Significant Shrinkage of Multifocal Liver Metastases and Long-Term Survival in a Patient With Rectal Cancer, After Trans-Arterial Chemoembolization (TACE): A Case Report

Synchronous Hepatocellular and Intrahepatic Cholangiocellular Carcinoma With Predominant Ductal Plate Malformation Pattern. A Case Report and Review of the Literature

BACKGROUND

Synchronous occurrence of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) is extremely rare.

CASE

A 67-year-old male was admitted to the hospital with hemoperitoneum caused by a liver mass rupture and elevated serum liver enzymes. Abdominal magnetic resonance imaging revealed a solid mass, with 38 mm in maximum diameter, located in the fifth/sixth segments of the liver, suggesting an HCC. Emergency surgery was performed and a second liver mass in the fourth segment was identified intraoperatively, with 20 mm in maximum diameter. Hepatic resection of the affected segments was performed with free resection margins. Histopathological examination revealed the synchronous occurrence of HCC and ICC with a predominant ductal plate malformation pattern. The patient is still alive at 41 months after its first surgery.

CONCLUSIONS

In patients with HCC, a proper intraoperative assessment is indicated, in addition to imaging investigations, to detect synchronous lesions that can change the therapeutic approach. This is the first case ever reported in the literature in which synchronous HCC and ICC with a predominant ductal plate malformation pattern were incidentally diagnosed in a patient with hemoperitoneum.

Combined hepatocellular-cholangiocarcinoma: from genesis to molecular pathways and therapeutic strategies

Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) are the most common primary liver cancers. Little is known about the combined hepatocellular-cholangiocarcinoma (cHCC-ICC) variant and the proper therapeutic strategies. Out of over 1200 available studies about cHCC-ICC, we selected the most representative ones that reflected updated information with application to individualized therapy. Based on literature data and own experience, we hypothesize that two molecular groups of cHCC-ICC can be identified. The proposed division might have a significant therapeutic role. Most cases develop, like HCC, on a background of cirrhosis and hepatitis and share characteristics with HCC; thus, they are named HCC-type cHCC-ICC and therapeutic strategies might be like those for HCC. This review also highlights a new carcinogenic perspective and identifies, based on literature data and the own experience, a second variant of cHCC-ICC called ICC-type cHCC-ICC. Contrary to HCC, these cases show a tendency for lymph node metastases and ICC components in the metastatic tissues. No guidelines have been established yet for such cases. Individualized therapy should be, however, oriented toward the immunoprofile of the primary tumor and metastatic cells, and different therapeutic strategies should be used in patients with HCC- versus ICC-type cHCC-ICC.

SALL4 upregulates brain-derived neurotrophic factor to mediate Hedgehog signaling to inhibit carboplatin sensitivity in colon adenocarcinoma

Aim: This study aimed to investigate the role of brain-derived neurotrophic factor (BDNF) in colon adenocarcinoma, specifically its impact on sensitivity to carboplatin.Methods: mRNA and clinical information of colon adenocarcinoma samples were obtained from TCGA database. Differential expression analysis, transcription factor prediction, gene set enrichment analysis were performed in silico. qRT-PCR, western blot, CCK-8 and CHIP assay were employed.Results: BDNF demonstrated high expression in colon adenocarcinoma. Silencing of BDNF enhanced carboplatin sensitivity, while exerting opposite effects on epithelial-mesenchymal transition (EMT). BDNF was enriched in Hedgehog (HH) signaling pathway. SALL4 was identified as an upstream regulator of BDNF. Upregulation of BDNF by SALL4 promoted EMT and inhibited carboplatin sensitivity.Conclusion: SALL4 promoted BDNF expression to facilitate the aggressive phenotypes of colon adenocarcinoma.

