Serotonin Pathway in Cancer

Serotonin (5-hydroxytryptamine, 5-HT) is a biogenic monoamine produced from the essential amino acid tryptophan. Serotonin's role as a neurotransmitter in the central nervous system and a motility mediator in the gastrointestinal tract has been well defined, and its function in tumorigenesis in various cancers (gliomas, carcinoids, and carcinomas) is being studied. Many studies have shown a potential stimulatory effect of serotonin on cancer cell proliferation, invasion, dissemination, and tumor angiogenesis. Although the underlying mechanism is complex, it is proposed that serotonin levels in the tumor and its interaction with specific receptor subtypes are associated with disease progression. This review article describes serotonin's role in cancer pathogenesis and the utility of the serotonin pathway as a potential therapeutic target in cancer treatment. Octreotide, an inhibitor of serotonin release, is used in well-differentiated neuroendocrine cancers, and the tryptophan hydroxylase (TPH) inhibitor, telotristat, is currently being investigated in clinical trials to treat patients with metastatic neuroendocrine tumors and advanced cholangiocarcinoma. Several in vitro studies have shown the anticancer effect of 5-HT receptor antagonists in various cancers such as prostate cancer, breast cancer, urinary bladder, colorectal cancer, carcinoid, and small-cell lung cancer. More in vivo studies are needed to assess serotonin's role in cancer and its potential use as an anticancer therapeutic target. Serotonin is also being evaluated for its immunoregulatory properties, and studies have shown its potential anti-inflammatory effect. Therefore, it would be of interest to explore the combination of serotonin antagonists with immunotherapy in the future.

Combined hepatocellular-cholangiocarcinoma: which preoperative clinical data and conventional MRI characteristics have value for the prediction of microvascular invasion and clinical significance?

Objectives

To explore which preoperative clinical data and conventional MRI findings may indicate microvascular invasion (MVI) of combined hepatocellular-cholangiocarcinoma (cHCC-CCA) and have clinical significance.

Methods

The study enrolled 113 patients with histopathologically confirmed cHCC-CCA (MVI-positive group [n = 56], MVI-negative group [n = 57]). Two radiologists retrospectively assessed the preoperative MRI features (qualitative analysis of morphology and dynamic enhancement features), and each lesion was assigned according to the LI-RADS. Preoperative clinical data were also evaluated. Logistic regression analyses were used to assess the relative value of these parameters as potential predictors of MVI. Recurrence-free survival (RFS) rates after hepatectomy in the two groups were estimated using Kaplan–Meier survival curves and compared using the log-rank test.

Results

The majority of cHCC-CCAs were categorized as LR-M. On multivariate analysis, a higher serum AFP level (OR, 0.523; 95% CI, 0.282–0.971; p = 0.040), intratumoral fat deposition (OR, 14.368; 95% CI, 2.749–75.098; p = 0.002), and irregular arterial peritumoral enhancement (OR, 0.322; 95% CI, 0.164–0.631; p = 0.001) were independent variables associated with the MVI of cHCC-CCA. After hepatectomy, patients with MVI of cHCC-CCA showed earlier recurrence than those without MVI (hazard ratio [HR], 0.402; 95% CI, 0.189–0.854, p = 0.013).

Conclusion

A higher serum AFP level and irregular arterial peritumoral enhancement are potential predictive biomarkers for the MVI of cHCC-CCA, while intratumoral fat detected on MRI suggests a low risk of MVI. Furthermore, cHCC-CCAs with MVI may have worse surgical outcomes with regard to early recurrence than those without MVI.

Key Points

• Higher serum levels of AFP combined with irregular arterial peritumoral enhancement are independent risk factors for the MVI of cHCC-CCA, while fat deposition might be a protective factor.

• cHCC-CCA with MVI may have a higher risk of early recurrence after surgery.

• Most cHCC-CCAs were categorized as LR-M in this study, and no significant difference was found in MVI based on LI-RADS category.

Lupeol and stigmasterol suppress tumor angiogenesis and inhibit cholangiocarcinoma growth in mice via downregulation of tumor necrosis factor-α

Lupeol and stigmasterol, major phytosterols in various herbal plants, possess anti-inflammatory activities and have been proposed as candidates for anti-cancer agents, but their molecular mechanisms are still unclear. Here, we investigated the effects of lupeol and stigmasterol on tumor and endothelial cells in vitro and their anti-cancer activities in vivo. Our results demonstrated that lupeol and stigmasterol suppressed cell viability, migration, and morphogenesis of human umbilical vein endothelial cells (HUVECs) but not cholangiocarcinoma (CCA) cells. Expression analyses showed that the treatment of both compounds significantly reduced the transcript level of tumor necrosis factor-α (TNF-α), and Western blot analyses further revealed a decrease in downstream effector levels of VEGFR-2 signaling, including phosphorylated forms of Src, Akt, PCL, and FAK, which were rescued by TNF-α treatment. In vivo, lupeol and stigmasterol disrupted tumor angiogenesis and reduced the growth of CCA tumor xenografts. Immunohistochemical analyses confirmed a decrease in CD31-positive vessel content and macrophage recruitment upon treatment. These findings indicate that lupeol and stigmasterol effectively target tumor endothelial cells and suppress CCA tumor growth by their anti-inflammatory activities and are attractive candidates for anti-cancer treatment of CCA tumors.

CEUS in hepatocellular carcinoma and intrahepatic cholangiocellular carcinoma in 320 patients - early or late washout matters: a subanalysis of the DEGUM multicenter trial

PURPOSE

The aim of the study was the comparison of tumor vascularization and contrast enhancement in contrast-enhanced ultrasound (CEUS) for the characterization of hepatocellular carcinoma (HCC) and intrahepatic cholangiocellular carcinoma (ICC). We present data of the subpopulations HCC and ICC examined in the DEGUM multicenter trial for the characterization of focal liver lesions in clinical practice.

MATERIALS AND METHODS

Based on the data of the DEGUM multicenter trial (1349 patients), all patients with histologically proven HCC (n = 278) and ICC (n = 42) were analyzed. The vascularity pattern and contrast enhancement pattern during the arterial, portal-venous and late phase were compared.

RESULTS

An underlying liver cirrhosis was found in 214/278 patients with HCC (76.9 %) and 7/42 patients with ICC (16.7 %). In CEUS, HCC showed a global arterial hyperenhancement compared to ICC (HCC: tumor center: 60.3 %; tumor periphery: 75 %; ICC: tumor center: 16.7 %; tumor periphery: 40.5 %). ICC showed an initial contrast enhancement primarily at the tumor periphery (ICC: 85.7 % vs. HCC: 61 %) followed by an early portal-venous contrast washout in the tumor center (ICC: 85.8 % vs. HCC: 49.8 %) and tumor periphery (ICC: 66.7 % vs. HCC: 32.6 %). HCC showed a delayed contrast washout (late phase hypoenhancement: HCC: 75 % vs. ICC: 92.9 %).

CONCLUSION

ICCs are rare in cirrhotic livers. CEUS can demonstrate differences in the vascularization patterns between HCC and ICC. HCC showed an arterial global hyperenhancement and delayed contrast washout in the late phase. ICCs are characterized by an arterial contrast enhancement at the tumor periphery with early contrast washout of the vascularized parts of the lesions in the portal-venous and late phase.

