[Experience of Using Immune Checkpoint Inhibitors and Chemotherapy in the Upper Gastrointestinal Tract at Our Hospital]

We investigated the gastric and esophageal cancer cases treated with immune checkpoint inhibitors and chemotherapy at our hospital. Out of 17 gastric cancer cases, 9 were treated with nivolumab(Nivo)plus S-1/oxaliplatin(SOX), 5 with Nivo plus 5-fluorouracil/Leucovorin/oxaliplatin(FOLFOX), and 3 with Nivo plus capecitabine/oxaliplatin(CapeOX), yielding a response rate of 35.3%. We also treated 3 cases of esophageal cancer. Two of these were treated with Nivo plus cisplatin/5- fluorouracil(CF)and 1 case with pembrolizumab(Pembro)plus CF, with a response rate of 33.3%. The incidence of Grade 3 or higher adverse events was 29.4% in gastric cancer and 33.3% in esophageal cancer, and no serious immune-related adverse events were observed. Further case accumulation and long-term studies are required to evaluate efficacy and adverse events in clinical practice.

Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy

INTRODUCTION

Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy.

METHODS

This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm2/m2 in men and <3.92 cm2/m2 in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher.

RESULTS

Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390-11.200; p = 0.010).

CONCLUSION

Sarcopenic obesity is an independent risk factor for severe postoperative complications.

Reevaluation of Makuuchi's criteria for resecting hepatocellular carcinoma: A Japanese nationwide survey

AIM

Although Makuuchi's criteria are widely used to determine the cut-off for safe liver resection, there have been few reports of concrete data supporting their validity. Here, we verified the utility of Makuuchi's criteria by comparing the operative mortality rates associated with liver resection between hepatocellular carcinoma (HCC) patients meeting or exceeding the criteria.

METHODS

A database was built using data from 15 597 patients treated between 2000 and 2007 for whom values for all three variables included in Makuuchi's criteria for liver resection (clinical ascites, serum bilirubin, and indocyanine green clearance) were available. The patients were divided into those fulfilling (n = 12 175) or exceeding (n = 3422) the criteria. The postoperative mortality (death for any reason within 30 days) and long-term survival were compared between the two groups.

RESULTS

The operative mortality rate was significantly lower in patients meeting the criteria than in those exceeding the criteria (1.07% vs. 2.01%, respectively; p < 0.001). On multivariate analysis, exceeded the criteria was significantly associated with the risk for operative mortality (relative risk 2.08; 95% confidence interval (CI), 1.23-3.52; p = 0.007). Surgical indication meeting or exceeding the criteria was an independent factor for overall survival (hazard ratio 1.27; 95% CI, 1.18-1.36; p < 0.001).

CONCLUSION

Makuuchi's criteria are suitable for determining the indication for resection of HCC due to the reduction in risk of operative mortality.

Evaluation of Safety-Related Outcomes of One-Segment and More-Than-One-Segment High-Level Hepatectomy in Hepatocellular Carcinoma Based on the Japanese Board Certification System

Background

We evaluated the impact of the Japanese board certification system for expert surgeons (JBCSES) on complications and survival outcomes in hepatectomy for hepatocellular carcinoma.

Methods

The postoperative outcomes of 493 patients who underwent high-level liver surgery involving one-segment (OSeg) hepatectomy and more-than-one-segment (MOSeg) resection were compared before and after JBCSES establishment. After the establishment of the JBCSES, the patients’ postoperative outcomes were compared using propensity score matching (PSM) to determine the influence of expert surgeons.

