[Radiofrequency ablation]

RF interstitial thermal ablation (RFA) has yielded satisfactory results in the treatment of both primary and secondary hepatic tumors with no serious complications. We describe our experience with 163 patients who had this treatment. We used the RITA Needle electrode (model 30; four hooks, model 70; seven hooks) in 101 cases, the LeVeen Needle electrode in 32 cases and the Cool-tips type electrode in 30 cases. Post treatment tumor necrosis was evaluated by dynamic CT or SPIO MRI in all cases. The mean number of RFA sessions to complete tumor nodule treatment was 1.2 (1 session; 85%, 2 sessions; 12%, more than 3 sessions 3%). The mean complete necrosis area of single ablation with RITA Needle electrode was 31.3 +/- 6.1 mm x 29.6 +/- 5.5 mm. Seventy-two patients were followed up for 6-24 months (means; 15.2 months). Of these patients, 4 (5.6%) showed local recurrence. No fatal or major complications related to the treatment or to the diagnostic procedure were observed. In one of 163 patients, a moderate-to-large pleural effusion was documented after RFA, and resolved by drainage. In conclusion, RF interstitial thermal ablation of hepatic tumor is a safe and effective technique for hepatic tumors.

Mixed carcinoid-adenocarcinoma of the liver

A 61-year-old man with a mixed carcinoid-adenocarcinoma of the liver is described. Microscopic examination of the lesion showed a differentiated adenocarcinoma with distinct carcinoid components that stained positively for argyrophil. The tumor cells contained serotonin granules on immunohistochemical studies. Detailed examination disclosed no primary tumor in the gastrointestinal tract or in any other organ. Resection was considered impractical because there were multiple tumors. The patient received chemotherapy six times (cisplatin 60 mg/m2, epirubicin 40 mg/ m2 per month). The multiple tumors gradually shrank. At the time of this writing, the patient is still alive. To our knowledge, this is the first reported case of mixed carcinoid-adenocarcinoma of the liver.

Close association between high serum ALT and more rapid recurrence of hepatocellular carcinoma in hepatectomized patients with HCV-associated liver cirrhosis and hepatocellular carcinoma

We investigated whether or not a high serum alanine aminotransferase (ALT) level is associated with a more rapid recurrence of hepatocellular carcinoma (HCC) in hepatectomized patients with hepatitis C virus (HCV)-associated liver cirrhosis (LC) (HCV-LC) and HCC. Thirty-three hepatectomized patients with HCV-LC and HCC of a single nodule who had no histologic evidence of portal or hepatic vein invasion and who had been followed up for more than 3 years were included in the study. They were subdivided into two groups according to their serum ALT levels, ALT being a well-known marker of inflammatory necrosis in the liver. Seventeen patients whose serum ALT levels showed several peaks or plateaus above 80 international units (IU) were designated as the high ALT group, and 16 patients whose serum ALT levels showed a sustained low level below 80 IU until the first recurrence were designated as the low ALT group, and the interval between hepatectomy and the first recurrence was observed. In the high ALT group, HCC recurred within 3 years in 70.6% of the patients. In contrast, it recurred in only 18.8% of the low ALT group within the same period (p < 0.05). There was a significant difference (p = 0.0201) between the two groups in the cumulative nonrecurrence rate. The mean interval in recurrent patients between hepatectomy and the first recurrence in the high ALT group (23.6 +/- 2.8 months; mean +/- SE) was significantly (p < 0.02) shorter than that in the low ALT group (49.3 +/- 9.7 months). The expected interval between hepatectomy and recurrence was as short as 2.8 +/- 0.5 years (mean +/- SE) in the high ALT group, compared with 5.8 +/- 0.7 years in the low ALT group (p < 0.05). These results showed that the recurrence of HCC was accelerated in the high ALT group, suggesting that suppression of the rise in ALT level after hepatectomy by treatment with anti-inflammatory drugs may prolong the interval until recurrence by about 2 years in hepatectomized patients with HCC and HCV-LC.

A combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than is ursodeoxycholic acid monotherapy

Inhibitors of 3-hydroxy,3-methylglutaryl coenzyme A (HMG-CoA) reductase have been reported to decrease the cholesterol saturation index (CSI) in duodenal bile in humans and to prevent formation of cholesterol gallstones in animal studies. We performed a prospective study to evaluate the role of HMG-CoA reductase inhibitors as gallstone-dissolving agents. Fifty patients with radiolucent gallstones in a gallbladder opacifying at drip infusion cholecystography were treated with either 10 mg/day simvastatin plus 600 mg/day ursodeoxycholic acid (group 1, n=26) or 600 mg/day ursodeoxycholic acid alone (group 2, n=24) for 12 months. The ratio of solitary to multiple gallstone cases was 21:29. Plasma lipid levels were assessed and ultrasonographic examination of the gallbladder was performed at baseline and at 3-month intervals during treatment. Duodenal bile sampling was performed in five patients in each group at baseline and after 12 months of treatment. Plasma cholesterol decreased significantly in group 1 but not in group 2. In solitary gallstone cases, no significant difference in dissolution rates was observed between groups 1 (3 of 9, 33%) and 2 (4 of 12, 33%). In contrast, the dissolution rate in multiple gallstone cases was significantly higher in group 1 (12 of 17, 71%) than in group 2 (3 of 12, 25%) (p < 0.01). Bile cholesterol saturation index was significantly decreased (p < 0.01) but did not significantly differ between the two groups. These results suggest that combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than ursodeoxycholic acid monotherapy in patients with multiple gallstones.