Dynamic contrast-enhanced ultrasound (DCE-US) for the characterization of hepatocellular carcinoma and cholangiocellular carcinoma

PURPOSE

In a prospective study, we compared the different perfusion kinetics of HCC and ICC using dynamic contrast-enhanced ultrasound (DCE-US).

MATERIALS AND METHODS

Patients with proven HCC and ICC were included. Three-minute video clips of CEUS examinations (CPS - low MI mode) after a bolus injection of 1.2 ml SonoVue were recorded and analyzed with quantification software (VueBox). Parameters for the arterial contrast enhancement [rise time (RT), time-to-peak (TTP)] towards portal venous contrast enhancement [mean transit time (local) (mTTl) and fall time (FT)] were quantified. Furthermore, contrast wash-out after peak enhancement (PE) (40 s, 80 s, 100 s and 120 s after PE) was compared between HCC and ICC.

RESULTS

43 patients with proven HCC (n = 23 HCC; cirrhosis n = 16) and ICC (n = 20 ICC; Cirrhosis n = 6) were examined. No statistical difference of the arterial DCEUS parameters was found between HCC and ICC. Contrast enhancement of the portal venous and late phases showed significantly lower values in the ICC group indicating early wash-out of the contrast agent: mTTl (p = 0.0209): HCC 118.4 s (SD± 88.4); ICC 64.8 s (SD± 49.7). FT (p = 0.0433): HCC 42.5 s (SD± 27.7); ICC 27.7 s (SD± 16.2). The percental loss of intensity at a definite time point after PE was significantly higher in ICC than in HCC lesions.

CONCLUSION

DCE-US is able to detect and quantify differences in perfusion kinetics between HCC and ICC. Whereas arterial contrast enhancement patterns may overlap between HCC and ICC, a timed characterization of wash-out kinetics may offer an additional tool to characterize HCC and ICC. The presence of a rapid loss of signal intensity in the early portal venous phase is significantly higher in ICC than in HCC lesions.

[A case of curatively resected intrahepatic cholangiocarcinoma with hepatic artery and portal vein reconstruction]

We report a case of curatively resected intrahepatic cholangiocarcinoma (ICC) with hepatic artery (HA) and portal vein (PV) reconstruction. A 25-year-old man was diagnosed with ICC. Computed tomography (CT) showed that the tumor had invaded the left and common hepatic duct, the right and left HA, and the main branch of the PV. Because the posterior HA was tumor free, we performed a left trisegmentectomy, PV and HA resection and reconstruction, and a hepatocholangiojejunostomy. Pathological examination revealed a tumor classification of T3, N1, M0, Stage IVB. The patient was discharged on postoperative day 59 and gemcitabine (1,000 mg/m²) was administered as adjuvant chemotherapy. However, abdominal CT revealed peritoneal metastasis 8 months after the surgery. A gemcitabine, cisplatin, and TS-1 (GCS) regimen was selected as treatment, and the patient is alive 13 months after surgery.

[A case of curative resection after downsizing chemotherapy in initially unresectable locally advanced intrahepatic cholangiocarcinoma]

This case report describes an 83-year-old man with intrahepatic cholangiocarcinoma who was referred by a local hospital. Abdominal computed tomography (CT) showed a large tumor in hepatic segments 4, 5, and 8 involving the right hepatic vein and inferior vena cava, which is normally indicative of an unresectable locally advanced tumor. After systemic chemotherapy with gemcitabine and cisplatin, the observed decrease in the level of tumor marker suggested that the cancer was responding to treatment, while radiological findings showed the main tumor shrunk without the presence of distant metastases. Thus, hepatic left trisectionectomy with bile duct resection was performed after portal vein embolization. Pathological examination revealed negative margins (R0). Eighteen months after surgery, the patient is free of disease and shows no signs of recurrence. An initially unresectable, locally advanced biliary tract cancer may be down sized by chemotherapy, which makes radical resection possible, at least in a proportion of patients. This approach provides longer survival and may have a potential for disease eradication as a new multidisciplinary approach for patients with unresectable locally advanced biliary tract cancer.

[Portal vein stenting as a bridge to chemotherapy for perihilar cancer with portal vein stenosis - a case report]

The stenting strategy for portal vein stenosis in cases with unresectable hilar malignancies reduces portal hypertension and maintains portal vein blood flow. This not only improves quality of life, but also leads to aggressive therapy with anticancer agents. A 65-year-old woman presented with painless jaundice 8 months after left hemihepatectomy with lymph node dissection for intrahepatic cholangiocellular carcinoma. Seven months after biliary stenting for bile duct stenosis, progressing pancytopenia and ascites were noted. Imaging studies revealed portal vein stenosis by the tumor at the hepatic hilum. Percutaneous transhepatic portal vein stent placement was performed, and pancytopenia and ascites improved immediately thereafter. Chemotherapy for recurrence of intrahepatic cholangiocellular carcinoma at the hepatic hilum has been initiated, and the patient has been alive 15 months since.

[Hepatic inferior vena cava resection and vascular prosthesis reconstruction for locally advanced intrahepatic cholangiocarcinoma - a case report]

A 61-year-old woman was referred to our hospital because of jaundice and general itching. Computed tomography (CT) scan demonstrated that the tumor was located in the caudate lobe of the liver with hilar invasion and involved the hepatic inferior vena cava (IVC) and the right renal artery and vein. The patient was diagnosed with locally advanced intrahepatic cholangiocarcinoma, for which she underwent right hemihepatectomy with right caudate lobectomy, portal vein resection, hepatic IVC resection, extrahepatic bile duct resection, and right nephrectomy. IVC was reconstructed using vascular prosthesis by expanded polytetrafluoroethylene (ePTFE)-ringed graft. The patient's postoperative course was uneventful. The patient was treated with gemcitabine for postoperative chemotherapy, and 3 years after the operation, she died due to recurrence resulting from peritoneal dissemination. Although the thrombosis-related vascular prosthesis obstruction had occurred 2 years after the operation, no clinical symptom were noted, such as lower leg edema or renal dysfunction, during the postoperative course. Hepatic IVC prosthesis reconstruction for locally advanced cancer with extensive IVC invasion can be a useful surgical procedure for improving the resection rate and maintaining quality of life (QOL) in such cases.

[Results of preoperative embolization of portal vein in patients with biliary hepatic tumors]

The results of preoperative embolization of portal vein (EPV) in 90 patients, operated on for biliary hepatic tumors, were analyzed. In 47 patients Klatskin tumor was revealed, in 29--peripheral cholangiocarcinoma, in 14--tumor of a gallbladder. In all the patients a radical major hepatic resection was planned, a checking hepatic volume (CHHV) did not exceed 40% of a noninvolved parenchyma. The EPV volume have corresponded generally to the planned resection volume. After performance of EPV a pressure in a portal vein have risen by 75%, and later it have had lowered step by step during 24 h. The CHHV index have raised from (354 +/- 72) up to (462 +/- 118) cm3, or from (33 +/- 7) up to (45 +/- 11)%, permitting to perform radical hepatic resection in 79 (87.8%) patients. Thus, application of EPV in patients, suffering biliary hepatic tumors, have permitted to increase the CHHV index after radical resection, and to raise resectability of such tumors.

