressing mucosal specimens were significantly greater than that in the ADH3 1-2 phenotypic and mu-ADH absent mucosal specimens, respectively. The activities of the ALDH2-inactive phenotypes were significantly lower than that of the ALDH2-active phenotypes at 200 micromol/L acetaldehyde. The gastric ADH and ALDH activities were not significantly different between men and women with respect to age and genetic polymorphism.

CONCLUSIONS

The stomach may contribute only a small portion of the alcohol metabolism observed in humans, and the liver may be the major site for first-pass metabolism. Differential expression patterns of ADH and ALDH in the alimentary tract suggest that different vulnerabilities to ethanol-induced mucosal injury may exist.

Prognostic factors affecting long-term survival after partial hepatectomy for human hepatocellular carcinoma

BACKGROUND

Various prognostic factors have been studied during the past few years to predict early tumor recurrence and survival in patients undergoing hepatectomy for primary hepatocellular carcinoma. However, the relationship between these factors and long-term survival has not been clarified. The purpose of this study was to identify the factors linked to long-term prognosis in patients with resectable hepatocellular carcinoma after hepatectomy.

METHODS

Records of 370 patients undergoing curative hepatectomy during a period from July 1981 to July 1994 were retrospectively reviewed. Only 110 patients with disease-free survival > or = 36 months were eligible for long-term survival analysis. Their further outcomes, including disease-free survival and overall survival, were analyzed in correlation with various prognostic factors by Kaplan-Meier's method, log rank test; and Cox's regression model. Analysis of prognostic factors linked to early tumor recurrence after curative hepatectomy was also performed in 324 patients who were followed up > or = 12 months.

RESULTS

Tumor behaviors were found to be the principal prognostic factors determining the early tumor recurrence and patients' survival (p < 0.05). However, when long-term survival was analyzed, the pathological status of the liver remnant such as the presence or absence of hepatitis B virus infection, chronic active hepatitis, hepatocyte dysplasia and age (< or = 60 y/o vs. > 60 y/o), as well as preoperative liver function (total serum bilirubin < or = 1.5 mg/dl vs. > 1.5 mg/dl), were found to make significant disease-free survival differences (p < 0.05), whereas the factors linked to tumor behaviors and surgical factors showed no influence on long-term prognosis.

CONCLUSIONS

Pathological status and host factors (age and liver function) have effect upon long-term prognosis after hepatic resection for hepatocellular carcinoma.

Diagnostic laparoscopy: indication and benefit

BACKGROUND

Patients with an obscure and unrelievable abdominal condition may be forced to receive open laparotomy for diagnosis. Diagnostic laparoscopy has been suggested as an alternative to diagnostic laparotomy in selected cases. The aim of this article is to evaluate the circumstances suitable for laparoscopic diagnosis of certain abdominal conditions and the possible advantages of that approach.

METHODS

Among 256 patients undergoing elective laparoscopic operations using conventionally pneumoperitoneal techniques from January 1994 to June 1995, twenty patients received diagnostic laparoscopy. The correlation between preoperative diagnosis, laparoscopic diagnosis and pathologic diagnosis as well as the outcome of laparoscopic diagnosis and treatment have been assessed.

RESULTS

Major indications for diagnostic laparoscopy included acute abdominal pain (n = 4), chronic abdominal pain (n = 6), differentiating intraabdominal tumor (n = 4), staging known malignancy (n = 3) and evaluating intraperitoneal implantation (n = 3). Two of the four patients with acute abdominal conditions, one of the six patients with chronic abdominal pain. Four of the seven patients with undifferentiated/unstaged abdominal tumors and all of the three patients with intraperitoneal-implanted drainage tubes had no reasons for a further exploratory procedure, thus preventing the morbidity or mortality which might occur after unnecessary laparotomy. The duration of operation and hospitalization was shorter than the group without laparotomy.

CONCLUSIONS

Diagnostic laparoscopy benefits patients by avoiding unnecessary surgery, avoiding unnecessary delay in diagnosis and treatment and shortening the operative and hospitalized period. However, it provides only an alternative not a substitute for traditional diagnostic procedures and will never lessen the importance of conventional laparotomy.

