Successful radical surgical resection of initially unresectable intrahepatic cholangiocarcinoma by downsizing chemotherapy with gemcitabine plus cisplatin: a case report

Background

Intrahepatic cholangiocarcinoma (ICC) is a subtype of biliary tract cancer (BTC). Recently, downsizing chemotherapy has been applied to initially unresectable BTCs, including ICC.

Case presentation

We report a case of liver resection in a 23-year-old woman who was diagnosed with initially unresectable ICC attached to the inferior vena cava, with portal vein (PV) cavernous transformation. Positron emission tomography (PET) showed fluorodeoxyglucose (FDG) uptake in the para-aortic lymph nodes. Upon using downsizing chemotherapy (the combination of gemcitabine [GEM] and cisplatin [CDDP]), the size of tumor reduced by 55% and FDG uptake in the para-aortic lymph node metastases disappeared. A right hemihepatectomy was performed, along with dissection of lymph nodes, including the para-aortic lymph nodes. The PV cavernous transformation was preserved to maintain collateral flow as much as possible, as it was considered to originate from a congenital anomaly. Pathological examination revealed that R0 resection was performed and that there were no viable neoplastic cells remaining in the para-aortic lymph nodes. The patient is alive at 31 months after initial treatment, with a local recurrence.

Conclusion

Downsizing chemotherapy with GEM plus CDDP followed by radical surgical resection is an attractive treatment for initially unresectable BTC.

[Severe Therapy-Related Pancytopenia Caused by UFT and LV in a Patient with Ascending Colon Cancer]

We report a case of a 79-year-old man who developed severe therapy-related pancytopenia from tegafur uracil(UFT)and Leucovorin(LV)as adjuvant chemotherapy for ascending colon cancer. Laparoscopic right hemicolectomy resection was performed for the ascending colon cancer. Pathohistological analysis revealed that the ascending colon tumor was moderately differentiated tubular adenocarcinoma(T3, N1, M0, and Stage III a). Postoperative adjuvant chemotherapy with UFT and LV was administered. After 2 courses of chemotherapies, severe thrombocytopenia(Grade 4)and neutropenia(Grade 4)were noted. Platelet and granulocyte-colony stimulating factor(G-CSF)were transfused. Furthermore, red blood cell transfusions were given for anemia(Grade 3). Dihydropyrimidine dehydrogenase(DPD)deficiency was suspected as the cause of the pancytopenia, and the ratio of dihydrouracil(DHU)and uracil(URA)was measured. However, the result was negative for DPD deficiency. Bone marrowaspiration revealed that therapy-related leukemia(TRL)and therapy-related myelodysplastic syndrome(T-MDS)were not the causes of the pancytopenia either. A total of 230 units of platelet transfusions and 20 units of red blood cell transfusions have been given for 32 weeks, and the patient currently requires routine blood transfusions. Fortunately, infection and bleeding never occurred. Subsequently, the patient should be monitored carefully.

Histology-Based Assessment of Sonazoid-Enhanced Ultrasonography for the Diagnosis of Liver Metastasis

This retrospective study aimed to assess the diagnostic performance of contrast-enhanced ultrasound with Sonazoid (S-CEUS) for liver metastasis. We enrolled in this study 98 patients with 148 histologically proven liver lesions, with 121 metastases and 27 non-metastases. The S-CEUS technique showed sensitivity in 95.0% (115 of 121), specificity in 44.4% (12 of 27) and accuracy in 85.8% (127 of 148) for the diagnosis of metastasis. Higher body mass index had a negative influence on the positive predictive value and accuracy, and a greater depth of the lesion had a negative influence on the accuracy. The management was changed in 8 patients (8.2%) because of S-CEUS findings. In conclusion, the addition of S-CEUS may offer a great benefit by improvement of the quality of diagnosis and management for patients with cancer who have a tentative diagnosis of liver metastasis by contrast-enhanced computed tomography.

Grainyhead-like 2 (GRHL2) regulates epithelial plasticity in pancreatic cancer progression

The epithelial‐mesenchymal transition (EMT) and mesenchymal‐epithelial transition (MET) contribute to cancer metastasis of pancreatic ductal adenocarcinoma (PDAC). We explored the role of grainyhead‐like 2 (GRHL2), a suppressor of EMT, in the progression of PDAC. Expressions of GRHL2 were assessed using surgically resected PDAC tissues by immunohistochemistry analysis, and in vitro using human and mouse PDAC cells. Effects on epithelial plasticity and stemness of GRHL2 were examined in vitro using liver metastatic PDAC cells (CFPAC‐1) with GRHL2 knockdown by specific siRNAs. GRHL2 has a significantly positive correlation with E‐cadherin and CD133 in 155 resected human primary PDAC tissues. GRHL2 is highly expressed in liver metastatic cells than in primary invasive cells of both human and mouse PDAC, accompanied by a positive correlation with E‐cadherin expression. GRHL2 knockdown CFPAC‐1 cells demonstrated morphological changes into mesenchymal appearances and reduced proliferation through EMT. Notably, knockdown studies followed by flow cytometry analysis for a subpopulation of CD133+ showed that GRHL2 facilitates CFPAC‐1 cells to maintain stem‐like characters including self‐renewal capacity and anoikis resistance. GRHL2 regulates epithelial plasticity along with stemness in PDAC, both of which are crucial for metastasis, implicating the possibility of GRHL2 as a therapeutic target for PDAC liver metastasis.

Clinical implication of surgical resection for recurrent biliary tract cancer: Does it work or not?

Although recent advances in imaging diagnosis, surgical techniques, and perioperative management can result in increased resectability and improved surgical outcomes, most resected patients still develop cancer recurrence. If patients develop cancer recurrence, their prognosis is very ominous. However, there have been some recent reports to show promising outcomes by aggressive surgical strategy in selected patients who developed cancer recurrence. Because there are various surgical procedures being selected at initial surgery in patients with biliary tract cancers, recurrent patterns after resection are very variable in each patient. However, surgical procedures might usually be very complicated and difficult if re‐surgical resection is considered in patients with recurrent biliary tract cancer, Therefore, surgical re‐resection could bring about high surgical morbidity and mortality rates in most previously reported series. Although re‐surgical resection might offer a chance of favorable outcome in selected patients with biliary tract cancers, these aggressive surgical approaches should be carried out in strictly selected patients by expert surgeons at high‐volume centers.

Developing better practices at the institutional level leads to better outcomes after pancreaticoduodenectomy in 3,378 patients: domestic audit of the Japanese Society of Pancreatic Surgery

BACKGROUND

The aim of the present study was to assess recent trends in pancreaticoduodenectomy (PD) and the role of institutional standardization on the development of postoperative complications in 3,378 patients who underwent PD in Japan.

METHODS

Data were collected from 3,378 patients who underwent PD in 2006, 2010 and 2014 at 53 institutions. A standardized institution (SI) was defined as one that implements ≥7 of 13 quality initiatives according to departmental policy. There were 1,223 patients in the SI group and 2,155 in the non-SI group. Clinical parameters were compared over time, and between groups. Risk factors for morbidity and mortality were assessed by logistic regression analysis with a mixed-effects model.