Risk factors associated with late hepatocellular carcinoma detection in patients undergoing regular surveillance

Hepatocellular carcinoma (HCC) has a very poor prognosis with a 5-year survival rate of < 20%; hence, early diagnosis is crucial. Despite regular checkups for high-risk groups of HCC, there are a few cases in which it is discovered as a late-stage HCC. Therefore, this study aimed to investigate the characteristics of patients with delayed HCC detection during regular surveillance. Between January 2010 and December 2020, we analyzed patients with newly diagnosed HCCs who underwent HCC surveillance by ultrasound or computed tomography scan at least twice and were followed up for more than 1 year for hepatitis B, hepatitis C, and chronic liver disease. The mean age of 223 HCC patients was 70 years, of which 152 were male, accounting for 68.1%. Among them, 196 patients (87%) were diagnosed with Barcelona clinic liver cancer stage 0 or A, while 27 (13%) were diagnosed with Barcelona clinic liver cancer stages B and C. When classified according to the TNM criteria, 154 patients (69%) were in stage I, and 69 (31%) were in stage II or higher. Multivariate analysis was performed to identify the risk factors for patients diagnosed with late-stage HCC. The Child-Turcotte-Pugh (CTP) score was identified as a highly significant factor (P = .002, HR 1.547, 95% CI 1.177-2.032), whereas the presence of cirrhosis, body mass index, and sex had no significant effect. We found that in patients with chronic liver disease who were screened regularly, those with higher CTP scores were more likely to be diagnosed with HCC in the late-stages. Therefore, although the presence of cirrhosis is also important for HCC surveillance, careful attention is needed in patients with high CTP scores.

In-House Validated Map of Lymph Node Stations in a Prospective Cohort of Colorectal Cancer: A Tool for a Better Preoperative Staging

Preoperative staging of colorectal cancer (CRC) based on imaging techniques such as computed tomography (CT) or magnetic resonance imaging (MRI) is crucial for identification and then removal of the positive lymph nodes (LNs). The aim of this study was to evaluate the correlation between preoperatively seen morphologic criteria (number, size, shape, structure, borders, or enhancement patterns) and histopathological features of LNs using an in-house validated map of nodal stations. A total of 112 patients with CRC that underwent surgery were preoperatively evaluated by CT scans. The locoregional, intermediate, and central LNs were CT-mapped and then removed during open laparotomy and examined under microscope. The analysis of correlations was interpreted using the suspicious-to-positive ratio (SPR) parameter. The greatest correlation was found in tumors located in the sigmoid colon, descending colon and middle rectum; SPR value was 1.12, 1.18, and 1.26, respectively. SPR proved to be 0.59 for cases of the transverse colon. Regarding the enhancement type, the dotted pattern was mostly correlated with metastatic LNs (OR: 7.84; p < 0.0001), while the homogenous pattern proved a reliable indicator of nonmetastatic LNs (OR: 1.99; p < 0.05). A total of 1809 LNs were harvested, with a median value of 15 ± 1.34 LNs/case. Transdisciplinary approach of CRC focused on pre-, intra-, and postoperatively mapping of LNs might increase the accuracy of detecting metastasized nodes for tumors of the distal colon and middle rectum but not for those of the transverse colon. In addition to morphologic criteria, the enhancement pattern of LNs can be used as a predictor of nodal involvement improving the CT-based preoperative staging.

The effect of transarterial chemoembolization therapy on survival in patients with non-resectable hepatocellular carcinoma: Single-center study results

Background and Aim

This study was designed to investigate the tumor response and effect of drug-eluting transarterial chemoembolization (DEB-TACE) treatment on survival in patients diagnosed with hepatocellular carcinoma (HCC).

Materials and Methods

The records of 40 patients who underwent DEB-TACE between March 2018 and November 2020 were retrospectively analyzed. Follow-up included abdominal computed tomography and measurement of serum albumin, bilirubin, prothrombin time, and alpha-fetoprotein values. The treatment response was evaluated using the European Association for the Study of the Liver criteria.

Results

A total of 70 TACE sessions were performed in the 40 study patients with HCC. The etiology was chronic hepatitis B virus (n=32), secondary biliary cirrhosis (n=2), cryptogenic (n=2), or chronic hepatitis C virus (n=4). Based on the TACE response, complete response was observed in 22 patients, a partial response in 8 patients, and progression in 10 patients. Liver transplantation was performed for 4 patients who had a complete response. The formation of new nodules was observed in 8 patients during the follow-up period. In all, 29 patients survived and 11 died.

Conclusion

The findings of this study suggest that DEB-TACE had a positive effect on the survival of patients diagnosed with HCC who could not be treated surgically.