Systematic review and meta-analysis of the role of vascular resection in the treatment of hilar cholangiocarcinoma

BACKGROUND

The management of hilar cholangiocarcinoma has evolved over time and extended liver resection, including the caudate lobe, and major vascular resection and extended lymphadenectomy have become established practice. The benefit of vascular resection has not been investigated.

METHODS

A systematic search of the MEDLINE and EMBASE databases was used to identify studies. A systematic review and a meta-analysis of the available studies were conducted according to PRISMA guidelines. Odds ratios were calculated using the Mantel-Haenszel method. Primary outcome variables assessed included morbidity, mortality, vascular complications and the effect of vascular resection on longterm survival.

RESULTS

Of 411 search results, only 24 studies reported the results of vascular resection in hilar cholangiocarcinoma. Meta-analysis showed increased morbidity and mortality with hepatic artery resection. Portal vein resection was achievable with no impact on postoperative mortality. Vascular resection did not improve negative margin rates and had no impact on longterm survival.

CONCLUSIONS

Portal vein resection does not preclude curative resection; however, it is not routinely recommended unless there is suspicion of tumour invasion. There was no proven survival advantage with portal vein resection. Arterial resection results in higher morbidity and mortality with no proven benefit.

Contrast-enhanced ultrasound (CEUS) in the diagnostic algorithm of hepatocellular and cholangiocellular carcinoma, comments on the AASLD guidelines

Contrast-enhanced ultrasound (CEUS) has long been present in important guidelines and recommendations for the diagnostic work-up of focal liver lesions in patients with cirrhosis. These guidelines have included the guidelines of the American Association for the Study of Liver Diseases (AASLD) 2005, the Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma, the recommendations of the Japanese Society of Hepatology, and the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) guidelines 2004, 2008 and 2012 (in preparation). Recently, the AASLD removed CEUS from their guidelines in part because of the perceived possibility of false-positive hepatocellular carcinoma (HCC) diagnosis in patients with intrahepatic cholangiocarcinoma (ICC), and in part because CEUS is not available in the USA. This latter factor means that published results are not entirely applicable to a North American population. The present manuscript discusses the diagnostic algorithm of hepatocellular carcinoma and provides information on the differential diagnosis between HCC and ICC.

[Resection of cholangiolocellular carcinoma successfully responding to neoadjuvant hepatic arterial infusion chemotherapy - report of a case]

A 78-year-old man who had hepatitis C was examined by computed tomography(CT)because of prostate cancer, and was found to have a liver tumor 8. 0 cm in size at S4/S8. The view of the liver tumor was enhanced by CTHA image and washed out by CTAP image. It was suspected to have invaded the RHV and MHV. The pathological examination of the liver biopsy sample revealed cholangiocellular carcinoma or cholangiolocellular carcinoma. Hepatic arterial infusion chemotherapy with gemcitabine and cisplatin was performed. The size of the tumor reduced to 6. 0 cm and the invasion to the RHV was no longer evident. Hepatic resection for the middle two segments was performed after 3 months of chemotherapy. After a histological examination of the resected specimen, the patient was given the final diagnosis of cholangiolocellular carcinoma. Over 50% of the tumor was estimated as necrosis by chemotherapy, indicating that the gemcitabine and cisplatin regimen was remarkably effective. The patient is alive with no evidence of recurrence.

Liver tumor characterization--comments and illustrations regarding guidelines

Contrast-enhanced ultrasound (CEUS) is a well established diagnostic imaging technique for a variety of indications and applications. One of the most important applications is in the liver where it is frequently a first-line technique for the detection and diagnosis (characterization) of focal liver lesions (FLLs). In this setting the accurate differentiation of benign lesions from malignant lesions is critical to ensure that the patient undergoes the appropriate therapeutic option. In this article the role of CEUS in the characterization of FLLs is described on the basis of recently published guidelines, in particular in terms of the enhancement patterns of the most common FLLs, e. g. hemangioma, focal nodular hyperplasia, hepatocellular adenoma and their differentiation from malignant lesions.

Liver tumor characterization--review of the literature

Multicenter trials to assess contrast-enhanced ultrasound (CEUS) for the imaging of focal liver lesions (FLLs) have included more than 1000 patients. This article reviews the published literature pertaining to these trials to determine the role of CEUS in the characterization of FLL.

Loss of liver-intestine cadherin in human intrahepatic cholangiocarcinoma promotes angiogenesis by up-regulating metal-responsive transcription factor-1 and placental growth factor

Liver-intestine cadherin (LI-cadherin) represents a novel type of cadherin within the cadherin superfamily that comprises seven cadherin repeats and a short cytoplasmic domain. In this study, we first examined LI-cadherin expression immunohistochemically in 34 specimens of human intrahepatic cholangiocarcinoma (ICC). LI-cadherin expression was positive (defined as positivity in > or = 10% of cells) in 18 of the ICCs (52.9%). LI-cadherin negativity was significantly correlated with tumor dedifferentiation (P=0.026) and vascular invasion (P=0.015). The cumulative survival rate of patients with LI-cadherin-negative ICC was significantly shorter than that of patients with LI-cadherin-positive ICC (P=0.021). Multivariate analysis identified the extent of LI-cadherin staining as an independent prognostic factor for ICC survival (P=0.027). Next, to elucidate the mechanism of loss of LI-cadherin-mediated aggressiveness in ICC, we knocked down LI-cadherin expression in an ICC cell line using small interfering RNA (siRNA) technology, and screened for genes that were expressed differentially between these cells and ICC cells transfected with scrambled siRNA using microarray analysis with real-time polymerase chain reaction confirmation. Among 21 identified genes, we focused on metal-responsive transcription factor-1 (MTF-1), whose target genes might contribute to tumor aggressiveness. Expression of placental growth factor (PlGF), one of the MTF-1 target genes, was up-regulated in the ICC cells transfected with LI-cadherin siRNA. Likewise, PlGF expression was up-regulated in LI-cadherin-negative ICC specimens. There was a significant inverse relationship between these expressions (P=0.033). Furthermore, the microvessel density of LI-cadherin-negative ICC specimens was higher than that of LI-cadherin-positive specimens. These findings suggest that loss of LI-cadherin in ICC is associated with tumor dedifferentiation and vascular invasion, and thus poor prognosis. Loss of LI-cadherin results in up-regulation of MTF-1 and PlGF, thereby regulating angiogenesis in ICC.