RESULTS

The number of patients who underwent PD in SIs increased from 16.5% in 2006 to 46.4% in 2014. The SI group experienced an improved process of care and a lower frequency of severe complications vs. the non-SI group (P < 0.001). Multivariate analysis revealed that the SI group was associated with a lower incidence of delayed gastric emptying (odds ratio -0.499, P = 0.008) and incisional surgical site infection (odds ratio -0.999, P < 0.001).

CONCLUSION

Standardization of care in PD may be important in reducing post-PD complications, and is a critical element for improving clinical outcomes.

Development of a sandwich ELISA for the thrombin light chain identified by serum proteome analysis

We previously identified novel biomarker candidates in biliary tract cancer (BTC) using serum proteome analysis. Among several candidates, we focused on thrombin light chain which is a 4204 Da peptide as the most promising biomarker for BTC. To move thrombin light chain toward potential diagnostic use, we developed an enzyme immunoassay that enables to measure serum thrombin light chain levels.

Both one monoclonal antibody specific to the N-termini and one polyclonal antibody were used to develop a sandwich ELISA for thrombin light chain. The assay was evaluated by comparing the results with those obtained by the ClinProt™ system. Serum samples were obtained from 20 patients with BTC, 20 patients with BBTDs and 20 HVs using the ClinProt™ system and ELISA.

The results of the established ELISA showed a positive correlation with the findings by ClinProt™ system (slope=0.3386, intercept=34.901, r²=0.9641). The performance of the ELISA was satisfactory in terms of recovery (97.9–102.5%) and within-run (1.5–4.8%) and between-day (1.9–6.7%) reproducibility. Serum thrombin light chain levels were significantly greater in BTC (176.5±47.2 ng/mL) than in BBTDs (128.6±17.4 ng/mL) and HVs (127.6±16.0 ng/mL) (p<0.001).

The sandwich ELISA developed in this study will be useful for validation of the diagnostic significance of serum thrombin light chain levels in various cancers.

•

We previously identified novel biomarker candidates in biliary tract cancer (BTC) using serum proteome analysis. Among several candidates, we focused on thrombin light chain which is a 4204 Da peptide as the most promising biomarker for BTC.

•

Both one monoclonal antibody specific to the N-termini and one polyclonal antibody were used to develop a sandwich ELISA for thrombin light chain.

•

The performance of the ELISA was satisfactory in terms of recovery (97.9–102.5%) and within-run (1.5–4.8%) and between-day (1.9–6.7%) reproducibility.

•

Serum thrombin light chain levels were significantly greater in BTC (176.5±47.2 ng/mL) than in BBTDs (128.6±17.4 ng/mL) and HVs (127.6±16.0 ng/mL) (p<0.001).

•

The sandwich ELISA developed in this study will be useful for validation of the diagnostic significance of serum thrombin light chain levels in various cancers.

Significance of preoperative fluorodeoxyglucose-positron emission tomography in prediction of tumor recurrence after liver transplantation for hepatocellular carcinoma patients: a Japanese multicenter study

BACKGROUND

In the present study, we conducted a multicenter nationwide survey to investigate the effects of preoperative fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) on the prediction of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT).

METHODS

From 16 Japanese LT centers, data were collected on 182 recipients with HCC who underwent living donor liver transplantation (LDLT) between February 2005 and November 2013. PET-positive status was defined as increased uptake of FDG in the tumor compared to the surrounding non-tumor liver tissue. The median follow-up after LDLT was 54.5 months (range 1-125 months).

RESULTS

Postoperative HCC recurrence occurred in 23 patients. Multivariate analysis revealed that exceeding the Milan criteria (MC), alpha-fetoprotein (AFP) level ≥115 ng/ml, and PET-positive status were significant and independent risk factors for recurrence. In the over-MC group, a subgroup of patients with AFP level <115 ng/ml and PET-negative status (n = 22) had a significantly lower 5-year recurrence rate than the other patients (n = 27, 19% vs. 53%, P = 0.019).

CONCLUSIONS

These results suggest that preoperative FDG-PET status offers additional information on HCC recurrence risk after LT. Over-MC patients with PET-negative status and lower AFP level may achieve successful outcome comparable to that of within-MC patients.

Metadherin promotes metastasis by supporting putative cancer stem cell properties and epithelial plasticity in pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) has a high metastatic potential. However, the mechanism of metastatic colonization in PDAC remains poorly understood. Metadherin (MTDH) has emerged in recent years as a crucial mediator of metastasis in several cancer types, although the biological role of MTDH in PDAC has not been investigated. Here, we demonstrated the functional roles of MTDH in PDAC progression, especially focusing on the metastatic cascade. In vitro studies showed that MTDH provides cancer stem cell (CSC) properties in metastatic PDAC cells and contributes to anoikis resistance with epithelial characteristics in PDAC cells. We also performed in vivo studies using both orthotopic transplantation and intra-portal vein injection as experimental models of liver metastasis to examine the function of MTDH at the metastatic site. MTDH knockdown dramatically reduced the incidence of liver metastases along with epithelial features in both experimental mouse models. Collectively, MTDH facilitates metastatic colonization with putative CSC and epithelial properties in PDAC cells. PDAC cells were transiently treated with TGF-β1 to investigate the roles of MTDH on epithelial plasticity. Intriguingly, MTDH expression was negatively correlated with Twist1 expression during the Mesenchymal-Epithelial transition (MET) induction in metastatic PDAC cells. These results suggest that MTDH may contribute to MET induction via downregulation of Twsit1. Lastly, immunohistochemistry indicated that MTDH overexpression is closely associated with hematogenous metastasis and predicts poor prognosis in patients with PDAC. This is the first demonstration of MTDH function in PDAC metastatic colonization. Our data suggest that MTDH targeting therapy could be applied to control PDAC metastasis.

Impact of sentinel lymph node biopsy by ultrasound-guided core needle biopsy for patients with suspicious node positive breast cancer

PURPOSE

The purpose of this study was to investigate the accuracy of preoperative diagnostic tools for axillary lymph nodes (LNs) staging of breast cancer.

MATERIALS AND METHODS

A total of 2464 consecutive patients with operable breast cancer were prospectively identified at our institution between April 2012 and March 2017. Patients with suspicious axillary LN of breast cancer were assessed using preoperative ultrasound(US) or computed tomography (CT), underwent fine-needle aspiration cytology (FNA) or core needle biopsy (CNB). The inclusion criteria for both FNA and CNB were a cortical thickness >3 mm or abnormal morphological characteristics. Patients with biopsy-proven metastasis underwent axillary lymph node dissection (ALND), and those with a negative FNA or CNB underwent sentinel lymph node biopsy (SNB). If the SNB was positive, ALND was performed. Diagnostic accuracy for SNB was calculated for both FNA and CNB. In addition, the patients in this study were divided into two groups as follows: the cN0-FNA group (suspicious LN but negative FNA) and cN0-CNB group (suspicious LN but negative CNB).