The Motor Impact of the Static Balance in the Up Plank Position on Three Different Balls in Physical Activities of Physical Education Students

The present study aimed to assess the capacity of stability and motor impact in the development of the balance of student athletes by reducing the support surface on the ball in the up plank position, by using three categories of balls of equal size, but with different elasticity and weight. In this study, the second aim was to investigate the differences in maintaining static balance, on different balls, between those who are practicing individual sports or team sports. The total study sample include 48 students, active athletes (45.8% of individual sports and 54.2% of team sports), age X ± SD 18.74 ± 1.94 years. The research included two test sessions (initial and final) applied in two stages. The static balance tests were performed by measuring the time maintaining the up plank position with two and three points of support on the three balls, with different characteristics of elasticity and ranges of deformation: medical ball, handball ball and fitness ball. The results of the study showed that the superior initial and final results were recorded on the fitness ball, and the inferior results on the medicine ball. The upper difference was recorded at the up plank position with two support points (arms, legs) on the fitness ball, at 4980 s, and the lowest in the same test on the medical ball, at 3420 s. The largest difference was recorded at the up plank position with three support points on the handball ball, at 7.082 s, and the lowest in the same test on the medical ball, at 3.093 s. The subjects of the study perceived that the most difficult position to execute was the up plank position on the medical ball with two support points, with 43.8%, and the easiest stability was registered in the up plank position on the fitness ball with three points of support, of 37.5%. The relevance of the research results from the possibility of using different balls in conditions of positioning and body posture with a diminished support base in order to improve physical fitness.

Hepatitis B virus core-related antigen is useful for surveillance of hepatocellular carcinoma recurrence in a patient with occult hepatitis B virus infection: Case report

Serum HBV core-related antigen (HBcrAg) is useful for detecting HCC in patients with occult HBV infection. Surveillance for HCC is needed in patients who are positive for HBcrAg, even if they are negative for HBsAg and HBV DNA.

Epithelial Mesenchymal and Endothelial Mesenchymal Transitions in Hepatocellular Carcinoma: A Review

PURPOSE

To present a comprehensive review of the literature data, published between 2000 and 2019 on the PubMed and Web of Science databases, in the field of the tumor microenvironment in hepatocellular carcinoma (HCC). All the data were combined with the personal experiences of the authors.

DESIGN

From 1002 representative papers, we selected 86 representative publications which included data on epithelial-to-mesenchymal transition (EMT), angiogenesis, cancer stem-like cells (CSCs), and molecular background of chemoresistance or resistance to radiotherapy.

RESULTS

Although the central event concerns activation of the Wnt/β-catenin pathway, other signal pathways, such as c-Met/HGF/Snail, Notch-1/NF-κB, TGF-β/SMAD, and basic fibroblast growth factor-related signaling, play a role in the EMT of HCC cells. This pathway is targeted by specific miRNAs and long noncoding RNAs, as explored in this paper. A central player in the tumor microenvironment proved to be the CSCs which can be marked by CD133, CD44, CD90, EpCAM, and CD105. CSCs can induce resistance to cytotoxic therapy or, alternatively, can be synthesized, de novo, after chemo- or radiotherapy, especially after transarterial chemoembolization- or radiofrequency ablation-induced hypoxia. The circulating tumor cells proved to have epithelial, intermediate, or mesenchymal features; their properties have a critical prognostic role.

CONCLUSION

The metastatic pathway of HCC seems to be related to the Wnt- or, rather, TGFβ1-mediated inflammation-angiogenesis-EMT-CSCs crosstalk link. Molecular therapy should target this molecular axis controlling the HCC microenvironment.

Challenges of transarterial therapy for hepatocellular carcinoma in patients with chronic kidney disease

Poor outcomes of hepatocellular carcinomas (HCC) in chronic kidney disease (CKD) patients are well described. Transarterial therapy is the standard treatment for HCC, following which regular contrast-enhanced imaging for residual disease is recommended. CKD is considered a relative contraindication for transarterial therapy owing to renal failure.This retrospective study investigated the outcomes of transarterial therapy in HCC patients with CKD. In total, 132 HCC patients who received transarterial therapy were enrolled, of whom 36 had CKD. Most CKD patients were elderly, with mean age of diagnosis of 69.7 ± 11.4 years. Hypertension (odds ratio [OR]; 5.06; 95% confidence interval [Cl]; 1.83-13.94), hepatitis C virus carrier rate (OR; 4.12, 95% CI; 1.13-14.99) and diabetes (OR; 3.62, 95% CI; 1.22-10.72) were significant predictors for CKD in HCC patients. Post therapy, the estimated glomerular filtration rate significantly decreased 13.7% from baseline in the CKD patients (P = .03). There were more post-therapy complications than in the non-CKD group, e.g. acute renal failure and sepsis (P < .01 vs P < .01). Overall survival in the CKD group was significantly poor (10.9 ± 8.5 vs 23.5 ± 16.3 months, P < .01).The lower survival of CKD patients was unrelated to treatment modality or less contrast-enhanced imaging follow-up. Further research on patient care and factors leading to poor outcomes for CKD is needed.