Results

The establishment of the JBCSES was associated with a decrease in the overall postoperative complication rates after high-level liver surgery from 50.2 to 38.1% (P = 0.008) and a decrease in Clavien–Dindo class ≥ IIIb complications from 10.2 to 5.0% (P = 0.035). The 90-day mortality rate decreased from 5.1 to 0.7% (P = 0.003), and the 5-year survival rate increased from 51.4 to 63.9% (P = 0.009). Using PSM, a comparison of OSeg hepatectomies that involved expert surgeons (n = 48) and those that did not (n = 48) showed significantly lower intraoperative blood loss in surgeries involving an expert surgeon (mean, 340 vs. 473 mL; P = 0.033). There were no significant differences in complication rates or long-term prognosis between these groups. A comparison of MOSeg hepatectomies that involved expert surgeons (n = 26) and those that did not (n = 26) showed no significant difference in surgical factors, complications, or overall survival between the two groups.

Conclusions

After establishment of the JBCSES, postoperative complication rates and mortality rates decreased and survival rates increased following liver surgery. Expert surgeon participation significantly decreased intraoperative blood loss during OSeg hepatectomies.

Validity of the Algorithm for Liver Resection of Hepatocellular Carcinoma in the Caudate Lobe

BACKGROUND

We aimed to validate our algorithm for resecting Hepatocellular carcinoma (HCC) in the caudate lobe based on tumor location, tumor size, and indocyanine green clearance rate.

METHODS

Patients who underwent curative resections for solitary HCC in the caudate lobe were included. The surgical outcomes of patients with HCC in the caudate lobe were compared with those of patients with HCC in other sites of the liver.

RESULTS

After one-to-one matching, the caudate-lobe group (n = 150) had longer operation time, greater amount of bleeding, lower weight of resected specimens, and shorter distance between tumor and resection line than the other-sites group (n = 150), but the complication rates were not different between the groups (38.0% vs. 34.1%, P = 0.719). After a median follow-up period of 3.0 years (range, 0.3-16.2 years), the median overall survivals were 6.5 (95% confidence interval [CI], 5.3-7.9) and 7.5 years (95% CI, 6.3-9.7) in the caudate-lobe and other-site groups, respectively (P = 0.430). Median recurrence-free survivals in the caudate-lobe group (1.9 years; 95% CI, 1.4-2.7) had a tendency to be shorter than those in the other-sites group (2.3 years; 1.7-3.4) (P = 0.052).

CONCLUSIONS

Patients' survival and complication rates in the caudate-lobe group were comparable to those in the other-sites group; therefore, our algorithm for resecting HCC in the caudate lobe is of clinical use.

Arterial chemoembolisation with cisplatin versus epirubicin for hepatocellular carcinoma (ACE 500 study): A multicentre, randomised controlled phase 2/3 trial

BACKGROUND

Transarterial chemoembolisation (TACE) is a treatment option for hepatocellular carcinoma (HCC), but the optimum agent for TACE remains unclear. We compared the efficacy of TACE with cisplatin versus with epirubicin in patients with unresectable HCC.

METHODS

This multicentre, randomised, phase 2/3 trial was performed at 21 hospitals in Japan. Patients with liver-confined HCC, performance status 0-2, and Child-Pugh class A/B were randomised to receive TACE with cisplatin or epirubicin. Patients were stratified in accordance with the institution, Child-Pugh class, tumour size, tumour thrombosis, α-fetoprotein and prior treatment. The primary end-point was overall survival in the intention-to-treat population. Tumour response was evaluated in accordance with the Response evaluation criteria in solid tumours criteria.

FINDINGS

Between 2008 and 2012, 455 patients were randomly assigned to undergo TACE with cisplatin (n = 228) or epirubicin (n = 227). Eleven patients were ineligible, and 444 patients were included in the full analysis. Twelve patients not receiving TACE were excluded, and 432 patients were included in the safety analysis set. In phase 2, disease control rates in cisplatin (91·7%) and epirubicin (91·8%) groups exceeded the predefined threshold of 70%, and the study proceeded to phase 3. After a median follow-up of 32·7 months (IQR = 15·3-49·3), median overall survival periods were 2·93 years (95% CI 2·60-3·79) and 2·74 years (95%CI 2·26-3·21), respectively (hazard ratio 0·90 [95% CI 0·71-1·15], p = 0·22). Median times to treatment failure were 1·38 and 1·46 years (hazard ratio 1·09 [95% CI 0·88-1·35], p = 0·88), response rates were 65·3% and 60·6% (p = 0·31), and serious adverse event rates were 49·8% and 48·3% (p = 0·56), respectively. No treatment-related deaths occurred in either group.

