A genome-wide DNA methylation signature for SETD1B-related syndrome

SETD1B is a component of a histone methyltransferase complex that specifically methylates Lys-4 of histone H3 (H3K4) and is responsible for the epigenetic control of chromatin structure and gene expression. De novo microdeletions encompassing this gene as well as de novo missense mutations were previously linked to syndromic intellectual disability (ID). Here, we identify a specific hypermethylation signature associated with loss of function mutations in the SETD1B gene which may be used as an epigenetic marker supporting the diagnosis of syndromic SETD1B-related diseases. We demonstrate the clinical utility of this unique epi-signature by reclassifying previously identified SETD1B VUS (variant of uncertain significance) in two patients.

Detection of copy number variations in epilepsy using exome data

Epilepsies are common neurological disorders and genetic factors contribute to their pathogenesis. Copy number variations (CNVs) are increasingly recognized as an important etiology of many human diseases including epilepsy. Whole-exome sequencing (WES) is becoming a standard tool for detecting pathogenic mutations and has recently been applied to detecting CNVs. Here, we analyzed 294 families with epilepsy using WES, and focused on 168 families with no causative single nucleotide variants in known epilepsy-associated genes to further validate CNVs using 2 different CNV detection tools using WES data. We confirmed 18 pathogenic CNVs, and 2 deletions and 2 duplications at chr15q11.2 of clinically unknown significance. Of note, we were able to identify small CNVs less than 10 kb in size, which might be difficult to detect by conventional microarray. We revealed 2 cases with pathogenic CNVs that one of the 2 CNV detection tools failed to find, suggesting that using different CNV tools is recommended to increase diagnostic yield. Considering a relatively high discovery rate of CNVs (18 out of 168 families, 10.7%) and successful detection of CNV with <10 kb in size, CNV detection by WES may be able to surrogate, or at least complement, conventional microarray analysis.

Identification of novel BCL11A variants in patients with epileptic encephalopathy: Expanding the phenotypic spectrum

BCL11A encodes a zinc finger protein that is highly expressed in hematopoietic tissues and the brain, and that is known to function as a transcriptional repressor of fetal hemoglobin (HbF). Recently, de novo variants in BCL11A have been reported in individuals with intellectual disability syndrome without epilepsy. In this study, we performed whole-exome sequencing of 302 patients with epileptic encephalopathies (EEs), and identified 2 novel BCL11A variants, c.577delC (p.His193Metfs*3) and c.2351A>C (p.Lys784Thr). Both the patients shared major physical features characteristic of BCL11A-related intellectual disability syndrome, suggesting that characteristic physical features and the persistence of HbF should lead clinicians to suspect EEs caused by BCL11A pathogenic variants. Patient 1, with a frameshift variant, presented with Lennox-Gastaut syndrome, which expands the phenotypic spectrum of BCL11A haploinsufficiency. Patient 2, with a p.Lys784Thr variant, presented with West syndrome followed by drug-resistant focal seizures and more severe developmental disability. These 2 newly described patients contribute to delineating the associated, yet uncertain phenotypic characteristics of BCL11A disease-causing variants.

Novel biallelic SZT2 mutations in 3 cases of early-onset epileptic encephalopathy

The seizure threshold 2 (SZT2) gene encodes a large, highly conserved protein that is associated with epileptogenesis. In mice, Szt2 is abundantly expressed in the central nervous system. Recently, biallelic SZT2 mutations were found in 7 patients (from 5 families) presenting with epileptic encephalopathy with dysmorphic features and/or non-syndromic intellectual disabilities. In this study, we identified by whole-exome sequencing compound heterozygous SZT2 mutations in 3 patients with early-onset epileptic encephalopathies. Six novel SZT2 mutations were found, including 3 truncating, 1 splice site and 2 missense mutations. The splice-site mutation resulted in skipping of exon 20 and was associated with a premature stop codon. All individuals presented with seizures, severe developmental delay and intellectual disabilities with high variability. Brain MRIs revealed a characteristic thick and short corpus callosum or a persistent cavum septum pellucidum in each of the 2 cases. Interestingly, in the third case, born to consanguineous parents, had unexpected compound heterozygous missense mutations. She showed microcephaly despite the other case and previous ones presenting with macrocephaly, suggesting that SZT2 mutations might affect head size.