Assessment of small hepatocellular carcinoma: perfusion quantification and time-concentration curve evaluation using color-coded and quantitative digital subtraction angiography

To explore the role of quantitative digital subtraction angiography (QDSA) in the diagnosis of small hepatocellular carcinoma (HCC).Between November 2015 and November 2017, all patients who underwent chemoembolization for HCC were retrospectively reviewed. Patients with tumors measuring more than 5 cm or evident post-processing imaging artifacts were excluded. Images were post-processed using the QDSA technique. Regions of interest were manually drawn on proper hepatic artery (as a reference), target HCC and peritumoral liver. Time-concentration curves and flow parameters of the peak ratio, subtracted time-to-peak (TTP), and area under the curve (AUC) ratio was obtained and analyzed.A total of 146 HCCs (mean diameter, 1.6 cm) of 71 cirrhotic patients (54 men, 17 women; mean age, 67.7 years) were enrolled. Compared with liver parenchyma, HCCs showed an increased and more rapid flow (peak ratio, AUC ratio, subtracted TTP, and wash-in slope; all P <.001). Compared with untreated HCCs, chemoembolized HCCs showed a slower flow (subtracted TTP and wash-in slope, P = .004 and .002, respectively). HCCs with a typical enhancement pattern on computed tomography (CT) or magnetic resonance imaging (MRI) had a trend toward Type III (washout pattern) time-concentration curves (P <.001). Chemoembolized HCCs had a trend toward Type II (plateau pattern) time-concentration curves (P = .005).QDSA technology can be used to quantify perfusion measurements of HCC and hepatic parenchyma and to assess perfusion changes after HCC chemoembolization.

Long-term outcomes of surgery alone versus surgery following preoperative chemoradiotherapy for early T3 rectal cancer: A propensity score analysis

Recently, a few studies have raised the question of whether preoperative chemoradiotherapy (PCRT) is essential for all T3 rectal cancers. This case-matched study aimed to compare the long-term outcomes of surgery alone with those of PCRT + surgery for magnetic resonance imaging (MRI)-assessed T3ab (extramural depth of invasion ≤5 mm) and absent mesorectal fascia invasion (clear MRF) in mid/lower rectal cancer patients.From January 2006 to November 2012, 203 patients who underwent curative surgery alone (n = 118) or PCRT + surgery (n = 85) were enrolled in this retrospective study. A 1:1 propensity score-matched analysis was performed to eliminate the inherent bias. Case-matching covariates included age, sex, body mass index, histologic grade, carcinoembryonic antigen, operation method, follow-up period, tumor height, and status of lymph node metastasis. The end-points were the 5-year local recurrence (LR) rate and disease-free-survival (DFS).After propensity score matching, 140 patients in 70 pairs were included. Neither the 5-year LR rate nor the DFS was significantly different between the 2 groups (the 5-year LR rate, P = 0.93; the 5-year DFS, P = 0.94). The 5-year LR rate of the surgery alone was 2% (95% confidence interval [CI] 0.2%-10.9%) versus 2% (95% CI 0.2%-10.1%) in the PCRT + surgery group. The 5-year DFS of the surgery alone was 87% (95% CI 74.6%-93.7%) versus 88% (95% CI 77.8%-93.9%) in the PCRT + surgery group.In patients with MRI-assessed T3ab and clear MRF mid/lower rectal cancer, the long-term outcomes of surgery alone were comparable with those of the PCRT + surgery. The suggested MRI-assessed T3ab and clear MRF can be used as a highly selective indication of surgery alone in mid/lower T3 rectal cancer. Additionally, in those patients, surgery alone can be tailored to the clinical situation.