INTERPRETATION

In our phase 2/3 randomised trial, cisplatin is not significantly superior to epirubicin in TACE for patients with HCC.

Magnetic resonance elastography-based prediction of hepatocellular carcinoma recurrence after curative resection

BACKGROUND

Liver stiffness measurement using magnetic resonance elastography can assess the severity of liver fibrosis, which is significantly associated with recurrence after curative resection for hepatocellular carcinoma. The aim of this prospective study was to investigate whether preoperative liver stiffness measurement by magnetic resonance elastograhy can predict recurrence after curative resection for hepatocellular carcinoma.

METHODS

Patients who underwent preoperative liver stiffness measurement and curative resection for hepatocellular carcinoma were enrolled in this study. Potential associations between liver stiffness measurement, along with other clinical and pathologic variables, and intrahepatic hepatocellular carcinoma recurrence were analyzed.

RESULTS

In total, 156 patients were included in this study. During a median follow-up period of 25.1 months (range, 6.0-60.5 months), 72 (46.1%) patients with hepatocellular carcinoma had an intrahepatic recurrence. The median disease-free period after resection was 17.9 months (range, 1.0-60.5 months). In the multivariate analysis, liver stiffness measurement (hazard ratio, 1.27; 95% confidence interval, 1.11-1.43; P <.001) and vascular invasion (hazard ratio, 1.96; 95% confidence interval, 1.15-3.25; P = .013) were identified as independent predictors of recurrence. When the optimal cutoff point was set at 4.53 kPa using the minimal P value approach, the disease-free period after curative resection in 71 patients with a liver stiffness measurement value ≥4.53 kPa (11.3 months [range, 2.0-60.5 months]) was significantly shorter than that of 85 patients with a liver stiffness measurement value <4.53 kPa (22.5 months [range, 1.1-60.5 months]; P <.001).

CONCLUSION

Liver stiffness measurement using magnetic resonance elastography is a useful preoperative predictor of intrahepatic recurrence after curative resection for hepatocellular carcinoma.

Impact of patient age on outcome after resection for hepatocellular carcinoma

There is little information on the impact of aging on liver resection of hepatocellular carcinoma (HCC). The aim of study was to evaluate the prognostic impact of the patient's age on the long-term survival after resection of HCC. The postoperative outcomes of the 291 elderly (≥ 70 years) and 340 younger (< 70 years) patients underwent curative liver resection for HCC were analyzed using multivariate and propensity-score matching. Risk score were calculated from the results of Cox regression analysis. The overall survival rate was significantly lower in the elderly group than that in the younger group (p = 0.01). Factors related to overall survival were vascular invasion (absent vs. present, HR 2.25; 95% CI 1.52-3.33, p = 0.0001), albumin level (< 3.0 vs. ≥ 3.0 g/dl, HR 2.23; 95% CI 1.31-3.79, p = 0.003), and number of tumors (solitary vs. multiple, HR 1.68; 95% CI 1.24-2.27, p = 0.001). The results of risk-score analysis with a Cox proportional-hazards model indicated that the proportion of poor-risk patients was significantly higher in the elderly than in the younger group. Propensity-score matching analysis yielded 234 pairs of patients. There were no significant differences in baseline profiles or risk scores between the two groups (p = 0.43). There were also no significant differences in the overall survival between the two groups (p = 0.23). Advanced age does not have a significant impact on the outcomes of patients after resection of HCC.