RESULTS

A number of patients with negative US/CT findings of LNs were 1406, with 744 undergoing FNA and 272 undergoing CNB for suspicious LNs. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 65, 99, 99, 80, and 85% in FNA, and 87, 100, 100, 93 and 95% in CNB, respectively. SNB was performed in 172 (cN0-CNB group) of 272 CNB and 487 (cN0-FNA group) of 744 FNA patients. One hundred and seventy-two patients from the cN0-CNB group (Tis 6, T1 97, T2 66, T3 3 patients) treated with SNB were compared to 487 from the cN0-FNA group (Tis 21, T1 225, T2 233, T3 8 patients) in terms of number of LN metastasis. A number of patients with more than 3 positive SNB and positive LNs were 9 (5%) and 0 (0%) in cN0-CNB group, and 78 (16%) and 24 (5%) in cN0-FNA group, respectively. A number of patients who had complications such as haematoma and pain at the time of 7 to 14 days after CNB and FNA were 1 (0.5%) and 1 (0.5%) in cN0-CNB group, and were 0% and 0.2% in cN0-FNA group (p = 0.44), respectively.

CONCLUSIONS

The preoperative diagnosis of axillary LNs was influenced by the diagnostic tool used. CNB is a reliable method for the preoperative diagnosis of LN metastasis.

The impact of quality and quantity of visceral fat on survival outcome of early-stage breast cancer patients with prior chemotherapy

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Background: Obesity not only increases morbidity, but also chemo-resistance of breast cancer (BC). Several studies focusing on body mass index (BMI) of BC patients have been performed; however, a recent report suggested that the quality of visceral adipose tissue (VAT) plays a crucial role in fat cell function. We set out to clarify the effect of quality and quantity of VAT on survival outcome of BC patients who underwent chemotherapy. Methods: From 2,230 patients who underwent treatment for BC at our institution from January 2004 to December 2015, we included 271 patients who received chemotherapy in neo-adjuvant (NAC) or adjuvant setting. Quantification was performed using computed tomography (CT) 3-dimensional volumetric software and quality of VAT was assessed based on the CT Hounsfield Unit of VAT (VAT-HU) using electrically stocked CT images. The correlation between BMI, amount of VAT (aVAT), and VAT-HU were analyzed using Pearson’s correlation test. The effect of these factors on pathologic complete response (pCR) was evaluated using Logistic regression model with the following covariates: menopausal status, size, nodal status, and subtype. Furthermore, survival analysis for distant disease-free survival (DDFS) was performed using Kaplan Meier method and Cox proportional hazard model. Results: aVAT and VAT-HU were significantly correlated with patient BMI (p<0.05). Forty-six patients achieved pCR (24%). Logistic regression model for pCR showed that aVAT and VAT-HU did not affect pCR (p=0.60 and 0.36). After a median follow-up of 112 months, tertile stratification revealed that the third tertile of aVAT had significantly shorter DDFS in the NAC setting (p<0.05). When adjusted by covariates in the Cox proportional regression model, aVAT and VAT-HU demonstrated significant contribution to worse DDFS ([p<0.05, hazard ratio {HR} 1.39; 95% confidence interval {CI} 1.11 to 1.75] and [p<0.05, HR 1.20, 95% CI 1.01 to 1.43], respectively). Conclusions: The quantity and quality of VAT was significantly related to the survival outcome especially in the NAC setting. This new insight would enable prediction of recurrence risk in obese BC patients with prior chemotherapy.

Intraductal neoplasms of the bile duct. A new challenge to biliary tract tumor pathology

Invasive biliary tract carcinomas are usually tubular adenocaricnomas with abundant desmoplastic reactions and frequent ductal and periductal invasion at the time of the diagnosis. Recently, several intraductal neoplasms of the bile duct, particularly at a pre-invasive stage, have been recognized. They include intraductal papillary neoplasm of the bile duct (IPNB), biliary intraepithelial neoplasm (BilIN), and others, such as intraductal tubulopapillary neoplasm (ITPN) of the bile duct. IPNBs are grossly visible predominantly intraductal-growing papillary neoplasms covered by well-differentiated neoplastic epithelium with fine fibrovascular cores in the dilated bile ducts. Regarding their similarities to intraductal papillary mucinous neoplasm of the pancreas (IPMN) of main pancreatic duct type, some IPNBs resemble IPMN ("pancreatic type"), while others are only somewhat similar or variably different from IPMN ("non-pancreatic type"). Some IPNBs develop via a common oncogenic signaling pathway, and others, particularly those of intestinal type, frequently show GNAS mutations, as in IPMN. BilINs are a microscopically recognizable flat or micropapillary pre-invasive neoplasm and are presumed to precede conventional nodular-sclerosing cholangiocarcinomas. ITPN of the bile duct is a rare neoplasm composed of densely packed tubular glands. These three types of neoplasms are not infrequently associated with invasive adenocarcinoma. Pre-invasive intraglandular neoplasms of the peribiliary glands, another epithelial system in the biliary tree, have been also reported. Further characterization of these intraductal and intraglandular neoplasms of the bile duct is needed to overcome devastating invasive biliary tract carcinoma.

Duffy antigen receptor for chemokines (DARC) expressing in cancer cells inhibits tumor progression by suppressing CXCR2 signaling in human pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis. Chemokines play important roles in the progression of many malignancies; however, the role of chemokine receptor expression in clinical cases of PDAC is unclear. Moreover, little is known about DARC, a decoy receptor of CXC chemokines, in the regulation of tumor progression.

METHODS

Functions of chemokine receptors were evaluated using surgical specimens collected from PDAC patients, and PDAC cell lines.

RESULTS

CXCR2 expression had no impacts on predicting prognosis, but low DARC expression in cancer cells was an independent risk factor for poor prognosis. In PDAC with low DARC expression, tumor sizes were larger and vascular invasion was increased. High CXCR2 expression was a significant predictor for poor prognosis, only in PDAC patients with low DARC expression. CXCR2 signaling induced STAT3 activation in PDAC, resulting in promoting cell cycle progression, inhibiting apoptosis, inducing angiogenesis, and enhancing invasiveness. DARC inhibited STAT3 activation by down-regulating CXCR2 signaling. These effects were confirmed by EMSA in vitro. DARC knockdown significantly increased cell proliferation in CFPAC-1 cells with high DARC expression, by activating STAT3. In contrast, CXCR2 knockdown inhibited the proliferative effects of IL-8 in MIA PaCa-2 cells with low DARC expression. Moreover, the inhibitory effect of CXCR2 antagonist on PDAC cell proliferation was more powerful in MIA PaCa-2 cells than CFPAC-1 cells.

CONCLUSIONS

DARC expressing in cancer cells inhibits PDAC progression by suppressing STAT3 activation through the inhibition of CXCR2 signaling. Therefore, DARC is a novel prognostic predictor and a potential therapeutic target for PDAC.

Portal vein stent placement for the treatment of postoperative portal vein stenosis: long-term success and factor associated with stent failure

Background

Portal vein stenosis develops due to different causes including postoperative inflammation and oncological processes. However, limited effective therapy is available for portal vein stenosis. The objectives of this study were to evaluate the efficacy of a portal vein stent for portal vein stenosis after hepatobiliary pancreatic surgery and to determine the factors associated with stent patency.

Methods

From December 2003 to December 2015, portal vein stents were implanted in 29 patients who had portal vein stenosis after hepatobiliary pancreatic surgery. We conducted a retrospective analysis to evaluate the efficacy and safety of portal vein stent placement. Twelve clinical variables were analyzed for their role in stent patency.