Molecular genetic analysis of 30 families with Joubert syndrome

Joubert syndrome (JS) is rare recessive disorders characterized by the combination of hypoplasia/aplasia of the cerebellar vermis, thickened and elongated superior cerebellar peduncles, and a deep interpeduncular fossa which is defined by neuroimaging and is termed the 'molar tooth sign'. JS is genetically highly heterogeneous, with at least 29 disease genes being involved. To further understand the genetic causes of JS, we performed whole-exome sequencing in 24 newly recruited JS families. Together with six previously reported families, we identified causative mutations in 25 out of 30 (24 + 6) families (83.3%). We identified eight mutated genes in 27 (21 + 6) Japanese families, TMEM67 (7/27, 25.9%) and CEP290 (6/27, 22.2%) were the most commonly mutated. Interestingly, 9 of 12 CEP290 disease alleles were c.6012-12T>A (75.0%), an allele that has not been reported in non-Japanese populations. Therefore c.6012-12T>A is a common allele in the Japanese population. Importantly, one Japanese and one Omani families carried compound biallelic mutations in two distinct genes (TMEM67/RPGRIP1L and TMEM138/BBS1, respectively). BBS1 is the causative gene in Bardet-Biedl syndrome. These concomitant mutations led to severe and/or complex clinical features in the patients, suggesting combined effects of different mutant genes.

Characterization of SPATA5-related encephalopathy in early childhood

Mutations in SPATA5 have recently been shown to result in a phenotype of microcephaly, intellectual disability, seizures, and hearing loss in childhood. Our aim in this report is to delineate the SPATA5 syndrome as a clinical entity, including the facial appearance, neurophysiological, and neuroimaging findings. Using whole-exome sequencing and Sanger sequencing, we identified three children with SPATA5 mutations from two families. Two siblings carried compound heterozygous mutations, c.989_991del (p.Thr330del) and c.2130_2133del (p.Glu711Profs*21), and the third child had c.967T>A (p.Phe323Ile) and c.2146G>C (p.Ala716Pro) mutations. The three patients manifested microcephaly, psychomotor retardation, hypotonus or hypertonus, and bilateral hearing loss from early infancy. Common facies were a depressed nasal bridge/ridge, broad eyebrows, and retrognathia. Epileptic spasms or tonic seizures emerged at 6-12 months of age. Interictal electroencephalography showed multifocal spikes and bursts of asynchronous diffuse spike-wave complexes. Augmented amplitudes of visually evoked potentials were detected in two patients. Magnetic resonance imaging revealed hypomyelination, thin corpus callosum, and progressive cerebral atrophy. Blood copper levels were also elevated or close to the upper normal levels in these children. Clinical delineation of the SPATA5-related encephalopathy should improve diagnosis, facilitating further clinical and molecular investigation.

Different X-linked KDM5C mutations in affected male siblings: is maternal reversion error involved?

Genetic reversion is the phenomenon of spontaneous gene correction by which gene function is partially or completely rescued. However, it is unknown whether this mechanism always correctly repairs mutations, or is prone to error. We investigated a family of three boys with intellectual disability, and among them we identified two different mutations in KDM5C, located at Xp11.22, using whole-exome sequencing. Two affected boys have c.633delG and the other has c.631delC. We also confirmed de novo germline (c.631delC) and low-prevalence somatic (c.633delG) mutations in their mother. The two mutations are present on the same maternal haplotype, suggesting that a postzygotic somatic mutation or a reversion error occurred at an early embryonic stage in the mother, leading to switched KDM5C mutations in the affected siblings. This event is extremely unlikely to arise spontaneously (with an estimated probability of 0.39-7.5 × 10(-28) ), thus a possible reversion error is proposed here to explain this event. This study provides evidence for reversion error as a novel mechanism for the generation of somatic mutations in human diseases.

Delineation of clinical features in Wiedemann-Steiner syndrome caused by KMT2A mutations

Wiedemann-Steiner syndrome (WSS) is an autosomal dominant congenital anomaly syndrome characterized by hairy elbows, dysmorphic facial appearances (hypertelorism, thick eyebrows, downslanted and vertically narrow palpebral fissures), pre- and post-natal growth deficiency, and psychomotor delay. WSS is caused by heterozygous mutations in KMT2A (also known as MLL), a gene encoding a histone methyltransferase. Here, we identify six novel KMT2A mutations in six WSS patients, with four mutations occurring de novo. Interestingly, some of the patients were initially diagnosed with atypical Kabuki syndrome, which is caused by mutations in KMT2D or KDM6A, genes also involved in histone methylation. KMT2A mutations and clinical features are summarized in our six patients together with eight previously reported patients. Furthermore, clinical comparison of the two syndromes is discussed in detail.