Selection of patients with esophageal varices for liver resection of hepatocellular carcinoma

The presence of esophageal varices (EV) is a phenotype of portal hypertension, and the indications of liver resection for hepatocellular carcinoma (HCC) in patients with concomitant EV are conflicting. This retrospective study aimed to elucidate if there is justification for liver resection in patients with EV. The surgical outcomes were compared between the patients who underwent resection for HCC with EV (EV group) and those without EV (non-EV group) after propensity-score matching. More bleeding was prevalent (P < 0.001) and refractory ascites was more frequently observed (P = 0.031) in the EV group (n = 277) compared with the non-EV group (n = 277); however, the numbers of patients with morbidities (P = 0.740) and re-operation (P = 0.235) were not significantly different between the two groups. After a median follow-up period of 3.0 years, the median overall and recurrencefree survival periods of patients with EV were 4.8 years (95% confidence interval [CI], 4.1-5.9) and 1.7 years (1.5-2.0), respectively, and were significantly shorter than those of patients without EV (7.6 years [95% CI, 6.3.9.7], P < 0.001, and 2.2 years [1.9-2.5], P = 0.016). On multivariate analysis, the independent factors for overall survival in the EV group were indocyanine green clearance rate at 15 minutes, des-gamma carboxyprothrombin, and the presence of multiple tumors. Considering that liver resection for patients with EV can be safely performed, it should not be contraindicated. However, surgical outcomes of these patients were unsatisfactory, suggesting that candidates for resection for HCC should be carefully selected.

Comparison of the surgical outcomes in patients with synchronous versus metachronous multiple hepatocellular carcinoma

Multiplicity is one of the characteristics of hepatocellular carcinoma (HCC), and patients with multiple HCC (≤ 3 nodules) are recommended as candidates for liver resection. To confirm the validity of resecting multiple HCC, we compared the surgical outcomes in patients with synchronous and metachronous multiple HCC. Patients who underwent resection for multiple HCC (2 or 3 nodules) were classified into the "synchronous multiple HCC" group, while those undergoing resection for solitary HCC and repeated resection for 1 or 2 recurrent nodules within 2 years after initial operation were classified into the "metachronous multiple HCC" group. After one-to-one matching, longer operation time and more bleeding were seen in the synchronous multiple HCC group (n = 98) than those in the metachronous multiple HCC group (n = 98); however, the complication rates were not different between the two groups. The median overall survival times were 4.0 years (95% CI, 3.0-5.9) and 5.9 years (4.0-NA) for the synchronous and metachronous multiple HCC (after second operation) groups, respectively (P = 0.041). The recurrence-free survival times were shorter in the synchronous multiple HCC group than in the metachronous multiple HCC group (median, 1.5 years [95% CI, 0.9-1.8] versus 1.8 years, [1.3-2.2]) (P = 0.039). On multivariate analysis, independent factors for overall survivals in the synchronous multiple HCC group were older age, cirrhosis, larger tumor, and tumor thrombus. Taken together, resection of metachronous multiple HCC still has good therapeutic effect, even better than synchronous multiple HCC, so resection is suggested for metachronous multiple HCC.

Liver Resection Versus Embolization for Recurrent Hepatocellular Carcinoma

BACKGROUND

Despite curative resection, hepatocellular carcinoma (HCC) has a high probability of recurrence. We validated the potential role of liver resection (LR) for recurrent HCC.

METHODS

Patients with intrahepatic recurrence with up to three lesions were included. We compared survival times of patients undergoing their first LR to those of patients undergoing repeated LR. Then, survival times of the patients who had undergone LR and transcatheter chemoembolization (TACE) for recurrent HCC after propensity score matching were compared.