Is gastric remnant cancer clinically different from primary gastric cancer?

BACKGROUND/AIMS

Poorer survival, uncertain etiology and a possible surgically induced carcinoma prompted the question of whether the gastric remnant cancer is a special form of gastric carcinoma. A retrospective study was done to see if gastric remnant cancer is clinically different from primary gastric cancer without consideration of its etiology.

MATERIALS AND METHODS

There are 77 patient with gastric remnant cancer diagnosed in our hospital in past 15 years. Thirty-two out of 77 patients underwent gastrectomy. Another 536 patients with primary gastric cancer and 73 patients with proximal third gastric cancer were used as the controls. The clinicopathological characteristics including gender, age, TNM tumor stage, Lauren's classification, degree of tumor cell differentiation, rate of curative resection and 5-year survival rate were analyzed to see if there is significant difference among the three groups.

RESULTS

Almost 90% of patients with gastric remnant cancer had a partial gastrectomy with Billroth II operation before and the median incubation interval was 24.5 years. Male predominance in gastric remnant cancer was shown in our series. However, the age distribution, TNM tumor stage, Lauren's classification, degree of tumor cell differentiation, rate of curative resection and 5-year survival after curative resection were no different among the three groups.

CONCLUSIONS

There was no difference in clinical behavior of resected gastric remnant cancer from other gastric carcinoma. Since most of the tumors were detected too late to be resected, early detection is the only way to increase the resection rate and improve the survival. Annual endoscopic surveillance after gastrectomy was recommended for early detection.

Novel patterns of p53 abnormality in breast cancer from Taiwan: experience from a low-incidence area

Among 114 breast cancers in Taiwan, the prevalence of p53 mutation (22.8%) and p53 accumulation (38.3%) was similar to that in high-incidence areas. However, novel patterns of p53 abnormalities, including unique sites or types of mutation (i.e. an excessive proportion of G:C to A:T transition at CpG site), and accumulation of wild-type p53 either within nuclear or cytoplasmic compartments were noted. These may have relevance to breast cancer in Taiwan, a low-incidence area.

A case-control study of breast cancer in Taiwan--a low-incidence area

To investigate risk factors for breast cancer in Taiwan, a low-incidence area, a case-control study was conducted. This comprised 244 subjects with diagnosed and pathologically confirmed breast cancer (age range 20-80 years) and 450 female ophthalmology outpatients as controls. Univariate and multiple logistic regression analysis suggests that breast cancer in Taiwan is aetiologically similar to breast cancer in high to moderate-incidence areas. A family history of breast cancer appears to be the most important factor contributing to the risk of breast cancer (odds ratio = 4.69). The effect of reproductive hormones (represented by the years of history of menses in premenopausal women, odds ratio = 3.35; or the age at menarche in post-menopausal women, odds ratio = 2.67) plays a significant role in tumorigenesis. Breast feeding appears to be a particularly important protective factor in Taiwanese women (odds ratio = 0.57).

Sulphonylureas reverse hypoxia induced K(+)-conductance increase in substantia nigra pars reticulata neurones

Membrane potentials were recorded from neuronal somata in the substantia nigra pars reticulata of the rat midbrain slice using the whole-cell patch-clamp technique. Hypoxia induced a consistent decrease in input resistance often accompanied by membrane hyperpolarization and cessation of firing. The membrane hyperpolarization was mediated by K+ as indicated by its reversal potential at -88 +/- 9 mV, which is close to the equilibrium potential of K+. The hypoxic response was not sensitive to 1 microM tetrodotoxin or superfusion with Ca2(+)-free medium. While glibenclamide at 30 microM and tolbutamide at 300 microM had no effect on the resting membrane properties of the neurones, these sulphonylureas reversed the hypoxia-induced membrane hyperpolarization and restored firing. Inclusion of 2 mM of ATP in the recording pipette also prevented the hyperpolarization. These observations suggest that post-synaptic ATP-sensitive potassium channels exist on the GABA neurones of SNR and that these channels are activated in energy-depleting conditions exemplified by hypoxia.