Loss of liver-intestine cadherin in human intrahepatic cholangiocarcinoma promotes angiogenesis by up-regulating metal-responsive transcription factor-1 and placental growth factor

Liver-intestine cadherin (LI-cadherin) represents a novel type of cadherin within the cadherin superfamily that comprises seven cadherin repeats and a short cytoplasmic domain. In this study, we first examined LI-cadherin expression immunohistochemically in 34 specimens of human intrahepatic cholangiocarcinoma (ICC). LI-cadherin expression was positive (defined as positivity in > or = 10% of cells) in 18 of the ICCs (52.9%). LI-cadherin negativity was significantly correlated with tumor dedifferentiation (P=0.026) and vascular invasion (P=0.015). The cumulative survival rate of patients with LI-cadherin-negative ICC was significantly shorter than that of patients with LI-cadherin-positive ICC (P=0.021). Multivariate analysis identified the extent of LI-cadherin staining as an independent prognostic factor for ICC survival (P=0.027). Next, to elucidate the mechanism of loss of LI-cadherin-mediated aggressiveness in ICC, we knocked down LI-cadherin expression in an ICC cell line using small interfering RNA (siRNA) technology, and screened for genes that were expressed differentially between these cells and ICC cells transfected with scrambled siRNA using microarray analysis with real-time polymerase chain reaction confirmation. Among 21 identified genes, we focused on metal-responsive transcription factor-1 (MTF-1), whose target genes might contribute to tumor aggressiveness. Expression of placental growth factor (PlGF), one of the MTF-1 target genes, was up-regulated in the ICC cells transfected with LI-cadherin siRNA. Likewise, PlGF expression was up-regulated in LI-cadherin-negative ICC specimens. There was a significant inverse relationship between these expressions (P=0.033). Furthermore, the microvessel density of LI-cadherin-negative ICC specimens was higher than that of LI-cadherin-positive specimens. These findings suggest that loss of LI-cadherin in ICC is associated with tumor dedifferentiation and vascular invasion, and thus poor prognosis. Loss of LI-cadherin results in up-regulation of MTF-1 and PlGF, thereby regulating angiogenesis in ICC.

Oxaliplatin-eluting microspheres for the treatment of intrahepatic cholangiocarcinoma: a case report

Intrahepatic cholangiocarcinoma account for 13% of annual cancer-related deaths worldwide and for 3% in the USA. Patient with unresectable disease can benefit from palliative therapies such as systemic chemotherapy. However, the only curative treatment for intrahepatic cholangiocarcinoma is complete surgical resection with histologically negative resection margins.

[Selective exclusion of hepatic outflow and inflow in hepatectomy for huge hepatic tumor]

OBJECTIVE

To evaluate the effects of selective hepatic vascular exclusion (SHVE) on prevention of serious hemorrhage and air embolism during hepatectomy and on the liver function after operation.

METHODS

From January 2004 to March 2007, 29 huge hepatic tumors were resected in our department. Both SHVE and Pringle maneuver were used to control the blood loss during hepatectomy. They were divided into two groups: SHVE group (15 cases) and Pringle group (14 cases). Data regarding the intraoperative and postoperative courses of the patients were analyzed.

RESULTS

There was no significant difference between the two groups regarding the age, sex, tumor size, cirrhosis, HbsAg positive rate and operating time (P > 0.05). Intraoperative blood loss was reduced significantly in the SHVE group (P < 0.05). The serum prealbumin levels on the postoperative day 1, 3 and 7 in SHVE group were significantly higher than those in the Pringle group (P < 0.05). The serum ALT value in SHVE group was significantly lower than that in the Pringle group on postoperative day 1, 3 and 7. The mean drainage volume in SHVE group was significantly less than that in the Pringle group on postoperative day 1 and 2. Liver failure occurred in two cases of the Pringle group, while no one in the SHVE group. Rupture of hepatic vein with massive blood loss occurred in 3 cases and air embolism in one case of the Pringle group, but did not occur in any case of the SHVE group.

CONCLUSION

When the selective exclusion of hepatic outflow and inflow is applied in hepatectomy, the resection rate of huge hepatic tumors and operative tolerance of hepatectomy are improved. It is a safe and rational operation type, and provides an optimal choice for hepatectomy.

Hepatectomy and pancreatectomy with combined vascular resection in patients with hepato-biliary and pancreas diseases at a single cancer institute

BACKGROUND/AIMS

In advanced cancers of hepatobiliary and pancreatic lesions, major vascular resection and reconstruction are necessary to accomplish curative resection, which may provide better patient outcomes.

METHODOLOGY

Surgical records, morbidity and mortality, and prognosis were examined in patients with combined vascular resection. Thirty-six patients underwent 18 hepatectomies and 18 pancreatectomies.

RESULTS

In 18 patients who underwent hepatic resection, the resected vessels were the portal vein (PV) in 10, vena cava or hepatic vein in 9 and right hepatic artery (RHA) in 3. An artificial graft was used in 2 to replace the vena cava. Vascular bypass was performed in 5 patients. Morbidity was due to biliary stricture in 1 patient and adult respiratory distress syndrome in another who died during hospital stay. Fourteen (82%) had cancer recurrence, of whom 12 died of cancer, one died of other disease, and 2 survived cancer-free. The 5-year survival was 28%. In 18 patients who underwent pancreatectomy, resected vessels were PV in 18 and RHA in 1. An artificial graft was used in 3 and vascular passive bypass was performed in 6. One patient died of sepsis after total pancreatectomy during hospital stay. Eleven (64%) had cancer recurrence, of whom 11 died of cancer, 2 died of other disease, and 4 survived cancer-free. The 3-year survival was 27%.

CONCLUSIONS

Complete surgical resection (R0) combined with main vascular resection could be safely performed in many patients with disease of the hepatobiliary and pancreas, which achieved longer survival in some patients even in the advanced stage.

Recent advances in the treatment of hilar cholangiocarcinoma: portal vein embolization

The clinical application of portal vein embolization (PVE) has contributed to improving the postoperative outcome of hilar cholangiocarcinoma. The enlarged nonembolized lobe after PVE protects the patient from postoperative hepatic failure, due to the increased functional reserve, and shortens the hospital stay. Although numerous reports have shown beneficial effects of PVE on postoperative outcome after extended hepatectomy, no randomized controlled study has been performed so far. It is urgent to establish a "gold standard" of PVE, because the indications, approach to the portal vein, types of embolic materials, and methods used to evaluate the function of the future liver remnant are variable among institutions. The indications and procedures of PVE for hilar cholangiocarcinoma may be different from those for hepatocellular carcinoma or colorectal metastasis, because, in many patients with hilar cholangiocarcinoma, biliary cancer is associated with biliary obstruction and cholangitis. This review article summarizes the contribution of PVE to the outcome of postoperative management in patients with hilar cholangiocarcinoma needing extended hepatectomy. We also describe our PVE procedure, which has been established from our experience of more than 240 cases of biliary cancer. Furthermore, the drawbacks of PVE, which may reduce the pool of candidates for surgery, are also discussed.

Two hundred forty consecutive portal vein embolizations before extended hepatectomy for biliary cancer: surgical outcome and long-term follow-up

OBJECTIVE

To assess clinical benefit of portal vein embolization (PVE) before extended, complex hepatectomy for biliary cancer.

SUMMARY BACKGROUND DATA

Many investigators have addressed clinical utility of PVE before simple hepatectomy for metastatic liver cancer or hepatocellular carcinoma, but few have reported PVE before hepatectomy for biliary cancer due to the limited number of surgical cases.

METHODS

This study involved 240 consecutive patients with biliary cancer (150 cholangiocarcinomas and 90 gallbladder cancers) who underwent PVE before an extended hepatectomy (right or left trisectionectomy or right hepatectomy). All PVEs were performed by the "ipsilateral approach" 2 to 3 weeks before surgery. Hepatic volume and function changes after PVE were analyzed, and the outcome also was reviewed.