RESULTS

After a median follow-up period of 3.1 years (range, 0.2-16.3), median overall survival times were 6.5 years (95% CI 6.0-7.0), 5.7 years (5.2-6.2), and 5.1 years (4.9-7.3) for the first LR (n = 1234), second LR (n = 273), and third LR (n = 90) groups, respectively. Severe complications frequently occurred in the first LR group (p = 0.059). Operative times were significantly longer for the third LR group (p = 0.012). After the first recurrence, median survival times after one-to-one pair matching were 5.7 years (95% CI 4.5-6.5) and 3.1 years (2.1-3.8) for the second LR group (n = 146) and TACE group (n = 146), respectively (p < 0.001). The median survival time of the third LR group (n = 41) (6.2 years; 95% CI 3.7-NA) was also longer than that of TACE group (n = 41) (3.4 years; 1.8-4.5; p = 0.010) after the second recurrence.

CONCLUSIONS

Repeated LR for recurrent HCC is the procedure of choice if there are three or fewer tumors.

Six autoantibodies as potential serum biomarkers of hepatocellular carcinoma: A prospective multicenter study

Serum autoantibodies have been reported to react with tumor-associated antigen (TAA) in various cancers. This multicenter study evaluated the diagnostic and prognostic value of six autoantibodies against a panel of six hepatocellular carcinoma (HCC)-associated antigens, including Sui1, p62, RalA, p53, NY-ESO-1 and c-myc. A total of 160 patients with HCC and 74 healthy controls were prospectively enrolled from six institutions. Serum antibody titers were determined by enzyme-linked immunosorbent assays. The sensitivities were 19% for Sui1, 18% for p62, 17% for RalA, 11% for p53, 10% for NY-ESO-1 and 9% for c-myc. Overall sensitivity of the TAA panel (56%) was higher than that of α-fetoprotein (41%, P < .05). The combined sensitivity of the TAA panel and α-fetoprotein was significantly higher than that of α-fetoprotein alone (P < .001). The difference in overall survival of TAA panel-positive and panel-negative patients was significant when the Stage I/II patients were combined (P = .023). Overall survival was worse in NY-ESO-1 antibody-positive than in NY-ESO-1 antibody-negative patients (P = .002). Multivariate analysis found that positivity for the TAA panel was independently associated with poor prognosis (P = .030). This TAA panel may have diagnostic and prognostic value in the patients with HCC.

Favorable outcomes of surgical resection for extrahepatic recurrent hepatocellular carcinoma

AIM

Repeat resection for intrahepatic recurrent hepatocellular carcinoma (HCC) is effective for the long-term survival of patients; however, little is known about the surgical outcomes of extrahepatic nodules. The aim of this study is to investigate whether resection can contribute to the survival of patients with extrahepatic recurrent HCC.

METHODS

Under the conditions that intrahepatic recurrent HCC was absent or controlled by locoregional therapies, patients who had resectable extrahepatic recurrent HCC in the lymph nodes, adrenal gland, peritoneum, lung, or brain were included in this study. The survival of patients who did (Surgical group) and did not (Non-surgical group, underwent other therapies) undergo resection for extrahepatic recurrent HCC was compared.

RESULTS

Thirty-eight and 26 patients were included in the Surgical and Non-surgical groups, respectively. No patient had severe postoperative complications. After a median follow-up of 1.2 (range, 0.2-8.8) years, the median cumulative incidence of extrahepatic recurrent HCC was 1.2 years (95% confidence interval [CI], 0.4-3.5) in the Surgical group. The median overall survival was 5.3 (95% CI, 2.5-8.8) and 1.1 (0.8-2.3) years in the Surgical and Non-surgical groups, respectively (P < 0.001). The 5-year rates of survival were 60.5% and 9.1% in the Surgical and Non-surgical groups, respectively. Surgical resection, α-fetoprotein, disease-free interval, and metastasis at the adrenal gland were the independent factors for overall survival.

CONCLUSIONS

Due to the favorable surgical outcomes, resection should be considered as one of the therapeutic choices for patients with extrahepatic recurrent HCC if intrahepatic recurrent HCC can be controlled by locoregional therapies.