Mutations in COG2 encoding a subunit of the conserved oligomeric golgi complex cause a congenital disorder of glycosylation

The conserved oligomeric Golgi (COG) complex is involved in intra-Golgi retrograde trafficking, and mutations in six of its eight subunits have been reported in congenital disorders of glycosylation (CDG). Here we report a patient showing severe acquired microcephaly, psychomotor retardation, seizures, liver dysfunction, hypocupremia, and hypoceruloplasminemia. Analysis of his serum glycoproteins revealed defects in both sialylation and galactosylation of glycan termini. Trio-based whole-exome sequencing identified two heterozygous mutations in COG2: a de novo frameshift mutation [c.701dup (p.Tyr234*)] and a missense mutation [c.1900T > G (p.Trp634Gly)]. Sequencing of cloned reverse-transcription polymerase chain reaction (RT-PCR) products revealed that both mutations were located on separate alleles, as expected, and that the mutant transcript harboring the frameshift mutation underwent degradation. The c.1900T > G (p.Trp634Gly) mutation is located in a domain highly conserved among vertebrates and was absent from both the public database and our control exomes. Protein expression of COG2, along with COG3 and COG4, was decreased in fibroblasts from the patient. Our data strongly suggest that these compound heterozygous mutations in COG2 are causative of CDG.

De novo EEF1A2 mutations in patients with characteristic facial features, intellectual disability, autistic behaviors and epilepsy

Eukaryotic elongation factor 1, alpha-2 (eEF1A2) protein is involved in protein synthesis, suppression of apoptosis, and regulation of actin function and cytoskeletal structure. EEF1A2 gene is highly expressed in the central nervous system and Eef1a2 knockout mice show the neuronal degeneration. Until now, only one missense mutation (c.208G > A, p.Gly70Ser) in EEF1A2 has been reported in two independent patients with neurological disease. In this report, we described two patients with de novo mutations (c.754G > C, p.Asp252His and c.364G > A, p.Glu122Lys) in EEF1A2 found by whole-exome sequencing. Common clinical features are shared by all four individuals: severe intellectual disability, autistic behavior, absent speech, neonatal hypotonia, epilepsy and progressive microcephaly. Furthermore, the two patients share the similar characteristic facial features including a depressed nasal bridge, tented upper lip, everted lower lip and downturned corners of the mouth. These data strongly indicate that a new recognizable disorder is caused by EEF1A2 mutations.

Coffin-Siris syndrome is a SWI/SNF complex disorder

Coffin-Siris syndrome (CSS) is a congenital disorder characterized by intellectual disability, growth deficiency, microcephaly, coarse facial features, and hypoplastic or absent fifth fingernails and/or toenails. We previously reported that five genes are mutated in CSS, all of which encode subunits of the switch/sucrose non-fermenting (SWI/SNF) ATP-dependent chromatin-remodeling complex: SMARCB1, SMARCA4, SMARCE1, ARID1A, and ARID1B. In this study, we examined 49 newly recruited CSS-suspected patients, and re-examined three patients who did not show any mutations (using high-resolution melting analysis) in the previous study, by whole-exome sequencing or targeted resequencing. We found that SMARCB1, SMARCA4, or ARID1B were mutated in 20 patients. By examining available parental samples, we ascertained that 17 occurred de novo. All mutations in SMARCB1 and SMARCA4 were non-truncating (missense or in-frame deletion) whereas those in ARID1B were all truncating (nonsense or frameshift deletion/insertion) in this study as in our previous study. Our data further support that CSS is a SWI/SNF complex disorder.

Exome sequencing in a family with an X-linked lethal malformation syndrome: clinical consequences of hemizygous truncating OFD1 mutations in male patients