RESULTS

There were no procedure-related complications requiring blood transfusion or interventions. Of the 240 patients, 47 (19.6%) did not undergo subsequent hepatectomy. The incidence of unresectability was higher in gallbladder cancer than in cholangiocarcinoma (32.2% versus 12.0%, P < 0.005). The remaining 193 patients (132 cholangiocarcinomas and 61 gallbladder cancers) underwent hepatectomy with resection of the caudate lobe and extrahepatic bile duct (n = 187), pancreatoduodenectomy (n = 42), and/or portal vein resection (n = 63). Seventeen (8.8%) patients died of postoperative complications: mortality was higher in gallbladder cancer than in cholangiocarcinoma (18.0% versus 4.5%, P < 0.05); and it was also higher in patients whose indocyanine green clearance (KICG) of the future liver remnant after PVE was <0.05 than those whose index was >or=0.05 (28.6% versus 5.5%, P < 0.001). The 3- and 5-year survival after hepatectomy was 41.7% and 26.8% in cholangiocarcinoma and 25.3% and 17.1% in gallbladder cancer, respectively (P = 0.011). In 136 other patients with cholangiocarcinoma who underwent a less than 50% resection of the liver without PVE, a mortality of 3.7% and a 5-year survival of 27.6% were observed, which was similar to the 132 patients with cholangiocarcinoma who underwent extended hepatectomy after PVE.

CONCLUSIONS

PVE has the potential benefit for patients with advanced biliary cancer who are to undergo extended, complex hepatectomy. Along with the use of PVE, further improvements in surgical techniques and refinements in perioperative management are necessary to make difficult hepatobiliary resections safer.

Angiogenesis in cholangiocellular carcinoma: expression of vascular endothelial growth factor, angiopoietin-1/2, thrombospondin-1 and clinicopathological significance

Angiogenesis in cholangiocellular carcinoma (CCC) has rarely been investigated. The aim of this study was to determine the angiogenesis status of CCC and assess its relationship with angiogenic factors and clinicopathological characteristics. We examined 33 surgically resected CCC specimens. Tumor angiogenesis was assessed by microvessel density (MVD) using the anti-CD34 antibody, and the expression of VEGF, Ang-1, Ang-2, and TSP-1 was determined by immunohistochemistry. The mean (+/- SD) MVD was 87.2+/-52.6/mm2 (range, 0-229/mm2). A total of 75.6% cases were positive for VEGF expression, 36% for Ang-1, 57.6% for Ang-2 and 45.5% for TSP-1. VEGF and Ang-2 expression was associated with a significantly higher level of MVD (p=0.004 and 0.015, respectively). TSP-1 expression was associated with a significantly lower level of MVD (p=0.005) and a higher level of intrahepatic metastasis (46.7% vs. 5.6%, p=0.012). There was no significant correlation between VEGF, Ang-1, Ang-2, and TSP-1 expression and tumor size, capsule formation, infiltration of capsule, portal vein invasion, intrahepatic metastasis or CCC differentiation. There was no significant correlation between MVD levels, VEGF, Ang-1, Ang-2, and TSP-1 expression and postoperative survival. A considerable degree of angiogenesis, comparable to that of other solid tumors, was observed in CCC. VEGF and Ang-2 might play a proangiogenic role, and TSP-1 may play an inhibitory role in CCC. Although TSP-1 may increase intrahepatic CCC metastases, neither MVD levels nor the expression of VEGF, Ang-1, or Ang-2 was associated with clinicopathological factors and prognosis.

Doppler assessment after right hepatectomy confirms the need to fix the remnant left liver in the anatomical position

Background

The remnant left liver after right hepatectomy tends to rotate spontaneously into the right subphrenic space. This rotation might induce venous outflow impairment. The aim of this study was to assess immediate venous outflow in the left hepatic vein by intraoperative Doppler ultrasound (US) according to the position of the remnant liver.

Methods

From August 2003 to February 2004, assessment of left hepatic venous outflow was systematically performed in 44 consecutive right hepatic resections by Doppler US in spontaneous and anatomical positions. The anatomical position was defined as the position in which the falciform ligament was in its strict median position.

Results

The placement of the left liver from the spontaneous position to the anatomical position resulted in a significant increase in left hepatic venous outflow (20·1 ± 5·7 versus 8·5 ± 4·4 cm/s; P &lt; 0·0001). In the spontaneous position, the decrease in left hepatic venous outflow persisted even without division of the left triangular ligament (10·2 ± 5·4 versus 21·7 ± 5·3 cm/s in the anatomical position) or removal of the middle hepatic vein (8·4 ± 3·4 versus 21·3 ± 5·8 cm/s).

Conclusion

Results of this study strongly suggest that after right hepatectomy the remnant left liver should always be fixed in the anatomical position.

Expression of sialyl Lewisa relates to poor prognosis in cholangiocarcinoma

AIM: High levels of serum sialyl Lewis^a (sLe^a) are frequently found in cholangiocarcinoma (CCA) patients and have been suggested to be a serum marker for CCA. However, the significance of this antigen in CCA is unknown. In this study, the clinical significance of sLe^a expression in CCA tissues and the possible role of sLe^a in vascular invasion in vitro were elucidated.

METHODS: Expression of sLe^a in tumor tissues of 77 patients with mass-forming CCA and 33 with periductal infiltrating CCA was determined using immunohistochemistry. The in vitro assays on adhesion and transmigration of CCA cells to human umbilical vein endothelial cells were compared between CCA cell lines with and without sLe^a expression.

RESULTS: sLe^a was aberrantly expressed in 60% of CCA tumor tissues. A significant relationship was found between the frequency of sLe^a expression and the mass-forming type CCA (P = 0.041), well differentiated histological grading (P = 0.029), and vascular invasion (P = 0.030). Patients with positive sLe^a expression had a significantly poorer prognosis (21.28 wk, 95% CI = 16.75-25.81 wk) than those negative for sLe^a (37.30 wk, 95% CI = 27.03-47.57 wk) (P<0.001). Multivariate analysis with adjustment for all covariates showed that patients positive for sLe^a possessed a 2.3-fold higher risk of death than patients negative for sLe^a (P<0.001). The role of sLe^a in vascular invasion was demonstrated using in vitro adhesion and transmigration assays. KKU-M213, a human CCA cell-line with a high expression of sLe^a, adhered and transmigrated to IL-1β-activated endothelial cells of the human umbilical vein more than KKU-100, the line without sLe^a expression (P<0.001). These processes were significantly diminished when the antibodies specific to either sLe^a or E-selectin were added to the assays (P<0.001).

CONCLUSION: This study demonstrates the clinical significance of sLe^a expression in vascular invasion, and an unfavorable outcome in CCA. The role of sLe^a in vascular invasion which may lead to poor prognosis is supported by the in vitro adhesion and transmigration studies.

[Radiofrequency ablation of recurrent intrahepatic cholangiocarcinoma: a case report]

A 45-years-old patient with recurrent intrahepatic cholangiocarcinoma 3 years after resection is described. 2 sessions of percutaneous radiofrequency ablation (RFA) were performed and complete destruction of the tumor was achieved. The patient was followed-up for 15 months by means of power-Doppler, CT and tumor markers. No local or heterotopic recurrences were observed. The case demonstrates the possibilities of RFA in the management of postoperative recurrences of intrahepatic cholangiocarcinoma and confirms the significance of the method in the complex approach to the liver tumors.