High platelet count as a poor prognostic factor for liver cancer patients without cirrhosis

A low platelet count, one of parameters of portal hypertension, is clinically a predictor of postoperative mortality, while platelets induce tumor development during growth factor secretion. In this study, we retrospectively investigated whether high platelet count negatively affects the survival of patients with hepatocellular carcinoma (HCC). Patients undergoing initial and curative resection for HCC were included. Surgical outcomes were compared between the high platelet (platelet count ≥ 20 × 10⁴/μL) and control (< 20 × 10⁴/μL) groups in patients without cirrhosis and between the low platelet (< 10 × 10⁴/μL) and control (≥ 10 × 10⁴/μL) groups in patients with cirrhosis. Among patients without cirrhosis, tumor was larger (P < 0.001) and tumor thrombus was more frequent (P < 0.001) in the high-platelet group than in the control group. After a median follow-up period of 3.1 years (range 0.2-16.2), median overall survival was 6.3 years (95% confidence interval [CI], 5.3-7.8) and 7.6 years (6.6-10.9) in the high-platelet (n = 273) and control (n = 562) groups, respectively (P = 0.027). Among patients with cirrhosis, liver function was worse (P < 0.001) and varices were more frequent (P < 0.001) in the low-platelet group. The median overall survival of patients in the low-platelet group (n = 172) was significantly shorter than that of patients in the control group (n = 275) (4.5 years [95% CI, 3.7-6.0] vs. 5.9 years [4.5-7.5], P = 0.038). Taken together, thrombocytopenia indicates poor prognosis in HCC patients with cirrhosis, while thrombocytosis is a poor prognostic predictor for those without cirrhosis.

Patients' prognosis of intrahepatic cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma after resection

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (ICC) are classified into one category, but comparison of prognosis of the two carcinomas remains controversial. The aim of the current study was to investigate surgical outcomes for patients with ICC or cHCC-CC who underwent resection in order to elucidate whether the classification of ICC and cHCC-CC is justified. Subjects were 61 patients with ICC and 29 patients with cHCC-CC who underwent liver resection from 2001 to 2017. Clinic-pathological data from the two groups were compared. Tumor number and vascular invasion were independent risk factors for recurrence-free survival (RFS) in both groups (P < .001 for both). Of note, for patients with ICC, tumor cut-off size of 5 cm showed statistical significance in median RFS (>5 cm vs ≤5 cm, 0.5 years vs 4.0 years, P = .003). For patients with cHCC-CC, tumor cut-off size of 2 cm showed statistical significance in median RFS (>2 cm vs ≤2 cm, 0.6 years vs 2.6 years, P = .038). The median RFS of patients with cHCC-CC was 0.9 years (95% confidence interval: 0.3-1.6), which was poorer than that of patients with ICC (1.3 years, 0.5-2.1) (P = .028); the rate of RFS at 5 years was 0% and 37.7% respectively. Our study supports the concept of classifying ICC and cHCC-CC into different categories because of a significant difference in RFS between the two.

Liver resection for recurrent hepatocellular carcinoma after radiofrequency ablation therapy

AIM

Although radiofrequency ablation (RFA) is an effective local treatment of hepatocellular carcinoma (HCC), local recurrence is relatively frequent. We aimed to elucidate the validity of salvage liver resection for recurrent HCC after RFA.

METHODS

Patients who underwent liver resection for recurrent HCC after RFA (LR after RFA) and those who underwent second liver resection for recurrent HCC (second LR) were included. The short-term outcomes were compared between the two groups. The survival rates between the two groups were compared after propensity-score matching to adjust for the variables, including patient background, liver function, and tumor status.

RESULTS

Major resection was frequently carried out in the LR after RFA group, but there was no significant difference both in operative data and complication rate between LR after RFA (n = 54) and second LR (n = 266) groups. After a median follow-up period of 1.8 years (range, 0.2-10.5), the median overall survival was 4.4 years (95% confidence interval [CI], 2.2 - not applicable) and 5.6 years (95% CI, 4.5-7.3; P = 0.023) in the LR after RFA group (n = 54) and second LR group (n = 54), respectively, and recurrence-free survival was 1.3 years (0.4-2.2) and 1.2 years (0.5-1.8, P = 0.469), respectively. The only independent factor for overall survival of the LR after RFA group was local recurrence (hazard ratio, 2.73; 1.06-9.00).