Oral-facial-digital syndrome type 1 (OFD1; OMIM #311200) is an X-linked dominant disorder, caused by heterozygous mutations in the OFD1 gene and characterized by facial anomalies, abnormalities in oral tissues, digits, brain, and kidney; and male lethality in the first or second trimester pregnancy. We encountered a family with three affected male neonates having an 'unclassified' X-linked lethal congenital malformation syndrome. Exome sequencing of entire transcripts of the whole X chromosome has identified a novel splicing mutation (c.2388+1G > C) in intron 17 of OFD1, resulting in a premature stop codon at amino acid position 796. The affected males manifested severe multisystem complications in addition to the cardinal features of OFD1 and the carrier female showed only subtle features of OFD1. The present patients and the previously reported male patients from four families (clinical OFD1; Simpson-Golabi-Behmel syndrome, type 2 with an OFD1 mutation; Joubert syndrome-10 with OFD1 mutations) would belong to a single syndrome spectrum caused by truncating OFD1 mutations, presenting with craniofacial features (macrocephaly, depressed or broad nasal bridge, and lip abnormalities), postaxial polydactyly, respiratory insufficiency with recurrent respiratory tract infections in survivors, severe mental or developmental retardation, and brain malformations (hypoplasia or agenesis of corpus callosum and/or cerebellar vermis and posterior fossa abnormalities).

Homozygous c.14576G>A variant of RNF213 predicts early-onset and severe form of moyamoya disease

OBJECTIVE

RNF213 was recently reported as a susceptibility gene for moyamoya disease (MMD). Our aim was to clarify the correlation between the RNF213 genotype and MMD phenotype.

METHODS

The entire coding region of the RNF213 gene was sequenced in 204 patients with MMD, and corresponding variants were checked in 62 pairs of parents, 13 mothers and 4 fathers of the patients, and 283 normal controls. Clinical information was collected. Genotype-phenotype correlations were statistically analyzed.

RESULTS

The c.14576G>A variant was identified in 95.1% of patients with familial MMD, 79.2% of patients with sporadic MMD, and 1.8% of controls, thus confirming its association with MMD, with an odds ratio of 259 and p < 0.001 for either heterozygotes or homozygotes. Homozygous c.14576G>A was observed in 15 patients but not in the controls and unaffected parents. The incidence rate for homozygotes was calculated to be >78%. Homozygotes had a significantly earlier age at onset compared with heterozygotes or wild types (median age at onset 3, 7, and 8 years, respectively). Of homozygotes, 60% were diagnosed with MMD before age 4, and all had infarctions as the first symptom. Infarctions at initial presentation and involvement of posterior cerebral arteries, both known as poor prognostic factors for MMD, were of significantly higher frequency in homozygotes than in heterozygotes and wild types. Variants other than c.14576G>A were not associated with clinical phenotypes.

CONCLUSIONS

The homozygous c.14576G>A variant in RNF213 could be a good DNA biomarker for predicting the severe type of MMD, for which early medical/surgical intervention is recommended, and may provide a better monitoring and prevention strategy.

Exome sequencing of two patients in a family with atypical X-linked leukodystrophy

We encountered a family with two boys similarly showing brain atrophy with reduced white matter, hypoplasia of the brain stem and corpus callosum, spastic paralysis, and severe growth and mental retardation without speaking a word. The phenotype of these patients was not compatible with any known type of syndromic leukodystrophy. Presuming an X-linked disorder, we performed next-generation sequencing (NGS) of the transcripts of the entire X chromosome. A single lane of exome NGS in each patient was sufficient. Six potential mutations were found in both affected boys. Two missense mutations, including c.92T>C (p.V31A) in L1CAM, were potentially pathogenic, but this remained inconclusive. The other four could be excluded. Because the patients did not show adducted thumbs or hydrocephalus, the L1CAM change in this family can be interpreted as different scenarios. Personal genome analysis using NGS is certainly powerful, but interpretation of the data can be a substantial challenge requiring a lot of tasks.

Paternal mosaicism of an STXBP1 mutation in OS

Ohtahara syndrome (OS) is one of the most severe and earliest forms of epilepsy. We have recently identified that the de novo mutations of STXBP1 are important causes for OS. Here we report a paternal somatic mosaicism of an STXBP1 mutation. The affected daughter had onset of spasms at 1 month of age, and interictal electroencephalogram showed suppression-burst pattern, leading to the diagnosis of OS. She had a heterozygous c.902+5G>A mutation of STXBP1, which affects donor splicing of exon 10, resulting in 138-bp insertion of intron 10 sequences in the transcript. The mutant transcript had a premature stop codon, and was degraded by nonsense-mediated mRNA decay in lymphoblastoid cells derived from the patient. High-resolution melting analysis of clinically unaffected parental DNAs suggested that the father was somatic mosaic for the mutation, which was also suggested by sequencing. Cloning of PCR products amplified with the paternal DNA samples extracted from blood, saliva, buccal cells, and nails suggested that 5.3%, 8.7%, 11.9%, and 16.9% of alleles harbored the mutation, respectively. This is a first report of somatic mosaicism of an STXBP1 mutation, which has implications in genetic counseling of OS.