Results

The symptoms before portal vein stent placements included nine patients with hepatic encephalopathy, six patients with gastrointestinal bleeding, four patients with ascites, and four patients with hyperbilirubinemia. Portal vein thrombosis due to postoperative portal stenosis was found in four patients. Portal vein stent were successfully implanted without any major complications. Of the 21 patients with symptoms, 17 showed improvement, and stent patency was maintained in 22 (76%) patients. The presence of a collateral vein is the only variable related to the development of an occlusion after portal stenting.

Conclusion

Portal vein stent were implanted safely and had good long-term patency. This procedure is useful to relieve portal hypertension-related symptoms and to improve the quality of life. Our data strongly suggest that embolization to block blood flow in a collateral vein during portal vein stent placement will improve the patency of the stent.

Abstract A35: SOX9 induces chemo-resistance in pancreatic cancer cells and its high expression predicts poor prognosis

Introduction: Although surgical resection still remains the most important treatment for pancreatic cancer, there is a growing body of evidence showing the importance of chemotherapy. On the other hand, despite the advances in chemotherapy, the outcome of patients with pancreatic cancer remains far from satisfactory. These facts suggest that the understanding of the molecular mechanisms underlying the chemo-resistance of pancreatic cancer is urgently needed for developing more effective chemotherapies. To identify the factors that regulate chemo-resistance in pancreatic cancer, we focused on a transcription factor, Sex determining region Y box 9 (Sox9), that maintains progenitor cells during pancreatic organogenesis and carcinogenesis. The purpose of this study is to evaluate the roles of Sox9 in pancreatic cancer. Methods: Pancreatic cancer tissue were obtained from 106 consecutive patients who underwent curative surgical resection in the Department of General Surgery, Chiba University Hospital, Japan, from June 2006 to October 2011. We analyzed these primary invasive pancreatic ductal adenocarcinoma (PDAC) tissues by immunohistochemistry of Sox9. Human pancreatic cancer cell lines, PANC-1, Sox9 high expressing cell, and BxPC-3, Sox9 low expressing cell were used for in vitro analysis. Sox9 was inhibited by siRNAs. Cell cytotoxicity assay was done with Gemcitabine and 5-FU by PANC-1 and BxPC-3 cells. To elucidate the mechanism of chemo-resistance, we focused on the stemness of Sox9 expressing cells and performed sphere formation assays and flow cytometry analysis. Gene expression was determined by quantitative RT-PCR and Western blotting. The expression levels of CD44 and CD24, which are thought to be stem cell markers of pancreatic cancer, were examined by flow cytometry analysis. Tet-On Inducible Sox9 shRNA transfected PANC-1 cells were established and injected subcutaneously into the bilateral flanks of mouse. Xenograft tumors were assessed four weeks after injection. Results: Expression of Sox9 predicts poor survival in PDAC. Sox9 high expressing patients showed poorer prognosis than Sox9 low expressing patients. Median overall survival time and 3-year survival rate was 25.3 months and 21.1% for the Sox9 high group, and not reached and 62.9% for the low group, respectively (p=0.011). The multivariate overall survival time analysis showed Sox9 expression level as an independent prognostic factor (HR 0.344; 95%CI 0.183-0.647; p=0.0009), along with histological grade, distant metastasis, arterial invasion, residual tumor, and adjuvant chemotherapy. Sox9 high expressing PANC-1 cells showed chemo-resistance against GEM and 5-FU treatments. PANC-1 cells with suppressed Sox9 expression by siRNA showed decreased cell numbers when they were treated with GEM. These data implicated that Sox9 induced chemo-resistance in pancreatic cancer cells. PANC-1 cells, which have strong Sox9 expression, successfully formed spheres during culture on ultra-low attachment plates. The knockdown of Sox9 expression in PANC-1 cells significantly decreased sphere formation rates, compared with cells treated with negative siRNA. In PANC-1 cells, knockdown of Sox9 by siRNA significantly decreased the proportion of the CD44highCD24high cells compared with cells treated with negative control siRNA (p=0.0005). Sox9 knockdown can reduce tumor initiation capacity in vivo analysis. Conclusions: These data indicate that Sox9 plays an important role in chemo-resistance by the induction of stemness in pancreatic cancer cells.

Citation Format: Shingo Kagawa, Taku Higasihara, Hideyuki Yoshitomi, Shigetsugu Takano, Hiroaki Shimizu, Masayuki Ohtsuka, Atsushi Kato, Katsunori Furukawa, Masaru Miyazaki.{Authors}. SOX9 induces chemo-resistance in pancreatic cancer cells and its high expression predicts poor prognosis. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr A35.

Abstract B30: Prrx1 isoforms regulate pancreatic cancer stem cell functions during pancreatic cancer progression

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is one of the most lethal malignancies with a propensity for metastasis and drug resistance. To overcome this and improve the outcome of patients with PDAC, there is an urgent need to elucidate the molecular mechanisms of metastasis in which cancer stem cells (CSCs) may play a role. Prrx1, a homeobox transcription factor has been identified by us, as a key molecule involved in pancreatic development, regeneration and early carcinogenesis (Reichert et al. Genes and Development 2013). Furthermore, we have reported recently that Prrx1 isoform switching governs EMT-MET plasticity to regulate PDAC invasion and metastasis (Takano et al. Genes and Development 2016). Herein, we examined that the correlation between the two Prrx1 isoforms and putative CSC markers to investigate the role of Prrx1 on pancreatic CSC functions.

Materials and Methods: Mouse pancreatic ductal cell lines were isolated and established from Pdx1Cre mice (normal pancreatic ductal cells), Pdx1Cre;KrasG12D/+ mice (PanIN cells), Pdx1Cre;KrasG12D/+;p53R175H/+ mice (primary and metastatic PDAC cells). Either Prrx1a and Prrx1b was overexpressed by lentiviral transduction in each cell line with controls. Prrx1 knockdown was done in primary PDAC cells and their matched liver metastatic cells by two isoform specific siRNAs. We immunophenotyped putative pancreatic CSCs using antibodies against CSC markers (CD133, CD44, CD24 and Epcam) by flow cytometry. These subpopulations of cells were evaluated in 3D cultures, invasion assays and single-pancreatosphere formation assays. Additionally, we evaluated the expression of pancreatic CSC markers in Prrx1a and Prrx1b overexpressing and knockdown cells by qRT-PCR and flow cytometry.

Results: CD133High cells and CD44HighCD24High cells are expressed highly in metastatic PDAC cells compared to primary PDAC cells. CD133High cells form spheroid cysts and CD133Low cells form spindle-shaped cells in 3D culture. CD133High cells demonstrate more invasiveness and higher self-renewal capacity compared to CD133 Low cells. The percentage of CD133High cells, CD44HighCD24High cells and EpCAMHigh cells are increased significantly in Prrx1a overexpressing primary PDAC cells. However, these cells are decreased in Prrx1a knockdown metastatic cells. Contrary to this, these subpopulation of cells are significantly decreased in Prrx1b overexpressing primary PDAC cells, and increased in Prrx1b knockdown metastatic cells. These data suggest that Prrx1a might regulate pancreatic CSC functions in metastatic PDAC cells.

Conclusion: Prrx1a may be associated with a subpopulation of pancreatic cancer cells that have features of cancer stem cells. This may influence metastatic properties of pancreatic cancer cells to the liver.