Efficacy of endoscopic variceal ligation for bleeding esophageal varices in patients with tumor thrombus of the portal vein trunk (Vp3) associated with hepatocellular carcinoma

We studied the efficacy of endoscopic variceal ligation (EVL) in 16 patients with tumor thrombus of the portal vein trunk (Vp3) associated with hepatocellular carcinoma. The average (+/-SD) number of O rings used was 9.0 +/- 5.0 for the esophageal varices (n = 7) and 16.4 +/- 4.5 for the esophagogastric varices (n = 9). The variceal size was quickly reduced in 11 of the 13 cases whose therapeutic outcome was able to be assessed by endoscopy. The red color sign improved in 10 of the 13 cases, but the therapeutic end point (F0, RC-) was achieved in only two patients, who were also treated by endoscopic injection sclerotherapy. Emergency EVL achieved only short-term survival (17.14 +/- 6.64 days) and transient hemostasis. Elective EVL was associated with a survival duration of 90.0 +/- 64.25 days. The difference in the survival rate between emergency and elective cases was significant (P < .05). With regard to the timing of its application, EVL, being a less-invasive treatment, should be performed electively before variceal rebleeding for those patients with Vp3 hepatocellular carcinoma whose liver function is preserved.

[Responses to surgical stress in blood coagulation and fibrinolysis, platelet counts and thromboxane B2 after esophageal cancer operation]

Studies on responses to surgical stress in blood coagulation and fibrinolysis, platelet counts and thromboxane B2 (TXB2) were carried out with 18 esophageal cancer patients who had undergone radical esophagectomy through right thoracotomy and reconstruction with gastric tube. Plasma levels were measured for the following for coagulation assessment: thrombin.antithrombin III complex (TAT), soluble fibrin monomer complex(SFMC), fibrinogen, antithrombin III, protein C and thrombomodulin. Selected fibrinolytic markers are: tissue plasminogen activator.plasminogen activator inhibitor 1 complex (tPA.PAI1C), plasminogen, alpha 2 plasmin inhibitor, plasmin. alpha 2 plasmin inhibitor complex(PIC), FDP and D-dimer. Peripheral venous blood samples were taken from the patients before the operation, immediately after the operation and on each of the first, second, third, seventh and fourteenth day after the operation. It was observed that TAT, SFMC, tPA.PAI-1C and TXB2 were remarkably altered immediately after the operation. This indicates that the major surgical stress significantly activated coagulation, fibrinolysis and platelets. Higher plasma levels of TAT compared to the pre-operation level was recorded for two weeks after the operation. Furthermore, in four cases, SFMC became positive during three to seven days after operation. These facts indicate that the activation of coagulation persisted during the days after operation. PIC began to increase from the 2nd to 3rd days after operation, reaching the maximum on the 7th day. Biphasic changes which peaked twice on the 1st and 7th days after operation were shown in plasma levels of FDP and D-dimer. These results indicate that the activation of fibrinolysis also persisted during the days after operation. The activation of coagulation and fibrinolysis may persist at least for two weeks after major surgical operation. Careful observation for the states of these systems was thought to be needed during the post-operative days, and the molecular markers could be useful to assess subclinical changes of these systems.

[Long-term survival in malignant atrophic papulosis: a case report and review of the Japanese literature]

Malignant atrophic papulosis (MAP) is characterized by skin lesion and high mortality rate caused by perforation of the GI tract or involvement of the central nervous system. Approximately 100 cases have been reported in the world literatures, but etiology is unknown. A 44-year-old female patient was admitted for chest and abdominal pain with characteristic papuloses, which had been noted by the patient seven years ago. Because of positive peritoneal irritation and intraabdominal free air, exploratory laparotomy was done. Multiple red inflammatory or yellow atrophic maculae on the entire intestine with no obvious perforation but with air-leak were found. Those perforations were closed with seromuscular sutures. The patient is doing well sixteen months after surgery. Fourteen MAP cases have been reported in the Japanese literature. As is found in the world literature, the mortality rate is extremely high. All of reported cases were initially diagnosed because of the particular skin lesions. Abdominal symptoms developed in 10 cases and six of these died. Three cases died within three weeks after bowel resection. There are three surviving cases. One was treated conservatively even though intraabdominal free air was present. Two had three operations, including one simple closure and two intraabdominal explorations. According to this result, a bowel resection should not be performed on MAP patients because of this high mortality. Administration of anticoagulants, i.e., heparin, prostaglandin E1 and ticlopidine seems to be effective in alleviating symptoms and might prevent further deterioration.

[Clinical study of the effect of cisplatin therapy in unresectable hepatocellular carcinoma]

Twenty-one cases of unresectable hepatocellular carcinoma (HCC), including 15 cases receiving intravenous infusion of CDDP in addition to transcatheter arterial embolization (TAE), and 6 cases receiving intraarterial infusion of CDDP in combination with sodium thiosulfate rescue (STS rescue) were studied. In the 15 cases given intravenous infusion therapy with TAE, favorable effects were observed in 33.3% of patients, and the 50% survival period was 22.5 months. In the 6 cases given intraarterial infusion, favorable effects were obtained in 66.6% of patients, but the 50% survival period was 2 months. The side effects observed most frequently were nausea and vomiting. All the other side effects observed were not so severe. These results suggest that intravenous CDDP infusion in addition to TAE is favorable, producing a life-prolongation effect.