Retrospective study on the effects of lipiodolization before a potentially curative hepatectomy for colorectal liver metastases: long-term results of a pilot study

BACKGROUND/AIMS

Lipiodolization, a selective regional cancer chemotherapeutic modality using lipiodol plus anticancer drugs, can prolong the survival time of patients with unresectable liver cancer. A preliminary study was conducted with adjuvant lipiodolization before a potentially curative hepatectomy for patients with metachronous colorectal liver metastases. The ultimate aim of this study was to improve the long-term survival after hepatectomy.

METHODOLOGY

Twenty-one consecutive patients with colorectal hepatic metastases were included in this study. Seven patients underwent preoperative lipiodolization, while the remaining 14 patients did not receive any preoperative adjuvant therapy. The clinicopathological features and prognoses of these patients were investigated. The median follow-up period after a curative hepatectomy was 56 months.

RESULTS

The clinicopathological factors did not differ markedly between the 2 groups. However, the cumulative survival rate of the 7 patients receiving preoperative lipiodolization was significantly (P < 0.05) better than that in those not receiving any preoperative treatment.

CONCLUSIONS

Based on the above encouraging findings, we therefore propose that a prospective randomized trial should be carried out to confirm the beneficial effects of our adjuvant chemotherapeutic modality on patient survival following a curative hepatectomy for the patients with colorectal liver metastases.

Intraoperative localization of right-sided small colonic lesions: a novel use of the cholangioscope

BACKGROUND/AIM

We describe a novel use of the cholangioscope to help in the intraoperative localization of small colonic malignancies on the right side of the colon.

METHODS

A small incision was made at the base of the appendix and a cholangioscope was inserted into the ascending colon through the incised hole of the appendix.

RESULTS

The site of the lesion was precisely determined by palpating the distal end of the cholangioscope while observing the area right under it.

CONCLUSION

Our procedure therefore appears to be worthy of consideration in patients with small colonic lesions on the right side of the colon in whom preoperative endoscopic marking techniques might otherwise be required.

A resected case of combined hepatocellular carcinoma and cholangiocarcinoma associated with cystic formation

Combined hepatocellular carcinoma and cholangiocarcinoma is a rare tumor. In addition, both hepatocellular carcinoma and cholangiocarcinoma are rarely associated with cystic lesions. We herein present a 62-year-old Japanese woman with combined hepatocellular carcinoma and cholangiocarcinoma which was associated with a rapidly enlarging cystic lesion. Both abdominal ultrasonography and computed tomography revealed a cyst with a solid portion in the left hepatic lobe. A partial hepatectomy was performed on the basis of a tentative diagnosis of a cystadenocarcinoma of the liver, while the diagnosis based on immunohistochemical studies was combined hepatocellular carcinoma and cholangiocarcinoma with cystic formation. The patient died of tumor recurrence, such as intrahepatic metastases and extensive lymph node metastases, 6 months after the operation. The prognosis of this entity, which has never been reported in the English medical literature and is difficult to preoperatively differentiate from hepatic cystadenocarcinoma, therefore seems to be extremely poor.

Rare occurrence of colorectal cancer metastasis in livers infected with hepatitis B or C virus

BACKGROUND

The rarity of the occurrence of metastatic malignancy in injured liver has been noted by many observers. However, since the clinicopathological features of primary carcinoma and the etiology of liver disease of these patients vary greatly, this phenomenon may not be universal.

METHODS

We evaluated the relationship between either hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and the incidence of colorectal liver metastasis in 438 patients undergoing surgical treatment for advanced colorectal carcinoma.

RESULTS

The liver function of the patients in the infection group (n = 37) was significantly worse than that of those in the noninfection group (n = 401). The incidences of tumor recurrence in the lung or peritoneum were comparable between the two groups. However, the percentage of patients with liver metastases in the infection group (3 of 37, 8.1%) was significantly lower (P <0.05) than that of those in the noninfection group (85 of 401, 21.2%). The patients in the infection group tended to survive longer than the patients in the noninfection group.

CONCLUSIONS

We herein report an initial finding that colorectal carcinoma rarely metastasizes to livers infected with HBV or HCV.