Citation Format: Shigetsugu Takano, Maximilian Reichert, Hideyuki Yoshitomi, Basil Bakir, Koushik K. Das, Steffen Heeg, Shingo Kagawa, Hiroaki Shimizu, Masayuki Ohtsuka, Katsunori Furukawa, Masaru Miyazaki, Anil K. Rustgi.{Authors}. Prrx1 isoforms regulate pancreatic cancer stem cell functions during pancreatic cancer progression. [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer: Advances in Science and Clinical Care; 2016 May 12-15; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2016;76(24 Suppl):Abstract nr B30.

Detection of Vascular Disease Risk in Women by Panoramic Radiography

Low bone mineral density and rapid bone loss of the skeleton are associated with mortality risk from vascular diseases in post-menopausal women. Panoramic radiographic measurements are considered as indicators of skeletal bone mineral density or bone turnover. We hypothesize that such measurements may be associated with vascular disease risk in post-menopausal women. Associations of mandibular cortical shape and width on panoramic radiographs with skeletal bone mineral density and risk factors related to vascular diseases were investigated in 87 post-menopausal women. Cortical shape was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, apolipoprotein B, resting heart rate, and endothelial dysfunction. Cortical width was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, and apolipoprotein A1. Dentists may be able to refer women with increased risk of vascular diseases, as well as low bone mineral density, to medical professionals for further examination by panoramic findings.

[A Rare Complication of Transcatheter Arterial Injection for Multiple Liver Metastases of Rectal Neuroendocrine Tumor - A Case Report]

A 50-year-old man was diagnosed with multiple bilobar liver metastases of rectal neuroendocrine tumor(NET). Although he received octreotide for 6 months and everolimus for 10 months, the liver metastases gradually increased in size. Therefore, we decided to perform transcatheter arterial infusion(TAI)with miriplatin. The serum total bilirubin level increased to 13.1 mg/dL 9 days after treatment, and it took 2 months to return to the normal range. CT scan demonstrated that most of the liver tumors had remarkably shrunk 4 months after treatment, and the patient has no sign of tumor regrowth even 12 months after treatment. Retrospective analysis of our cases(98 procedures of[transcatheter arterial chemoembolization: TACE]or TAI for liver tumors performed at the Department of General Surgery, Chiba University from 2012 to 2015)revealed that serum biliary enzymes levels 7 days after TACE were significantly higher in patients with metastatic liver tumors than those in patients with hepatocellular carcinoma. These data suggest that the TACE procedure might lead to severe damage of the biliary system in patients with metastatic liver tumors. Although the morbidity rate of TAI is very low, the procedure should be performed with caution, especially for patients with liver metastases.

[A Case of Early-Onset Rapidly Progressive Cerebral Infarction with Trousseau's Syndrome in a Patient with Pancreatic Cancer Undergoing Surgery]

Trousseau's syndrome refers to cerebral infarction associated with hypercoagulability caused by cancer. Here, we report a case of Trousseau's syndrome in a patient with pancreatic cancer undergoing surgery. A 71-year-old woman was diagnosed with pancreatic head cancer with portal vein invasion; she underwent pancreaticoduodenectomy combined with portal vein resection. Pathological examination showed poorly differentiated adenocarcinoma with para-aortic lymph nodal metastasis. Although the patient had an uneventful postoperative course, she suddenly developed right hemiplegia and dysarthria 6 weeks after surgery, resulting in multiple cerebral infarctions scattered over both hemispheres. Owing to elevated D-dimer and CA125 levels as well as multiple liver metastases, the patient was diagnosed with Trousseau's syndrome and treated using heparin-based anticoagulant therapy. However, her cerebral infarction progressed rapidly and she died within 35 days of admission. Therefore, Trousseau's syndrome should be suspected when a patient with cancer is diagnosed with cerebral infarction, and anticoagulation therapy with heparin should be promptly initiated.

[Two Cases of Remnant Pancreatic Cancer Treated Using Remnant Pancreatectomy Combined with Hepatic Arterial Resection]

Case 1: A 40-year-old man was diagnosed with remnant pancreatic cancer invading the celiac axis 8 months after pancreaticoduodenectomy for pancreatic head cancer. As his gastroduodenal artery had been resected, the patient underwent preoperative coil embolization of the common hepatic artery for the development of extrahepatic collaterals. Eighteen days after the coil embolization, remnant pancreatectomy combined with celiac axis resection without reconstruction was performed. The patient was discharged without postoperative hepatic complications. Case 2: A 62-year-old woman was diagnosed with remnant pancreatic cancer 13 months after distal pancreatectomy with celiac axis resection for pancreatic body cancer. As the coil that had accidentally migrated to the proper hepatic artery during preoperative coil embolization for initial surgery remained, the flow to the liver through the gastroduodenal artery had weakened. In contrast, collateral flow from the right inferior phrenic artery to the right hepatic artery had increased. Remnant pancreatectomy with gastroduodenal artery resection was performed with no postoperative hepatic complications. Changes in the hemodynamics of the liver, resulting from preoperative coil embolization, may reduce the risk of postoperative hepatic ischemia after remnant pancreatectomy combined with hepatic arterial resection.

[A Radically-Resected Case of Ruptured IPMC of the Pancreas after Abscess Drainage Using an Endoscopic Naso-Pancreatic Drainage Tube]

A 79-year-old man was referred to our hospital because of sudden upper abdominal pain. Enhanced computed tomography revealed a huge multilocular cystic tumor with a thickened wall, which was connected with the main pancreatic duct of the pancreatic body. Abscess formation was seen inside the omental bursa; however, there were no signs of direct invasion of the cystic tumor into the stomach or transverse colon. Therefore, we performed emergency endoscopic naso-pancreatic drainage(ENPD)under the diagnosis of an intraperitoneal abscess caused by rupture of intraductal papillary mucinous carcinoma(IPMC). Four weeks later, distal pancreatectomy with omentectomy was performed to achieve curative resection of the ruptured IPMC. The postoperative course was uneventful and the patient was discharged on postoperative day 14. The pathological diagnosis was noninvasive IPMC. No signs of recurrence were seen until 12 months after surgery. Rupture of IPMC into the intraperitoneal space is rare; however, the prognosis is relatively poor because of the difficulty of curative resection. ENPD drainage before surgery is potentially useful for patients with ruptured IPMC to control local inflammation, which improves surgical curability.

Activation of peroxisome proliferator-activated receptor-gamma inhibits tumor growth by negatively regulating nuclear factor-κB activation in patients with hepatocellular carcinoma

BACKGROUND

The prognosis of advanced hepatocellular carcinoma (HCC) is poor because of its rapid progression. Peroxisome proliferator-activated receptor-gamma (PPARγ) is known to inhibit tumor growth in vitro; however, the behavior of PPARγ in clinical cases of HCC remains uncertain.

METHODS

Surgical specimens were collected from 104 HCC patients. The anti-neoplastic effects of PPARγ were evaluated.

RESULTS

PPARγ and its ligand expression were increased in some cases of HCC. When HCC patients were divided into two groups, tumor size was larger in patients with low PPARγ expression. Moreover, low PPARγ expression in HCC was an independent predictor of poorer prognosis. PPARγ expression was positively correlated with PPARγ activation and negatively correlated with NF-κB activation in HCC. PPARγ activation inhibited cell proliferation by inducing cell cycle arrest, through increased expression of p27(kip1) and decreased expression of cyclin D1 and interleukin-8. When HCC cells were treated with PPARγ ligands, PPARγ activation was increased and cell proliferation was inhibited in a dose-dependent manner. In contrast, PPARγ ligands negatively regulated NF-κB activation.