CONCLUSIONS

Salvage liver resection of recurrent HCC after RFA could be recommended due to the safety of the procedure, especially in patients without local tumor progression after RFA.

Arterial infusion of cisplatin plus S-1 against unresectable intrahepatic cholangiocarcinoma

Conventional regimens for unresectable intrahepatic cholangiocarcinoma are considered of limited effectiveness. To evaluate the efficacy and toxicity of combination chemotherapy with hepatic arterial infusion of IA-call (a fine-powder formulation of cisplatin) plus oral S-1 in patients with unresectable intrahepatic cholangiocarcinoma. The clinicopathological data and long-term outcome of 12 patients who were received with IA-call plus S-1 were compared with those of 16 patients who were received other treatments, such as radiation therapy, trans-arterial chemoembolization, and systemic chemotherapy. The IA-call plus S-1 regimen consisted of IA-call (65 mg/m², administered into the hepatic artery) on day 1 and oral S-1 (60 mg/m²/day) on days 1-28, every 42 days, repeated cycle. Prognostic factors of these patients were evaluated by uni- and multivariate analysis. There was no significant difference between the two groups in the disease status, such as the number of tumor and the tumor size. The overall survival was significantly longer in the patients receiving the arterial IA-call and S-1 regimen (median survival time = 10.1; range, 3.6-24.2 months) than in the receiving other treatments (median survival time = 4.0; range; 0.3-24.2 months, p = 0.01). The multivariate analysis revealed that chemotherapy regimen was significantly related to survival, with a hazard ratio of 3.97 (p = 0.02). In the IA-call plus S-1 group, the overall response rate was 33.3%. The major toxic effect was grade 3 anemia, occurring in 1 patient (4.5%). Combination chemotherapy with arterial IA-call plus oral S-1 is an effective regimen that may improve survival in patients with unresectable intrahepatic cholangiocarcinoma.

Administration of donor splenocytes via the respiratory tract generates CD8α+ regulatory dendritic cells and induces hyporesponsiveness to fully allogeneic cardiac grafts

BACKGROUND

We previously showed that pretreatment with intratracheal delivery (ITD) of alloantigen induced prolonged cardiac allograft survival and generated regulatory T cells (Tregs) in mice. In this study, we examined the role of splenic dendritic cells (DCs) in the ITD model.

METHODS

CBA mice were treated with ITD from C57BL/10 splenocytes and 7 days later received transplantation of C57BL/10 hearts. In adoptive transfer studies, splenic DCs from ITD-treated mice were transferred into naïve CBA recipients that received C57BL/10 hearts immediately after the transfer. In addition, to determine the role of splenic DCs isolated from ITD-treated mice, the cells were incubated under stimulation with lipopolysaccharide (LPS).

RESULTS

ITD-treated CBA recipients had markedly prolonged allograft survival (median survival time [MST], 67 days) while naïve recipients rejected allografts acutely (MST, 8 days). In adoptive transfer studies, CBA recipients of the transfer of splenic DCs from ITD-treated mice had prolonged allograft survival (MST, 85 days), while CBA recipients of the transfer of splenic DCs from naïve mice did not have prolonged allograft survival (MST, 8 days). In another transfer study, CBA recipients of the transfer of splenic CD8α⁺ DCs from ITD-treated mice had prolonged allograft survival (MST, 79 days), while those receiving splenic CD8α^- DCs from ITD-treated mice did not have prolonged allograft survival (MST, 8 days). In vitro studies showed that ITD-treated splenic DCs produced more IL-10 and less IL-12 than naïve splenic DCs under stimulation with LPS.