CD4+ hepatic cancer-specific cytotoxic T lymphocytes in patients with hepatocellular carcinoma

We investigated T cell immunity against hepatocellular carcinoma (HCC), and showed that both peripheral blood mononuclear cells and tumor-infiltrating lymphocytes incubated with interleukin-2 alone displayed HLA-nonrestricted but hepatic cancer-specific cytotoxicity in a majority of patients with HCC. Namely, they lysed both HCC and cholangiocellular carcinomas in an HLA-nonrestricted manner, but they did not lyse any tumors with the other histological types tested, normal hepatocytes, or the cells transfected with hepatitis C virus or MUC1 gene. These CTL lines and clones were phenotypically CD3+CD4+CD8-. These unique CTL could play important roles in T cell immunity against HCC.

A prospective randomized trial of the preventive effect of pre-operative transcatheter arterial embolization against recurrence of hepatocellular carcinoma

To clarify whether pre-operative transcatheter arterial embolization (TAE) improves survival after hepatectomy, a prospective randomized comparative study was done. Of a total of 115 registered patients having solitary hepatocellular carcinoma (HCC) 2 to 5 cm in diameter, 18 (15.7%) were excluded after randomization. As a result, 97 patients were chosen as subjects and divided into two groups: hepatectomy with (group A: n=50) and without (group B: n=47) pre-operative TAE. The period of observation of the patients who survived the surgery was between 4.0 and 6.6 years. The randomization appeared to have provided well-balanced groups of patients and the clinico-pathological characteristics of the two groups were quite similar. The necrotic part of the cancerous lesions, as confirmed by operative specimens, amounted to 74.8+/-33.4% (mean +/-SD) in group A and 6.8+/-7.2% in group B (P<0.01). However, the cancer-free survival rates after hepatectomy in both groups showed little difference (39.1+/-7.0 (%+/-SE) and 31.1+/-0.1, respectively). We speculate that TAE is not effective against such HCC accessory lesions as minute intrahepatic metastasis and tumor thrombus and that pre-operative TAE does not improve post-operative survival.

Evaluation of surgical risk in preoperative biliary drainage patients by blood chemistry laboratory data--with special reference to rate of reduction of serum bilirubin levels

BACKGROUND/AIM

In Japan, it is generally accepted that biliary decompression should be performed before surgical operations on patients with obstructive jaundice. However, even when adequate decompression and effective reduction of serum bilirubin levels are achieved before surgical operations, it is not uncommon for unforeseen postoperative complications to occur. In this study, we analyzed the effectiveness of biliary drainage prior to pancreatoduodenectomy in patients with malignant obstruction of the papilla of Vater clinically manifested by obstructive jaundice.

PATIENTS AND METHODS

We retrospectively examined the serial blood chemistry laboratory data of 44 patients with periampullary carcinoma who had preoperative obstructive jaundice and underwent pancreatoduodenectomy during the last 10 years. We divided the cases into three groups according to the rate of decrease in serum bilirubin levels, "b": group I, b <-0.09; group II, -0.09<b<-0.05; and group III, -0.05<b. There were no significant differences between the three groups in regard to sex, location of tumor and method of biliary decompression, however, there was significantly higher morbidity rate in group III.

RESULTS

The level of biliary enzymes (gamma-GTP, ALP) tended to be higher in group I and lower in group III. Although TB and DB decreased to below 5 mg/dl before pancreatoduodenectomy in all three groups, transaminase levels instead rose in group III just before pancreatoduodenectomy.

CONCLUSION

This suggested that liver damage continued to progress after biliary decompression when the reduction rate was low, and thus we should carefully monitor such patients for postoperative complications.

A patient with hepatocellular carcinoma who underwent resection of the primary lesion 10 years ago and resection of a giant adrenal metastasis 8 and a half years later

A 56-year-old male consulted us because of a palpable mass and pain of the left flank 8 and a half years after resection of hepatocellular carcinoma of the left lobe about 3 cm in diameter. Ultrasound examination of the abdomen demonstrated a tumor about 10 cm in diameter showing a mosaic of hyperechoic and hypoechoic areas on the upper pole of the left kidney. By angiography, the tumor was found to be supplied mainly by the inferior adrenal artery. PIVKA-II was increased. Adrenal metastasis of hepatocellular carcinoma was suspected, and adrenalectomy was carried out. No intrahepatic metastasis was noted. The tumor was histopathologically identified as a pseudo-glandular type of moderately differentiated hepatocellular carcinoma with a trabecular pattern similar to the primary lesion. In this patient, a resectable giant metastasis was observed only in the left adrenal gland and no intrahepatic metastasis was demonstrated 8 and a half years after resection of hepatocellular carcinoma. The patient has survived 10 years after the first operation. This case is considered to be important for evaluation of the treatment for distant metastasis of hepatocellular carcinoma.

