A case of resection under the IVC-atrial venovenous bypass of a hepatoblastoma after intraarterial chemotherapy

Resection of giant liver adenoma in a 17-year-old adolescent boy using venovenous bypass, total hepatic vascular isolation, and in situ cooling

Giant liver adenomas are rare pediatric tumors. Hepatocellular adenomas account for approximately 2% to 4% of all pediatric liver tumors. We present the case of a biopsy-proven 21 x 20.5 x 10.5-cm hepatocellular adenoma in a 17-year-old adolescent boy resected using venovenous bypass and total hepatic isolation. Hepatic adenomas of this size are historically treated with orthotopic liver transplantation. Resection of a massive centrally located giant liver adenoma using total hepatic vascular isolation and venovenous bypass with in situ hepatic cooling and is not previously reported. By combining these techniques, we were able to defer the risks of orthotopic liver transplantation and life-long immunosuppression for our patient. The patient's recovery was uncomplicated and hepatic regeneration was excellent. At 9 months' follow-up, the patient reported enjoying an athletic adolescent life-style with no evidence of recurrence.

Preliminary experience with arterial chemoembolization for hepatoblastoma and hepatocellular carcinoma in children

The objective of this work was to test feasibility and efficacy of hepatic artery chemoembolization (HACE) in unresectable malignant liver tumors. Five patients aged from 1-12 years were treated in the Medical University of Gdansk from 1999 to 2002. All had locally advanced tumors, which did not respond to systemic chemotherapy: four, hepatoblastoma (HB) and one, hepatocellular carcinoma (HCC). Arteriography was performed and chemoembolization suspension (cisplatin + doxorubicin + mitomycin mixed with lipiodol) was injected, followed by gelatin foam particles. The procedure was performed one to three times in each patient. In four patients (three, HB, one, fibrolamellar HCC), tumor response was observed, with decrease in the diameter of the mass of 25-33% and fall in the AFP level of 83-99%. One child with HB was non-evaluable due to early death caused by systemic myelotoxicity. Two patients (2 HB) underwent macroscopically complete tumor resection, 1 is alive and well, and 1 died at the end of surgery for an unknown reason (possibly related to cardiotoxicity of earlier systemic chemotherapy). One HB patient was successfully transplanted after two HACE courses. The only HCC patient died because of pulmonary oil embolism immediately after the third HACE course. HACE can lead to tumor regression in most cases and may be considered an alternative for patients with unresectable liver tumors who do not respond to primary systemic chemotherapy and are not candidates for liver transplantation for various reasons.

Expression profiling and differential screening between hepatoblastomas and the corresponding normal livers: identification of high expression of the PLK1 oncogene as a poor-prognostic indicator of hepatoblastomas

Hepatoblastoma is one of the most common malignant liver tumors in young children. Recent evidences have suggested that the abnormalities in Wnt signaling pathway, as seen in frequent mutation of the beta-catenin gene, may play a role in the genesis of hepatoblastoma. However, the precise mechanism to cause the tumor has been elusive. To identify novel hepatoblastoma-related genes for unveiling the molecular mechanism of the tumorigenesis, a large-scale cloning of cDNAs and differential screening of their expression between hepatoblastomas and the corresponding normal livers were performed. We constructed four full-length-enriched cDNA libraries using an oligo-capping method from the primary tissues which included two hepatoblastomas with high levels of alpha-fetoprotein (AFP), a hepatoblastoma without production of AFP, and a normal liver tissue corresponded to the tumor. Among the 10,431 cDNAs randomly picked up and successfully sequenced, 847 (8.1%) were the genes with unknown function. Of interest, the expression profile among the two subsets of hepatoblastoma and a normal liver was extremely different. A semiquantitative RT-PCR analysis showed that 86 out of 1188 genes tested were differentially expressed between hepatoblastomas and the corresponding normal livers, but that only 11 of those were expressed at high levels in the tumors. Notably, PLK1 oncogene was expressed at very high levels in hepatoblastomas as compared to the normal infant's livers. Quantitative real-time RT-PCR analysis for the PLK1 mRNA levels in 74 primary hepatoblastomas and 29 corresponding nontumorous livers indicated that the patients with hepatoblastoma with high expression of PLK1 represented significantly poorer outcome than those with its low expression (5-year survival rate: 55.9 vs 87.0%, respectively, p=0.042), suggesting that the level of PLK1 expression is a novel marker to predict the prognosis of hepatoblastoma. Thus, the differentially expressed genes we have identified may become a useful tool to develop new diagnostic as well as therapeutic strategies of hepatoblastoma.

Hepatic artery infusion of adriamycin combined with hemoperfusion in dogs

AIM

To observe the concentration of circulating ADM and its side effects by hepatic artery infusion of Adriamycin(ADM) combined with hemoperfusion (HP).

METHODS

ADM was infused through the dogs hepatic artery. At the same time, the femoral artery and femoral vein catheters were inserted and HP(NK-107 resin (HPI) and Japanese activated charcoal(HP II) as adsorbents) was performed. The concentration of circulating blood ADM was determined and blood routine, myocardiac enzymes, liver and kidney function were observed.