CONCLUSIONS

Activation of PPARγ induces cell cycle arrest and inhibits tumor progression by negatively regulating NF-κB activation in HCC. Therefore, PPARγ is an important endogenous regulator of HCC progression, and is a potential therapeutic target for HCC.

Successful Management of Graft Reinfection of HCV Genotype 2 in Living Donor Liver Transplantation from a Hepatitis B Core Antibody-Positive Donor with Sofosbuvir and Ribavirin

Direct-acting antivirals (DAAs) are relatively safe and highly effective for the eradication of hepatitis C virus (HCV) in liver transplant recipients. In this case study, we present a female with a graft reinfected with HCV genotype 2 who was treated with a combination of sofosbuvir and ribavirin after living donor liver transplantation (LDLT). Because the graft was from a hepatitis B core antibody-positive donor, passive immunization with hyperimmune hepatitis B immunoglobulin (HBIG) and entecavir were also provided to prevent hepatitis B virus (HBV) reactivation. It became clear that the combination of sofosbuvir and ribavirin promptly led to a sustained virologic response and that this combination was safe to treat graft reinfection with HCV genotype 2 after LDLT. Adverse events caused by DAAs were not observed, except for slight anemia. HBIG and entecavir were useful in the prevention of HBV reactivation. In conclusion, the present case indicated that DAA treatment for graft reinfection with HCV is safe and effective in LDLT from hepatitis B core antibody-positive donors.

Kartagener's syndrome presenting in old age

It is considered that Kartagener's syndrome is caused by ciliary dysfunction. This syndrome is characterized by the clinical triad of bronchiectasis, sinusitis, and dextrocardia. We describe an elderly patient with Kartagener's syndrome who reached advanced age. We suppose that it may be possible for patients with Kartagener's syndrome to live a full span with optimal therapy for respiratory tract infection and control progression of this disease. Chronic Respiratory Disease 2007; 4: 75—76

Successful Management of Acute Liver Failure Patients Waiting for Liver Transplantation by On-Line Hemodiafiltration with an Arteriovenous Fistula

On-line hemodiafiltration (OLHDF) is one of the treatment options in the management of acute liver failure (ALF) in Japan. It is essential to avoid infection in the management of ALF. In fact, infection is one of the prognostic factors in ALF. In this report, we present a middle-aged Japanese man with ALF associated with benzbromarone use. He was successfully managed without infection until liver transplantation by creating an arteriovenous fistula for OLHDF. Utilizing an arteriovenous fistula for OLHDF, rather than inserting a vascular access catheter, is a beneficial option to avoid infectious diseases in the management of ALF.

Immunonutrition suppresses acute inflammatory responses through modulation of resolvin E1 in patients undergoing major hepatobiliary resection

BACKGROUND

Although several studies have reported the effects of immunonutrition on clinical outcomes, detailed mechanisms of immunonutrition after an operation are still unclear. It was recently reported that resolvin E1, a novel lipid mediator generated from eicosapentaenoic acid (EPA), activates factors that reduce inflammation. This randomized clinical trial was designed to investigate not only the effect of immunonutrition on postoperative complications but also the participation of resolvin E1 on anti-inflammatory effects of immunonutrition in patients undergoing major hepatobiliary resection.

METHODS

Forty patients who underwent major hepatobiliary resection were divided into 2 groups. Twenty patients received oral supplementation enriched with EPA, arginine, and nucleotides before the operation (group IN). Twenty patients (control group) received no artificial nutrition before the operation (group C).

RESULTS

The rate of infectious complications and severity of complications in group IN was significantly lower than in group C (P < .05). Immediately after the operation, plasma resolvin E1 levels were significantly higher in group IN than in group C (P < .05), and plasma interleukin-6 levels were significantly lower in group IN than in group C (P < .05). Preoperative serum EPA levels correlated with plasma resolvin E1 levels immediately after the operation. Plasma resolvin E1 levels correlated with plasma interleukin-6 levels immediately after the operation.

CONCLUSION

Preoperative immunonutrition reduced inflammatory responses and protected against the aggravation of postoperative complications in patients undergoing major hepatobiliary resection. Resolvin E1 may play a key role in the resolution of acute inflammation when immunonutrition is supplemented with EPA. (ClinicalTrials.gov Identifier: NCT01256047.).

Peripheral portal vein-oriented non-dilated bile duct puncture for percutaneous transhepatic biliary drainage

AIM: To evaluate the efficacy of peripheral portal vein (PV)-oriented non-dilated bile duct (BD) puncture for percutaneous transhepatic biliary drainage (PTBD).

METHODS: Thirty-five patients with non-dilated BDs underwent PTBD for the management of various biliary disorders, including benign bilioenteric anastomotic stricture (n = 24), BD stricture (n = 5) associated with iatrogenic BD injury, and postoperative biliary leakage (n = 6). Under ultrasonographic guidance, percutaneous transhepatic puncture using a 21-G needle was performed along the running course of the peripheral targeted non-dilated BD (preferably B6 for right-sided approach, and B3 for left-sided approach) or along the accompanying PV when the BD was not well visualized. This technique could provide an appropriate insertion angle of less than 30° between the puncture needle and BD running course. The puncture needle was then advanced slightly beyond the accompanying PV. The needle tip was moved slightly backward while injecting a small amount of contrast agent to obtain the BD image, followed by insertion of a 0.018-inch guide wire (GW). A drainage catheter was then placed using a two-step GW method.

RESULTS: PTBD was successful in 33 (94.3%) of the 35 patients with non-dilated intrahepatic BDs. A right-sided approach was performed in 25 cases, while a left-sided approach was performed in 10 cases. In 31 patients, the first PTBD attempt proved successful. Four cases required a second attempt a few days later to place a drainage catheter. PTBD was successful in two cases, but the second attempt also failed in the other two cases, probably due to poor breath-holding ability. Although most patients (n = 26) had been experiencing cholangitis with fever (including septic condition in 8 cases) before PTBD, only 5 (14.3%) patients encountered PTBD procedure-related complications, such as transient hemobilia and cholangitis. No major complications such as bilioarterial fistula or portal thrombosis were observed. There was no mortality in our series.

CONCLUSION: Peripheral PV-oriented BD puncture for PTBD in patients with non-dilated BDs is a safe and effective procedure for BD stricture and postoperative bile leakage.

[Two Cases of Curative Resection of Locally Advanced Rectal Cancer after Preoperative Chemotherapy]

Reports of conversion in cases of locally advanced colorectal cancer have been increasing. Here, we present 2 cases in which curative resection of locally advanced rectal cancer accompanied by intestinal obstruction was achieved after establishing a stoma and administering chemotherapy. The first case was of a 46-year-old male patient diagnosed with upper rectal cancer and intestinal obstruction. Because of a high level of retroperitoneal invasion, after establishing a sigmoid colostomy, 13 courses of mFOLFOX6 plus Pmab were administered. Around 6 months after the initial surgery, low anterior resection for rectal cancer and surgery to close the stoma were performed. Fourteen days after curative resection, the patient was discharged from the hospital. The second case was of a 66-year-old male patient with a circumferential tumor extending from Rs to R, accompanied by right ureter infiltration and sub-intestinal obstruction. After establishing a sigmoid colostomy, 11 courses of mFOLFOX6 plus Pmab were administered. Five months after the initial surgery, anterior resection of the rectum and surgery to close the stoma were performed. Twenty days after curative resection, the patient was released from the hospital. No recurrences have been detected in either case.