[Microwave coagulo-necrotic therapy for hepatocellular carcinoma]

We performed microwave coagulo-necrotic therapy (MCN), a new surgical treatment for hepatocellular carcinoma (HCC) under laparotomy on 41 cases and under laparoscopy on 5 cases for a total of 46 cases (70 cancer nodules). The indications for MCN include: 1) cases in which an early recurrence is judged as likely to occur. For example, multinodular cases, or intrahepatic metastasis (im1-3) 25 cases (54.3%), 9 cases (19.6%) in which multiple adenomatous hyperplasia was detected, VP2 1 case (2.2%). 2) 7 cases (15.2%) in which if hepatectomy is conducted, there is a high risk of postoperative liver failure, or cases in which it is judged postoperative management will be very difficult. In only 4 cases was it because the patients requested laparoscopic MCN (lapa. MCN). Also, the tumor size was less than 15 mm in 4 cases, 16 to 20 mm in 6 cases, 21-30 mm in 21 cases, 31-50 mm in 6 cases, and larger than 51 mm in 9 cases (maximum 90 x 65 mm). Only 1 case who died on the 17th postoperative day due to sudden ventricular arrhythmia, and 3 cases who died cancer death at 1 year 6 months, 2 year 2 months, and 4 years 1 months after the operation for a total of 4 cases, so that 42 patients have survived 4 years and 3 months as of this writing. Thus MCN was in no way inferior to hepatectomy.

[Investigation of microwave coagulo-necrotic therapy for 21 patients with small hepatocellular carcinoma less than 5 cm in diameter]

Microwave coagulo-necrotic therapy (MCN) was performed in 21 patients with small hepatocellular carcinoma less than 5cm in diameter and this therapeutic method was determined to be effective from the following results. 1) A marked low density area was seen in the region receiving the therapy and no enhanced findings were observed by enhanced CT one month postoperatively. 2) Recurrence appeared in 5 patients (23.8%) and only one patient died 1 year and 6 months after the operation. However, the other 20 patients survived for a maximum of 3 years and 2 months postoperatively. 3) The levels of total bilirubin and GOT in these patients were similar to those of patients who underwent hepatectomy. However, the levels of prothrombin time and hepaplatin test in patients with MCN changed less than in those who received hepatectomy. 4) Tendency of the renal failure was seen in 2 patients, and the other 19 patients did not have any complication postoperatively.

[A device for hepatic arterial catheterization using saphenous vein graft]

We performed regional arterial infusion chemotherapy for hepatocellular carcinoma by retaining a hepatic arterial reservoir. The catheters were placed via gastroduodenal artery and positioned at the junction with common hepatic artery during operation. But we encountered many complications and did not perform regional arterial infusion chemotherapy. This time we cannulated through the saphenous vein graft by which hepatic perfusion was maintained by the superior mesenteric artery; we did not cannulate through the common femoral artery using a subcutaneously implanted reservoir. Venous arterial anastomosis is performed with interrupted (7-0 Prolene) vascular suture. Postoperative angiography by the reservoir showed total hepatic perfusion. There have been no instances of hemorrhage, thrombosis, or catheter dislodgement with this technique. Duration of follow-up varied from 2 to 7 months.

A new technique of hepatectomy using an occlusion balloon catheter for the hepatic vein

To minimize intraoperative bleeding and allow more accurate resection, we have devised a new technique for hepatectomy. In addition to occlusion of the afferent vessels, we occlude the hepatic vein at the hepatocaval junction using a balloon catheter inserted transhepatically under intraoperative ultrasonic guidance. We have performed eight hepatectomies using this method. A sequence of 15 minutes of vascular occlusion followed by 5 minutes reperfusion was repeated throughout the operation, and the total ischemic time ranged from 45 to 90 minutes. This method greatly decreased intraoperative bleeding without causing significant elevation of the postoperative transaminase or lactic dehydrogenase levels when compared with occlusion of only the afferent vessels or nonischemic resection using a microwave tissue coagulator in patients undergoing equivalent resections. Also, the postoperative prothrombin time recovered to a significantly higher level, and there were no fatal postoperative complications using this method. Our method is useful for systematic hepatic resection along the hepatic vein or for resection of tumor sited at the confluence of the hepatic vein.