Intraoperative three-dimensional visualization of liver vasculature by ultrasonography

BACKGROUND/AIMS

To understand the three-dimensional relationship between the liver vasculature and tumor by intraoperative sonography, some training is inevitable. Three-dimensional ultrasound has been evaluated in various fields, but not yet in intraoperative sonography.

METHODOLOGY

Extracorporeal 3-D ultrasonography was performed in 32 patients. Of these, 20 underwent intraoperative 3-D ultrasonography. Using these images, we evaluated whether or not the portal vein, hepatic vein and its branches were discernible.

RESULTS

Satisfactory images were obtained in all 32 patients by extracorporeal methods and in 15 by intraoperative 3-D ultrasonography. The number of visualized veins, including the right portal vein, its anterior branch, posterior branch, anterior superior branch, anterior inferior branch and right hepatic vein, was 32, 32, 23, 28, 22, and 30 by extracorporeal 3-D ultrasonography, and 15, 14, 10, 8, 5, and 12 by intraoperative 3-D ultrasonography. The relationships between the intrahepatic artery, portal vein, and hepatic vein were more clearly visualized by intraoperative 3-D sonography.

CONCLUSIONS

Intraoperative 3-D ultrasonography clearly showed small branches of the liver vasculature and their 3-D relation, which may be helpful for liver surgery. However, this method requires further improvement.

Hemodynamics of intrahepatic cholangiocarcinoma: evaluation with single-level dynamic CT during hepatic arteriography

BACKGROUND

We determined the radiologic characteristics of intrahepatic cholangicarcinoma (ICC) on single-level dynamic computed tomography during hepatic arteriography (CTHA) and assessed the hemodynamics of the tumor.

METHODS

Eleven patients with pathologically confirmed ICC underwent single-level dynamic CTHA. After placing the catheter tip in the proper hepatic artery and running a 30-s continuous scan, scanning was performed every 15 or 30 s for 120 s. The change of contrast-enhancement pattern of the ICCs were interpreted retrospectively.

RESULTS

The pattern of enhancement was classified into two types: vascular and hypovascular. In the vascular type, the contrast enhancement gradually spread from each intratum oral artery and became mottled. It changed from a mottled and hypoattenuated pattern to an even and hyperattenuated appearance in comparison with the adjacent liver approximately 120 s after the injection of contrast agent. In the hypovascular type, the tumor was barely enhanced and remained hypoattenuated compared with the adjacent liver at 120 s after the beginning of the injection. The 11 ICCs were classified into eight vascular types and three hypovascular types. Intratumoral arteries were visualized in nine tumors: eight vascular types and one hypovascular type.

CONCLUSION

The contrast-enhancement pattern of ICC on single-level dynamic CTHA is related to the intratumoral artery.

Prognostic factors in node-negative intrahepatic cholangiocarcinoma with special reference to angiogenesis

BACKGROUND

The aim of this study was to clarify prognostic factors and recurrence patterns in patients with node-negative intrahepatic cholangiocarcinoma (IHCC).

METHODS

A retrospective study was performed to review prognostic factors and recurrence patterns (1) in 22 patients with node-negative IHCC after curative hepatic resection and (2) in 49 patients who underwent resection and lymph node dissection for IHCC. In addition to determining the clinicopathologic factors, the investigators also performed immunohistochemical examination of microvessel counts using antihuman CD-31 and antibody.

RESULTS

The significant poor prognostic factors in node-negative IHCC were the presence of intrahepatic metastasis, portal vein invasion of cancer cells, and high microvessel counts. After multivariate analysis was conducted, the independent poor prognostic factors were the presence of intrahepatic metastases and high microvessel counts. Of 9 patients who had postoperative recurrence of their disease, intrahepatic recurrence was observed in 7 (78 %).

CONCLUSIONS

The factors linked to poor prognosis in IHCC were tumor angiogenesis and the presence of intrahepatic metastasis. Because intrahepatic recurrence was common, regional and adjuvant chemotherapy to the liver may improve the outcome of patients with these risk factors and node-negative IHCC.

Longer than 3-Year Survival Following Hepato-Ligamento-Pancreatoduodenectomy for Hilar Cholangiocarcinoma with Vascular Involvement: Report of a Case

A 70-year-old man presented with a mass-forming perihilar cholangiocarcinoma in his left liver, and both the portal trunk and proper hepatic artery were involved by the tumor. We performed a hepato-ligamento-pancreatoduodenectomy (HLPD), including an extended left lobectomy with a caudate lobectomy, and the external iliac vein graft was harvested for portal vein reconstruction while the right middle colic artery was anastomosed to the right posterior hepatic artery. Vascular involvement (portal vein and hepatic artery) and peripancreatic lymph node metastases were proven histologically. Although the liver abscess and pancreatic fistula both occurred postoperatively, the patient is now healthy and still alive 3 years 9 months after surgery without recurrence. We consider that the absence of para-aortic lymph node metastases and hepatic invasion which is not involved beyond the second order of the hepatic ducts in the future remnant liver might therefore have contributed to the satisfactory outcome after performing HLPD in this case.

Incremental value of advanced image processing of multislice computed tomography data in the evaluation of hypervascular liver lesions

Multiplanar volume rendering and maximum intensity projection of multislice computed tomography data allow for robust evaluation of the hepatic parenchyma, with early detection of neovascularity and tumor stain, and enable better assessment of the tumor burden compared with routine axial images. Lesion characterization can also potentially improve. This is in addition to accurate delineation of the hepatic vascular anatomy, which allows for segmental localization and assists in surgical and nonsurgical planning.

Contrast media-enhanced power Doppler sonography for evaluation of hemangiomas and malignant tumors in the liver

AIM

To evaluate the characterization of liver hemangiomas and malignant tumors using power Doppler sonography before and after intravenous injection of a sonocontrast agent.

METHODS

Forty-five patients with 57 liver tumors (22 hemangiomas, 24 metastases, 10 hepatocellular carcinomas (HCC) and one cholangiocellular carcinoma) were examined prospectively. The distribution (peripheral, central, mosaic) and extent (none, minimal, moderate and strong) of intratumoral flow pattern in each sonographic examination was subjectively classified.

RESULTS

The administration of the sonocontrast agent by bolus injection caused enhancement to gradually increase up to 2 min and lasted for 4-5 min. After injection of contrast agent, flow signals appeared or increased in 34 tumors. No signal enhancement was observed in 18 hemangiomas, four metastases and one HCC. The sensitivity and specificity of intratumoral vascularity for the detection of malignant liver tumors was 37.1 and 90.9% for unenhanced power Doppler sonography, and 85.7 and 81.8% for contrast-enhanced power Doppler sonography, respectively.

CONCLUSION

Contrast-enhanced power Doppler sonography is superior to unenhanced power Doppler sonography in the demonstration of malignant tumor vascularity, and is helpful in differentiating between hemangiomas and malignant liver tumors. A specific flow pattern within the tumor is not established in primary and metastatic malignant tumors with contrast-enhanced power Doppler sonography.