[Surgical Resection of Metachronous Hepatic Metastasis from Pancreatic Acinar Cell Carcinoma after Total Pancreatectomy]

Pancreatic acinar cell carcinoma is rare. There is no consensus on a treatment strategy for metastatic lesions to the liver. We report of a 68-year-old man who received total pancreatectomy for pancreatic acinar cell carcinoma. One year after surgery, abdominal enhanced CT showed a small liver tumor in segment 8. We diagnosed this tumor as hepatic metastasis of pancreatic acinar cell carcinoma, and we resected it via partial liver resection. Pathological studies indicated a metastasis from pancreatic acinar cell carcinoma. The patient has been alive without recurrence for 7 months after the hepatectomy. There is no consensus on surgery for hepatic metastasis of acinar cell carcinoma, but if surgical resection is possible and safe, we consider it an appropriate treatment option.

[A Case of Pancreatic Head Cancer Treated with Pancreaticoduodenectomy Combined with Hepatic Artery Resection Following Neoadjuvant Chemotherapy]

A 70-year-old woman was diagnosed with pancreatic head cancer with hepatic artery invasion by multi-detector computed tomography (MD-CT). After 3 courses of gemcitabine plus S-1 neoadjuvant therapy, the tumor size was not diminished; however, the tumor marker CA19-9 level was decreased to less than 90% of its initial level. Pancreaticoduodenectomy combined with hepatic artery resection was performed, and an end-to-end anastomosis was made between the common and proper hepatic artery to reconstruct the hepatic artery. The pathological examination indicated adenosquamous carcinoma, no vascular invasion, and negative margin status, and the efficacy of chemotherapy was classified as GradeⅡb using Evans' classification. Usually, pancreatic head cancer with hepatic artery invasion is considered unresectable due to its high morbidity/mortality and poor prognosis. However, with the recently developed surgical strategy and appropriate therapeutic interventions, such as a combination of neoadjuvant chemotherapy and resection/reconstruction of the hepatic artery, a curative operation can be feasible for locally advanced pancreatic head cancer.

[Peritoneovenous Shunting as a Palliative Therapy for Refractory Ascites after Biliary Cancer Surgery]

The quality of life of patients with recurrence of biliary cancer is remarkably diminished by the occurrence of refractory ascites caused by peritoneal dissemination or portal vein obstruction. In this study, we examined the effectiveness of peritoneovenous shunting (PVS) in patients with refractory ascites after recurrence of biliary cancer. PVS was performed 7 times in 5 patients, with 6 shunts (85.7%) placed from the left-side abdomen to the left subclavian vein. During the median observation period of 136 days, the ascites and symptoms of abdominal distension disappeared in 4 patients. Severe complications consisting of shunt obstruction in 2 patients and post-shunt coagulopathy in 1 patient were also observed. PVS is a useful palliative therapy for refractory ascites in patients with recurrence of biliary cancer. In patients after cancer resection, an appropriate choice of a safe placement route is critical for avoiding abdominal organ injury. The feasibility of PVS in patients with refractory ascites should be considered carefully and in context of their prognosis and performance status because severe complications may occur after this procedure.

[Two Cases of Pancreatic Neuroendocrine Tumor with Liver Metastases Successfully Treated with Multidisciplinary Therapy including Multiple Surgical Resections]

We report 2 cases of pancreatic neuroendocrine tumor with liver metastases successfully treated with multidisciplinary therapy, including multiple surgical resections. Case 1: A 63-year-old man underwent distal pancreatectomy and portal vein resection for a pancreatic body tumor. Histological analysis revealed the tumor was a pancreatic neuroendocrine tumor (p-NET), classified as NET G2. His metachronous liver metastases were treated with lateral sectionectomy and 2 rounds of transcatheter arterial chemoembolization (TACE). He is being treated with everolimus for para-aortic lymph node metastases and is alive 90 months after the primary operation. Case 2: A 64-year-old man underwent distal gastrectomy for a duodenal ulcer and distal pancreatectomy for a pancreatic tumor. The histological diagnosis was gastrinoma classified as NET G2. Hepatectomy (segmentectomy of segment 8 and partial hepatectomy) was performed twice for metachronous liver metastases. Everolimus has been administered for liver and para-aortic lymph node metastases, and the patient is alive 108 months after the primary operation.

CONCLUSION

Multidisciplinary treatment should be considered for patients with p-NETs with multiple metastases.

[Surgical Resection for Mediastinal Lymph Node Metastasis of Combined Hepatocellular and Cholangiocarcinoma--A Case Report]

We report the case of a 77-year-old woman with mediastinal lymph node metastasis of combined hepatocellular and cholangiocarcinoma who was successfully treated with S8 segmentectomy and lymphadenectomy. A hepatic nodule was detected in segment 8 during follow-up computed tomography (CT) after left iliac arterial aneurysm repair. The patient was diagnosed with a hepatocellular carcinoma (HCC), and transcatheter arterial chemoembolization (TACE) was selected for HCC because of the patient's condition. The levels of tumor markers did not change after TACE was performed twice. Therefore, TACE treatment was considered to be ineffective for HCC, and the patient was admitted to our hospital for surgical resection. In addition to the primary lesion, a lymph node with a diameter of 20 mm was detected in the anterior mediastinum using CT and magnetic resonance imaging(MRI). We did not find any other metastases, and therefore, S8 segmentectomy and lymphadenectomy in the anterior mediastinum were performed. Recovery was uneventful, and the patient was discharged from the hospital on postoperative day 12. Based on histopathologic findings, combined hepatocellular and cholangiocarcinoma with mediastinal lymph node metastasis was confirmed. Levels of tumor markers normalized, and the patient survived without recurrence for 6 months.

[A Case of R0 Resection of Locally Advanced Pancreatic Cancer Following Chemoradiation Therapy]

Patients with borderline resectable pancreatic cancer have a poorer prognosis than patients with resectable pancreatic cancer, but some cases treated with neoadjuvant chemoradiation therapy and radical surgery (R0 surgery) show long-term survival. A 72-year-old woman presented with a history of back pain and weight loss. Computed tomography revealed a cancer of the pancreatic body encasing the celiac trunk, common hepatic artery, and portal vein. After neoadjuvant chemotherapy ( S-1) and carbon-ion radiotherapy, the tumor was considered to be resectable. Distal pancreatectomy with en bloc celiac trunk resection (DP-CAR), portal vein resection, and reconstruction was performed. The histopathologic findings showed that the effect of NACRT was gradeⅡa (Evens' classification), and the surgical margins were histologically clear. S-1 was administered again for half a year as postoperative chemotherapy. With post-operative follow-up of 1 year and 1 month after surgery, the patient shows no signs of recurrent disease.