Clinicopathological significance of intestinal and diffuse types of gastric carcinoma in Taiwan Chinese

The present study sought to evaluate the clinicopathological features of our gastric cancer patients in terms of a modified Lauren's histological classification and compared the results with those from studies from Japan and Western countries. A total of 536 consecutive patients with gastric cancer were treated surgically between December 1987 and December 1993. A clinicopathological analysis was only performed for intestinal types (IT) and diffuse types (DT) of gastric cancer because patients falling into the 'other' category were too small to produce meaningful data. Of 536 cases of gastric cancer, 268 (50%) were IT, 231 (43.1%) were DT and 37 (6.9%) were of the other type. The overall IT:DT ratio was 1.2. Gastric cancer patients with IT (in contrast to DT) were characterized by older age, male dominance, smaller tumours, the tumour often being located in the lower and upper third of the stomach and less peritoneal metastasis. In both sexes, the peak incidence of gastric cancer patients was in the age group 65-74 years. Men had higher proportions of IT carcinoma than women. The IT:DT ratio for men and women was 1.4 and 0.4, respectively. Although the increased ratio of IT:DT paralleled the advance of age in both sexes, the transitional age (the age at which the IT:DT ratio exceeds 1.0) in male patients (age group 51-64 years) was earlier than for female patients (age group 65-74 years). Patients with IT gastric cancer had a significantly better survival rate than those with DT. However, the type of carcinoma (IT or DT) was not an independent predictor of survival. These data indicate that gastric cancer in Taiwan Chinese has different biological behaviour in terms of IT and DT. The clinicopathological features in IT and DT carcinoma are similar to studies from Japan and from Western countries.

A prospective randomised study of laparoscopic v. open cholecystectomy in aged patients with cholecystolithiasis

Between August 1992 and July 1993, 27 patients aged 70 years of older with cholelithiasis were prospectively randomised into 2 groups. Fifteen patients underwent laparoscopic cholecystectomy and 12 patients underwent open cholecystectomy. Shorter operation time (93.3 +/- 25.3 minutes v. 176.3 +/- 26.1 minutes, P < 0.00001), fewer postoperative analgesic requirements (0.53 +/- 0.52 days v. 2.00 +/- 0.74 days, P < 0.00001), shorter postoperative hospital stay (3.93 +/- 1.71 days v. 7.92 +/- 0.79 days, P < 0.00001) and better cosmesis were found in the laparoscopic cholecystectomy group. The above data suggest that laparoscopic cholecystectomy is the treatment of choice for cholecystolithiasis in elderly patients.

Surgical resection of primary hepatocellular carcinoma extending to adjacent organ(s)

Primary hepatocellular carcinoma (HCC) extending to the adjacent organ(s) is sometimes encountered in patients with large, peripherally located tumours. Over a 4-year period, a total of 151 patients received curative resection of HCC at the Surgical Department of Veterans General Hospital-Taipei, Taiwan. Of these patients, 21 underwent hepatic resection combined with en-bloc resection of the adjacent organ(s) because tumour extension was found during operation. Subsequent histological examination of the resected specimens found evidence of HCC invasion into the resected adjacent organ(s) in only nine patients (group I), and the remaining 12 patients showed no evidence of extrahepatic HCC invasion (group II). Twenty-seven HCC patients with clinico-pathologically matched tumours but without extrahepatic extension were selected as controls (group III). One patient in group I died of hepatic failure after the operation. The morbidity rate was 48% in group I and group II patients, and 30% in group III patients. The difference was not statistically significant. On evaluating the clinico-pathological factors, including DNA ploidy status of the tumours, there were no significant differences between tumours with and without extrahepatic invasion. Patients with locally invasive HCC (group I) had disease-free and overall survival rates comparable with those of the patients without local tumour invasion (group II and III). We conclude that HCC with invasion to the adjacent organ(s) does not seem to be directly related to the 'aggressiveness' of the tumour, and extrahepatic infiltration of the tumour does not preclude a chance of cure. Our results underscore the need for en-bloc resection as treatment of choice for these patients.