The role of thymidine phosphorylase and thrombospondin-1 in angiogenesis and progression of intrahepatic cholangiocarcinoma

Thymidine phosphorylase (TP), an important regulator of angiogenesis, is correlated with progression, metastasis, and prognosis in various types of tumor. In contrast, both positive and negative effects of thrombospondin-1 (TSP-1) on angiogenesis have been reported. In the present study, we examined the expression of TP and TSP-1 in carcinoma cells in 67 primary intrahepatic cholangiocarcinomas (ICCs) immunohistochemically and its correlation with angiogenesis, clinicopathological features, and prognosis. Twenty-six (38.8%) cases were classified as exhibiting positive TP expression. TP expression showed a significant correlation with vascular invasion, lymphatic permeation, perineural invasion, and lymph node metastasis. Thirty-four (50.7%) cases were classified as exhibiting positive TSP-1 expression. TSP-1 expression was significantly correlated with only lymphatic permeation. The microvessel count in positive TP expression cases was significantly higher than that in negative cases. In contrast, the microvessel count in negative TSP-1 expression cases was significantly higher than that in positive cases. Survival in patients who were positive for both TP and TSP-1 expression was significantly poor. Our results suggest that the increased TP expression and decreased TSP-1 expression contribute to angiogenesis, but that the role of angiogenesis in ICC is not closely related to tumor aggressiveness. The TP and TSP-1 expression in ICC may enhance tumor aggressiveness.

Arterial chemoinfusion therapy through an implanted port system for patients with unresectable intrahepatic cholangiocarcinoma--initial experience

Arterial chemoinfusion therapy through an implanted port system was performed for patients with unresectable intrahepatic cholangiocarcinoma (ICC). Eleven patients with unresectable ICC were studied. Seven patients had stage-IV disease, two had stage-III disease, and two had stage-II disease. The mean tumor size was 7.0+/-2.6 cm (range 3.8-13.5 cm). A catheter and port system was percutaneously implanted, and anticancer drugs featuring fluorouracil were administered via the infusion system every 1-2 weeks on the outpatient basis in all patients except 2. Arterial chemoinfusion therapy was repeated 12-84 times per patient (mean 51 times). Partial and minor responses were achieved in sevenents (64%). Disease was stable in two patients (18%), and progressed in the other two patients (18%). Tumor growth was controlled during a mean period of 14.5 months in seven responders and two patients with stable disease. The survival rates were 91% at 1 year, 51% at 2 years, 20% at 3 years, and 10% at 4 years, respectively. The mean survival period was 26 months. Toxicity such as cholangitis and pancytopenia was found in three patients (27%). This treatment seems to improve the prognosis of patients with unresectable ICC and deserves further studies.

A new staging system for mass-forming intrahepatic cholangiocarcinoma: analysis of preoperative and postoperative variables

BACKGROUND

The objective of this study was to analyze the clinicopathologic variables and the postoperative outcome in patients with mass-forming intrahepatic cholangiocarcinoma (ICC) to identify important factors for predicting postresection prognosis. Although it has been reported that mass-forming ICC has a different etiology and biologic features compared with hepatocellular carcinoma (HCC), patients with ICC have been dealt with clinicopathologically in the same manner as patients with HCC.

METHODS

Sixty patients who underwent hepatectomy for mass-forming ICC with curative intent between 1981 and 1999 were studied. Fourteen preoperative clinical and diagnostic parameters and 12 postoperative surgicopathologic parameters were analyzed.

RESULTS

The rate of operative mortality in this patient cohort was 5%, and the overall 1-year, 3-year, and 5-year survival rates were 68%, 35%, and 29%, respectively, with a median survival of 19.6 months. A multivariate analysis revealed that independent negative prognostic factors were 1) hepatic regional lymph node metastasis, 2) multiple tumor presentation, 3) symptomatic tumor, and 4) the presence of vascular invasion. Using these factors, a new staging system was devised: Stage I disease was defined as a solitary tumor without vascular invasion, Stage II disease was defined as a solitary tumor with vascular invasion, Stage IIIA disease was defined as multiple tumors with or without vascular invasion, Stage IIIB disease was defined as any tumor with regional lymph node metastasis, and Stage IV disease was defined as any tumor with distant metastases. The Kaplan-Meier estimated 3-year survival rate and the median survival for each subgroup were 74% for patients with Stage I disease (median survival is the time when the cumulative survival rate of some patients' group declined to 50%; thus, the median survival could not be calculated in patients with Stage I disease because survival was 74% at the latest follow-up), 48% and 26.2 months for patients with Stage II disease, 18% and 16.8 months for patients with Stage IIIA disease, and 7% and 11.2 months for patients with Stage IIIB disease, respectively (P < 0.0001). None of the patients met the criteria for Stage IV disease.

CONCLUSIONS

The current results support the use of a new staging system for patients with ICC that is simple and predicts well the differences in survival after patients undergo hepatic resection.

Intrahepatic peripheral cholangiocarcinoma: CT evaluation

BACKGROUND

The purpose of our study was to evaluate the imaging features and patterns of contrast enhancement in peripheral cholangiocarcinomas with computed tomography (CT) and correlate these features with histologic findings when available.

METHODS

We reviewed the CT scans of 24 patients with 25 peripheral cholangiocarcinomas proved by orthotopic liver transplantation (n = 1), liver resection (n = 7), percutaneous needle biopsy (n = 10), and fine needle aspiration biopsy (n = 6). Incremental dynamic nonhelical CT was performed in four cases and helical CT in 21 cases. Portal venous phase images were obtained in all 25 cases. Fourteen patients underwent helical CT during arterial and portal phases. Delayed images were obtained in 20 patients.

RESULTS

The size of the tumors ranged from 1.2 to 17 cm. Bile duct dilatation was present in 13 patients (52%), and regional lymph node enlargement was observed in six patients (24%). Retraction of the liver capsule was present in nine patients (36%). In eight patients (32%), satellite nodules were also detected. All tumors were globally hypodense during the portal phase. In 14 patients (70%), delayed images disclosed hyperattenuating tumors. Rimlike contrast enhancement was the most frequent pattern observed in either arterial (57% of patients) or portal (60% of patients) phase imaging. Portal venous encasement was seen in 10 patients (40%).

CONCLUSION

In the proper clinical setting, detection of a hypodense hepatic lesion with peripheral enhancement, biliary dilatation, and contrast enhancement on delayed images are highly suggestive of peripheral intrahepatic cholangiocarcinoma.

[Percutaneous implantation of port-catheter systems for intraarterial chemotherapy of the liver]

PURPOSE

The objective of this study was to determine the usefulness, safety and acceptance of a new technique of percutaneous implantation of port-catheter-systems (PIPS) for locoregional intraarterial chemotherapy of the liver.

MATERIAL AND METHODS

In 50 patients with malignant hepatic disease, 52 percutaneously implantable port-catheter systems were implanted for intraarterial chemotherapy of the liver as an interventional radiological technique. A commercially available angiographic catheter was placed in the hepatic artery under fluoroscopic control via a transfemoral approach and connected to a Port-A-Cath situated in the groin. This procedure was done on an outpatient basis; no medical treatment was administered.

RESULTS

Percutaneous placement of the port-catheter system was successful in all cases, also in those with a hepatomesenteric trunk. No peri- and post-interventional complications occurred. The median patency was 312 days (13-547 days). The catheter-related complication rate was 12%. The function could be restored by replacement or an interventional procedure in all but one case (2%). Infection and leakage did not occur. The system had been withdrawn without complications in 7/52 cases for a variety of reasons (e.g. hemihepatectomy, desire of the patient or clinician, dissection after intervention, replacement).