Accelerated growth rates of recurrent hepatocellular carcinoma after liver transplantation

The growth rates of recurrent hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLTX) were estimated by calculating the tumor doubling time (TDT) in 20 patients. The mean TDT, calculated by multiple measurement of tumor size, was 44.3 +/- 11.3 days (mean +/- standard error) in 12 patients with pulmonary metastasis (range, 10 to 161 days) and 37.6 +/- 8.9 days (range, 7 to 65 days) in 5 patients with liver allograft recurrence. The TDT as estimated by serum alpha-fetoprotein (AFP) levels in 6 patients was 37.3 +/- 10.0 days (range, 12 to 84 days). The mean TDT obtained from 5 control subjects with HCC who were treated with liver resection (without immunosuppression) was 273.8 +/- 79.1 days (range, 82 to 560 days). The disease-free period and survival time after OLTX both correlated well with the TDT (r = 0.546 and r = 0.701, respectively). The patients with fibrolamellar HCC had a greater TDT and a longer survival time than those with nonfibrolamellar HCC. Despite a wide range of TDT in patients who received transplants, their recurrent HCC tumors grew significantly faster than those of patients with the same disease who did not receive transplants. The factors involved in this accelerated growth rate may include the use of immunosuppressive drugs and the consequent suppression of host immunity against the growth of micrometastasis.

Accelerated growth rates of recurrent hepatocellular carcinoma after liver transplantation

The growth rates of recurrent hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLTX) were estimated by calculating the tumor doubling time (TDT) in 20 patients. The mean TDT, calculated by multiple measurement of tumor size, was 44.3 +/- 11.3 days (mean +/- standard error) in 12 patients with pulmonary metastasis (range, 10 to 161 days) and 37.6 +/- 8.9 days (range, 7 to 65 days) in 5 patients with liver allograft recurrence. The TDT as estimated by serum alpha-fetoprotein (AFP) levels in 6 patients was 37.3 +/- 10.0 days (range, 12 to 84 days). The mean TDT obtained from 5 control subjects with HCC who were treated with liver resection (without immunosuppression) was 273.8 +/- 79.1 days (range, 82 to 560 days). The disease-free period and survival time after OLTX both correlated well with the TDT (r = 0.546 and r = 0.701, respectively). The patients with fibrolamellar HCC had a greater TDT and a longer survival time than those with nonfibrolamellar HCC. Despite a wide range of TDT in patients who received transplants, their recurrent HCC tumors grew significantly faster than those of patients with the same disease who did not receive transplants. The factors involved in this accelerated growth rate may include the use of immunosuppressive drugs and the consequent suppression of host immunity against the growth of micrometastasis.

[An assessment of therapeutic effects by transcatheter arterial embolization (TAE) with degradable starch microspheres (DSM) for hepatic malignant tumors]

Transcatheter arterial embolization (TAE) by using degradable starch microspheres (DSM) as embolic material, 40 microns in diameter and degraded by serum amylase within one hour, was carried out for thirteen cases with hepatic malignancies including eleven cases with hepatocellular carcinoma (HCC), one case with cholangiocarcinoma and one case with metastatic liver cancer. DSM were mixed with anticancer agents and administered through the catheter, which was introduced by Seldinger's method, via the hepatic artery immediately after hepatic angiography in ten cases and through subcutaneously implanted drug delivery system (Port-A-Cath) in three cases. The dose of DSM was 900 mg/body and adriamycin 30-40 mg/m2 or 12-14 mg/m2 were used. The former was administered through the catheter immediately after angiography and the latter through Port-A-Cath for HCC and cholangiocarcinoma. A same dose of DSM and mitomycin C 15-16 mg/m2 was administered for metastatic liver cancer through the catheter immediately after angiography. The administration was repeated weekly in three cases in which Port-A-Cath was implanted, and at five weeks' interval through the catheter immediately after hepatic angiography in the other ten cases. Therapeutic effects were assessed and pharmacokinetics of adriamycin were studied. Results were as follows; 1) Partial response (PR) was obtained in five cases out of eleven cases with HCC (45.5%) and there were three cases with minor response (MR) in the other six cases. Totally, decrease of tumor size was demonstrated in eight cases out of eleven cases (72.7%). 2) In nine cases in which AFP was positive, the titer of AFP was decreased in seven cases (77.8%). 3) No change (NC) was obtained in cholangiocarcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)