The incidence and outcome of major complication following conventional TAE/TACE for hepatocellular carcinoma

To investigate the incidence and outcome of major complication following conventional transarterial embolization/chemoembolization (TAE/TACE) therapy for hepatocellular carcinoma (HCC).From May 2010 to May 2016, all patients with major complication following conventional TAE/TACE for HCC were included. Major complication was defined as admission to a hospital for therapy, an unplanned increase in the level of care, prolonged hospitalization, permanent adverse sequelae, or death after conventional TAE/TACE therapy by Society of Interventional Radiology.During the study period, a total of 2863 TAE/TACE procedures were performed among 1120 patients, and a total of 24 patients (21 male and 3 female) developed major complication with the incidence of 2.1% (24/1120) per patient and 0.84% (24/2863) per TAE/TACE procedure. The major complications were liver rupture (n = 6), liver abscess (n = 5), femoral artery pseudoaneurysm (n = 3), cholecystitis (n = 2), biloma (n = 2), pulmonary embolism (n = 2), and 1 each of the following: cerebral lipiodol embolism, tumor lysis syndrome, partial intestinal obstruction, gallbladder perforation. The mean interval from last TAE/TACE procedure to the diagnosis of major complication was 11.1 ± 7.7 days. The treatments of the complications were conservative treatment (n = 12), conservative treatment plus percutaneous drainage (n = 3), ultrasound-guided thrombin injection (n = 3), conservative treatment plus TAE (n = 2), and conservative treatment plus surgery (n = 2). Of the 24 patients, 20 patients were recovered, and remaining 4 patients were died of major complications; therefore, the mortality rate of major complication was 16.7% (4/24).Major complication following conventional TAE/TACE therapy is uncommon; the outcomes are benign of most major complications, but some are mortality.

Systematic review of partial hepatic resection to treat hepatic metastases in patients with gastric cancer

OBJECTIVE

To examine overall survival and mortality following hepatic resection in patients with hepatic metastases from gastric cancer.

METHODS

EMBASE, PubMed, Web of Science, and Cochrane databases were systematically searched for publications involving more than 10 patients who underwent hepatic resection to treat hepatic metastases from gastric cancer and who did not have peritoneal disease or involvement of other distant organs.

RESULTS

A total of 39 studies were included, involving a median of 21 hepatic resections (range, 10-64). Resection was associated with median 30-day morbidity of 24% (range, 0%-47%) and 30-day mortality of 0% (range, 0%-30%). Median overall survival was 68% at 1 year, 31% at 3 years, and 27% at 5 years. Asian studies reported higher rates than Western studies for overall survival at 1 year (73% vs 59%), 3 years (34% vs 25%), and 5 years (27% vs 17%). Compared with palliative treatment, resection was associated with significantly lower mortality at 1 year (risk ratio [RR] 0.47, P < 0.001) and 2 years (RR 0.70, P < 0.001).

CONCLUSION

Patients with hepatic metastases from gastric cancer may benefit from hepatic resection in case of good physical condition, absence of peritoneal dialysis, and optimum liver function with single metastases. More trials are needed to confirm this finding.

Duodenal perforation and esophageal ischemia following transarterial chemoembolization for hepatocellular carcinoma: A case report

Transarterial chemoembolization (TACE) is frequently used for treatment of unresectable hepatocellular carcinoma (HCC) and can also be used for case of liver metastases from rectal cancer. Although it is recognized as safe and effective treatment, various complications have been reported. However, post-TACE duodenal perforation with duodenal and esophageal ischemia has not been reported in the literature. A 43-year-old male had experienced duodenal perforation combined with duodenal and lower esophageal ischemia after 8 times of repeated TACE for recurrent and unresectable HCCs, that was confirmed on esophagogastroduodenoscopy and abdominal computed tomography. Interestingly, operative findings showed complete recovery of duodenal ischemia except perforation, and he recovered with just the segmental duodenectomy and gastrojejunostomy. We report a case of duodenal perforation with necrosis and esophageal ischemia after 8th TACE for unresectable HCC. Although this complication is rare and unexpected, it may result in severe sequelae requiring surgical repair.The careful procedure during TACE followed by post-TACE careful monitoring is required in patients with posthepatectomy or repeated TACE, especially in the case with unusual clinical manifestations.