CONCLUSION

Percutaneous placement of a port-catheter system is a safe and easy alternative to the surgical placement of port systems for hepatic intraarterial chemotherapy. Long-term complication rates are comparable. The option of easy withdrawal and interventional correction of dysfunction as well as lower costs are additional advantages.

Hepatocellular carcinoma and intrahepatic peripheral cholangiocarcinoma: enhancement patterns with quadruple phase helical CT--a comparative study

PURPOSE

To define the hemodynamic features of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma by using quadruple phase helical computed tomography (CT) and determine the value of this information in characterizing tumors.

MATERIALS AND METHODS

Helical CT of the liver was performed in 45 patients with newly diagnosed HCC or peripheral cholangiocarcinoma. Scans were obtained before and 25 seconds, 70 seconds, and 2-6 minutes after the start of the contrast material injection. The intensity and spatial distribution of contrast material uptake were evaluated during all phases. Time-attenuation curves were established for each lesion. Relative attenuation and lesion conspicuity were assessed. A diagnostic confidence level was assigned to each lesion.

RESULTS

In the majority of HCC lesions, a single, early peak of enhancement followed by a continuous decrease in tumor attenuation over time was seen. The greatest tumor conspicuity occurred during the delayed phase. In cholangiocarcinoma, tumor attenuation increased during the delayed phase. In the majority of lesions, the greatest tumor conspicuity was seen during the portal venous phase. In both tumor types, the diagnostic confidence level improved when the delayed phase was used.

CONCLUSION

The variation over time in the intensity of contrast enhancement in HCC and cholangiocarcinoma differs sufficiently to make this a useful diagnostic criterion. The delayed phase is particularly important because it amplifies this difference.

Contrast-enhanced power Doppler sonography: improved detection of characteristic flow patterns in focal liver lesions

PURPOSE

The aim of this study was to evaluate whether intravenous injection of an ultrasound contrast agent aids in the visualization of focal liver lesions on power Doppler images.

METHODS

Fifty patients with focal liver lesions were studied by B-mode and power Doppler sonography before and after intravenous injection of the contrast agent Levovist (galactose-based microbubbles; 10 ml of a concentration of 300 mg/ml). Thirty-two patients had malignant liver lesions (19 metastases, 12 hepatocellular carcinomas, 1 cholangiocellular carcinoma), while 18 had benign lesions (12 hemangiomas, 2 focal nodular hyperplasias, 4 others).

RESULTS

After contrast medium injection, the number of lesions with no intralesional flow dropped from 18 to 9. Flow signal intensity was rated subjectively as marked on contrast-enhanced images in 17 patients; only 4 patients had marked flow on precontrast images. On precontrast studies, central flow in 10 lesions and peripheral flow in 29 lesions could be observed. After enhancement, the numbers increased to 18 and 34 lesions, respectively.

CONCLUSIONS

On power Doppler images, a greater number of intratumoral vessels are seen in focal liver lesions after contrast medium administration.

Intrahepatic cholangiocarcinoma with marked hypervascularity

Two rare cases of small intrahepatic cholangiocarcinoma with marked hypervascularity are reported. Dynamic computed tomographic and magnetic resonance images of the two cases revealed strong enhancement of the whole tumor on the early phase and prolonged enhancement on the late and delayed phases. In both cases, the tumors turned out to be well-differentiated tubular cholangiocarcinoma that contained a large number of tumor cells and few interstitial fibrous tissues. These results suggest that some intrahepatic cholangiocarcinoma should be differentiated from other hypervascular hepatic tumors, especially hepatocellular carcinoma, and that prolonged enhancement of the tumor on late and delayed phases of dynamic images could be of diagnostic value.

Development of extrahepatic arterial blood supply to the liver during hepatic arterial infusion chemotherapy

The aim of this study was to evaluate the correlation of development of the collateral circulation to the liver during hepatic arterial infusion chemotherapy (HAIC) with the presence of hepatic tumours adjacent to the hepatic surface, and with pretreatment occlusion of aberrant hepatic arteries. In 102 patients with unresectable malignant hepatic tumours treated with HAIC using an implantable port system, development of collaterals to the liver was assessed with CT arteriography using the implantable port and pre- and postoperative angiography. Aberrant hepatic arteries, if present, were occluded prior to treatment for hepatic arterial redistribution. Collaterals to the liver were seen in 29 patients, who had 35 areas with collateral perfusion: 22 areas were in the right posterosuperior area, 6 in the left peripheral area and 7 in the right or left lobar area. Collaterals were revealed more frequently in patients with hepatic tumours adjacent to the hepatic surface than in those without hepatic tumours in peripheral areas in the liver (p < 0.0001). In addition, collaterals developed more frequently in patients with an aberrant hepatic arterial anatomy compared with those with conventional anatomy (p = 0.0007). Our results indicated that patients with hepatic tumours adjacent to the hepatic surface and with pretreatment occlusion of aberrant hepatic arteries had the potential to develop collaterals to the liver during HAIC.

Enhanced expression of thrombospondin-1 and hypovascularity in human cholangiocarcinoma

Cholangiocarcinoma (CCC) is relatively hypovascular, in contrast to hepatocellular carcinoma (HCC), which is often highly vascular. We investigated if the diminished vascularity of CCC is related to altered expression of thrombospondin-1 (TSP-1), an antiangiogenic factor, and/or vascular endothelial growth factor (VEGF), a potent angiogenic factor, comparing the relationships with those of high- and low-vascular HCC. We also investigated the relationship between the mutation of the p53 gene and TSP-1 expression or VEGF expression. Northern blot analysis and immunohistochemical staining were performed on surgically resected human CCC and HCC. The ratios of TSP-1 mRNA level in cancer cells versus adjacent noncancerous cells (T/N ratios) were significantly higher in CCC (n = 11) than in HCC with high vascularity (n = 15). In contrast, T/N ratios of VEGF mRNA level in CCC (n = 11) were comparable with those in HCC with low vascularity (n = 5). In CCC, the cancer cells and fibroblasts were positively stained with anti-TSP-1 antibody. We observed that T/N ratios of VEGF mRNA level, but not those of the TSP-1 mRNA level, were significantly correlated with vascularity in HCC. The relative increase in TSP-1 and the relative decrease in VEGF in tumors compared with normal tissue may underlie the limited angiogenesis of CCC. The p53 gene did not affect the expression of TSP-1 in CCC or VEGF in HCC.

Immediate increase in arterial blood flow in embolized hepatic segments after portal vein embolization: CT demonstration

OBJECTIVE

This study was conducted to determine whether an immediate change occurs in the blood flow distribution in hepatic segments after segmental portal vein embolization.

CONCLUSION

We found an immediate change in the distribution of blood flow in the liver after embolization; with portal vein embolization, we found an immediate increase in the hepatic artery blood flow in the affected segments.

[Value of color Doppler ultrasound in preoperative planning of the resection of liver tumors]

New color Doppler sonography with high resolution improves the detection of liver tumors and provides better information on the hepatic vessels. Echo contrast agents which pass through the lungs open up new fields of application in the investigation of blood flow.