Downsizing Chemotherapy for Initially Unresectable Locally Advanced Biliary Tract Cancer Patients Treated with Gemcitabine Plus Cisplatin Combination Therapy Followed by Radical Surgery

BACKGOUND

We have treated patients with initially unresectable locally advanced biliary tract cancer (BTC) by administering gemcitabine and have found that surgical resection became feasible in some downsized patients. The aim of this study was to investigate the usefulness of downsizing combination chemotherapy using gemcitabine plus cisplatin to treat initially unresectable locally advanced BTC.

METHODS

The subjects of the study were 150 consecutive patients who were treated for BTC between October 2011 and April 2014. Downsizing chemotherapy was carried out for 39 patients (26.0 %) whose lesions were unresectable because of locally advanced BTC.

RESULTS

Reduction in tumor size with downsizing chemotherapy was seen in 18 patients, and surgical resection was performed in 10 of 39 patients (25.6 %). Median survival time in patients with surgical resection following downsizing chemotherapy and those with chemotherapy alone was 17.9 and 12.4 months, respectively (p = 0.0378). According to the historical comparison between gemcitabine and gemcitabine plus cisplatin chemotherapy, there is no significant difference in overall survival. However, there was a significant difference for the pathologic response rate (≥Grade III) to be higher in patients with gemcitabine plus cisplatin chemotherapy compared with gemcitabine monotherapy.

CONCLUSIONS

Preoperative downsizing chemotherapy with gemcitabine plus cisplatin provides longer survival by the conversion to the surgical resection in patients with initially unresectable locally advanced BTC. It may have the potential for disease eradication as a new multidisciplinary approach for initially unresectable locally advanced BTC.

Incidence, risk factors, and management options for portal vein thrombosis after hepatectomy: a 14-year, single-center experience

BACKGROUND

Portal vein thrombosis (PVT) after hepatectomy is rare; however, it increases mortality and morbidity. Few studies have been conducted that focused on PVT following major hepatectomy.

METHODS

Patients who underwent hepatectomy at a single institution were retrospectively reviewed, and risk factors and management options were evaluated.

RESULTS

Of the 1,193 patients undergoing hepatectomy, 25 patients developed PVT. Right-sided hepatectomy, caudate lobectomy, splenectomy, and postoperative bile leakage were independent risk factors for PVT following hepatectomy. PVT occurred more frequently after major hepatectomy compared with minor hepatectomy. Increased instability and reduced portal venous flow caused by kinking was the reason for increasing the risk of PVT after right-sided hepatectomy with caudate lobectomy. The new operative procedure, suturing the posterior wall of the portal vein with the anterior wall of the inferior vena cava, was effective for reducing the risk of PVT following right-sided hepatectomy. Operative thrombectomy showed significant benefits for PVT detected within 5 days after hepatectomy.

CONCLUSIONS

PVT frequently occurs following major hepatectomy. Urgent operative thrombectomy is strongly recommended for PVT with early detection.

Pancreaticoduodenetomy combined with hepatic artery resection following preoperative hepatic arterial embolization

BACKGROUND

The possibility of resection for locally advanced pancreatic ductal adenocarcinoma (PDAC) with involvement of hepatic or superior mesenteric artery is low. The treatment strategy for these locally advanced PDAC needs to be elucidated.

METHODS

We retrospectively reviewed the medical records of 107 patients undergoing pancreaticoduodenectomy for PDAC between 2007 and 2012. Among these patients, seven patients who had unresectable PDAC because of cancer involvement of hepatic artery underwent preoperative hepatic arterial embolization and subsequent pancreaticoduodenectomy combined with resection of hepatic artery without reconstruction (PDCAR). We specifically focused on these seven patients to clarify the benefit and drawback of PDCAR.

RESULTS

Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels on 1 day after hepatic arterial embolization increased, but returned to baseline before pancreaticoduodenectomy. There was no arterial embolization-related complication before surgery. Serum ALT and AST levels increased 1 day after surgery, but thereafter returned to baseline. Although postoperative morbidity such as hepatic infarction was observed in one case, there were no in-hospital deaths. The median survival time was 12.6 months and 5-year survival rate was 19%.

CONCLUSION

Preoperative hepatic arterial embolization and subsequent PDCAR might be a feasible procedure in selected patients with unresectable locally advanced PDAC with hepatic artery involvement.

Sustained virologic response achieved after curative treatment of hepatitis C virus-related hepatocellular carcinoma as an independent prognostic factor

BACKGROUND AND AIM

Whether an antiviral interferon (IFN)-based therapy (IBT) after curative treatment of hepatocellular carcinoma (HCC) improves the prognosis in patients with hepatitis C virus (HCV)-related HCC remains to be elucidated.

METHODS

A total of 178 patients within the Milan criteria underwent curative treatment for HCV-related HCC. Both the time to beyond the Milan criteria (TTBMC) and overall survival (OS) were compared between the sustained virologic response (SVR) (IFN with SVR, n = 22), non-SVR (IFN without SVR, n = 19), and non-IBT (control, n = 82) groups using propensity score matching analysis. Prognostic factors to predict survival were also determined by the Cox proportional-hazards model.

RESULTS

TTBMC in the IFN with SVR group was significantly longer than those in the control and IFN without SVR groups (P < 0.001 and P = 0.006, respectively), although no significant difference existed between the IFN without SVR and control groups. Similarly, OS of the IFN with SVR group was significantly longer than that of the control and IFN without SVR groups (P < 0.001 and P = 0.029, respectively), although no significant difference existed between the IFN without SVR and control groups. The Cox proportional-hazards model identified SVR as an independent prognostic factor in these patients. The IFN with SVR group showed a 0.096-fold decrease in mortality risk compared with the control group (95% confidence intervals = 0.023-0.405; P = 0.001).

CONCLUSION

Elimination of HCV after curative treatment of patients with HCC within the Milan criteria inhibits recurrence and contributes to a preferential prognosis.

Clinical significance of anatomical variant of the left hepatic artery for perihilar cholangiocarcinoma applied to right-sided hepatectomy

BACKGROUND

Full understanding of the hilar anatomy is crucial for successful surgical resection of perihilar cholangiocarcinoma (PHC).

METHODS

The three-dimensional positional relationship between the left hepatic artery (LHA) and the umbilical portion of the left portal vein (UP) was evaluated using multidetector-row computed tomography (CT) in 58 consecutive patients who underwent right-sided hepatectomy for Bismuth-Corlette IIIa or IV tumors. The positional relationship of the LHA related to UP was classified into the following three types: L-UP type, LHA runs into the left lateral section (LLS) from the left caudal side of the UP; R-UP type, LHA runs into the LLS from the right cranial side of the UP; and combined type, one branch of the LHA runs into the LLS from the right cranial side of the UP, and the other from the left caudal side of the UP.

RESULTS

L-UP-type LHA was observed in 53 cases (91.4 %), R-UP type in three cases (5.2 %), and combined type in two cases (3.4 %). No cancer involvement of the LHA was seen in any cases with L-UP type. In one case with R-UP type (one of three; 33.3 %) and one case with combined type (one of two, 50 %), cancer invasion to the LHA was observed at the right side of the UP, requiring combined resection of the involved LHA.

CONCLUSIONS

R-UP-type LHA running just along the left hepatic duct may be easily involved by right-side predominant PHC when extending to the left hepatic duct. Hepatobiliary surgeons should recognize this anatomical variant and carefully evaluate the running courses of LHA to successfully perform R0 resection in right-sided hepatectomy for PHC.