RESULTS

The plasma concentration of ADM at 1 h, 2 h; 3 d and 14 d in HP I, II groups (89±9, 60±15, 21±5, 10±2; 99±14, 61±13, 26±5, 12±2 mg.l^-1) were decreased apparently as compared with the control group (312±23, 237±12, 116±15, 58±8 mg.l^-1) (P<0.01). After HP 24 h (0.9±0.4, 11.9±6.4, 1.0±0.3; 1.1±0.3, 4.3±3.7, 1.9±0.6 μkat.l^-1) and 72 h (0.9±0.4, 8.2±4.5, 0.8±0.3; 1.1±0.1, 2.6±2.3, 2.7±2.3 μkat.l^-1), myocardiac enzymes (LDH, CPK-MB, α-HBDH) had no change (P>0.05). But in control group, after HP 24 h (1.6±0.2, 23.9±12.9, 2.7±0.3 μkat.l^-1), they began to increase (P<0.05) and increased markedly after 72 h (3.1±0.1, 33.7±10.4, 8.5±0.3 μkat.l^-1) (P<0.01) as compared with before HP (0.8±0.1, 11.1±10.7, 1.4±0.1 μkat.l^-1). Before and after HP, the peripheral WBC, RBC, Hb and Pt at 3, 7 and 14 d had no significant change (P >0.05). But in the control group WBC, Pt, RBC and Hb were lower than before (16.3±4.2×10⁹/L, 131±38×10⁹/L, 5.9±1.6×10¹²/L, 131±28 g/L) at 7 d (8.5±5.4×10⁹/L, 77±35×10⁹/L, 4.8±1.2×10¹²/L, 94±27 g/L) (P<0.05) and much lower than before at 14 d (6.2±4.4×10⁹/L, 69±39×10⁹/L, 5.2±1.6×10¹²/L, 109±28 g/L P<0.01). Before and after HP, no obvious changes were found in liver function (ALT, AST and TBil) and kidney function (BUN and Cr) (P>0.05).

CONCLUSION

ADM hepatic artery infusion combined with HP, using NK-107 resin and Japanese activated charcoal as adsorbents, can decrease the concentration of circulating blood ADM and its side effects.

Hepatocellular carcinoma with lung metastasis in a 9-year-old-boy

Hepatocellular carcinoma (HCC) remains chemoresistant and, therefore, the principal treatment of HCC is surgical resection. After a 9-year-old boy with huge HCC with lung metastasis received the 5 cycles of chemotherapy (cisplatin and Adriamycin), the lung metastasis had been resolved completely and the size of HCC in liver had decreased. Right hepatic trisegmentectomy was performed, and then the additional 3 cycles of chemotherapy was given. Currently, the patient shows no recurrence of HCC 42 months after surgical extirpation.

Induction of E-selectin after partial hepatectomy promotes metastases to liver in mice

BACKGROUND

The liver is the most frequent site of tumor metastasis. It has been suggested that partial hepatectomy promotes liver metastasis of malignant disease and that expression of E-selectin, a cell adhesion molecule, plays roles in tumor metastasis. However, no reports are available concerning the expression of E-selectin after hepatectomy.

METHODS

In the present study, we used BALB/c mice subjected to 30% partial hepatectomy after injection of 1 x 10(4) colon 26 cells to determine the effects of partial hepatectomy on tumor metastasis to liver. E-Selectin expression within the liver after partial hepatectomy was evaluated using reverse transcription polymerase chain reaction and Western blotting. In addition, we injected polyclonal antibody to E-selectin into mice in which partial hepatectomy had augmented liver metastasis.

RESULTS

Mice subjected to partial hepatectomy had significantly increased numbers of liver metastases (sham operation, 1.5 +/- 2.0, vs partial hepatectomy, 35.5 +/- 19.3; P < 0.001). Expression of E-selectin mRNA within the liver was markedly increased 4 h after partial hepatectomy, but subsequently decreased at 24 h. E-Selectin protein was detected 8 h after hepatectomy, but subsequently decreased at 24 h as measured by Western blotting. Mice subjected to intraperitoneal injection of neutralizing antibody after operation had significantly decreased numbers of liver metastases (phosphate-buffered saline, 20.6 +/- 9.2, P < 0.05, and normal IgG, 18.0 +/- 8.0, P < 0.05, compared with polyclonal antibody to E-selectin, 5.6 +/- 4.8).

CONCLUSION

Induction of E-selectin by partial hepatectomy promotes hematogenous liver metastasis. Our findings can be applied to surgical treatment of liver tumor to reduce the recurrence of liver metastasis after hepatectomy by inhibiting E-selectin-mediated adhesion using reagents to E-selectin.

A new technique for resecting 'unresectable' liver tumors

BACKGROUND/PURPOSE

Liver tumors that surround the three major hepatic veins traditionally have been considered unresectable. This report describes an extended atypical left hepatectomy technique for tumors around the major hepatic veins.

METHODS

Three children with tumors surrounding the 3 hepatic veins underwent intraoperative evaluation for extended atypical left hepatectomy. The left hepatic artery, left branch of the portal vein, and the 3 hepatic veins are occluded with vascular clamps. Perfusion of the remaining liver is through the right hepatic artery and portal vein into the retrohepatic vena cava via the retro hepatic veins. If the liver remains soft and does not become mottled, division of the 3 hepatic veins and resection of the tumor are carried out.

RESULTS

Extended atypical left hepatectomy was successful in 2 children. Bile leak occurred in 1 instance and healed spontaneously. Both patients had transiently elevated serum bilirubin and transaminase levels and an elevated prothrombin time for 2 weeks. Both survived after treatment with chemotherapy. In the third child the liver became tense and mottled, and the procedure was abandoned.

CONCLUSIONS

Successful extended atypical left hepatectomy depends on the ability of the retro hepatic veins to adequately drain blood into the vena cava after interruption (clamping) of the main hepatic veins. If the liver becomes mottled and tense the procedure must be abandoned and the patient should be considered for hepatic transplantation.