CONCLUSIONS

ITD pretreatment induces regulatory DCs, which produce high amounts of IL-10 resulting in the prolongation of graft survival in our model.

Liver resection of hepatocellular carcinoma in patients with portal hypertension and multiple tumors

AIM

Liver resection for hepatocellular carcinoma (HCC) has been recommended only for patients with a single tumor without portal hypertension. We aimed to validate this treatment strategy that is based on by the Barcelona Clinic Liver Cancer staging system.

METHODS

Patients undergoing liver resection were divided into two groups: patients with single HCC without portal hypertension (Group 1) and those with at least one factors of portal hypertension and multiple tumors, up to three lesions each ≤3 cm (Group 2). We compared survival and postoperative complications between the two groups.

RESULTS

The median overall and recurrence-free survival periods of patients in Group 1 (n = 695) were 8.5 years (95% confidence interval [CI], 6.6-9.0) and 2.4 years (2.2-2.7), respectively, and were significantly longer compared with those of patients in Group 2 (n = 197) (5.6 years [95% CI, 4.8-6.7], P = 0.001, and 1.9 years [1.6-2.1], P < 0.001). On multivariate analysis, the independent factors for overall survival were hepatitis C virus infection (hazard ratio, 1.29 [95% CI, 1.02-1.65], P = 0.032), multiple tumors (1.42 [1.01-1.98], P = 0.040), and vascular invasion (1.66 [1.31-2.10], P < 0.001). Frequency of morbidity (23 [3.3%] patients vs 11 [5.5%] patients, P = 0.143) and mortality (3 [0.4%] patients vs 2 [1.0%] patients, P = 0.305) was not significantly different between the two groups.

CONCLUSIONS

Patients with HCC with portal hypertension and/or multiple tumors could be candidates for liver resection due to the safety of the procedure.

Predicting postoperative outcomes of liver resection by magnetic resonance elastography

BACKGROUND

Cirrhosis is associated with blood loss during liver resection and postoperative complications. The liver stiffness measurement has recently become available for assessment of liver fibrosis.

METHODS

This prospective study was performed to predict postoperative outcomes of liver resection. The liver stiffness measurement was measured prospectively using magnetic resonance elastography for patients who had undergone liver resection for malignancy. We investigated whether the liver stiffness measurement by magnetic resonance elastography is correlated with liver fibrosis and postoperative outcomes.

RESULTS

The median liver stiffness measurement by magnetic resonance elastography in 175 patients was 3.4 (range: 1.5-11.3) kPa, and the pathologic grade of liver fibrosis was significantly correlated with the liver stiffness measurement (r = 0.68, P < .001). The median blood loss during transection per unit area was 4.1 mL/cm² (range: 0.1-37.0 mL/cm²), and the frequency of major complications was 16.0%. The liver stiffness measurement was the only independent prognostic factor for both blood loss (regression coefficient: 1.14, 95% confidence interval: 0.45-1.83, P = .001) and major complications (odds ratio: 2.14, 95% confidence interval: 1.63-2.93, P < .001). Receiver operating characteristic curve analysis indicated a significant correlation between the liver stiffness measurement and major complications with calculated area under the curve of 0.81 (P < .001), and the sensitivity and specificity for prediction of major complications (cutoff value: 5.3 kPa) were 64.3% and 87.8%, respectively. On the other hand, the amount of blood loss was significantly correlated with the frequency of major complications (P = .003).

CONCLUSION

The liver stiffness measurement by magnetic resonance elastography could be used as a predictive marker for the risk of major complications due to blood loss during liver resection.

Liver Transplantation Is a Potential Treatment Option for Systemic Light Chain Amyloidosis Patients with Dominant Hepatic Involvement: A Case Report and Analytical Review of the Literature

Systemic light chain (AL) amyloidosis is caused by abnormal plasma cell clones producing amyloidogenic light chains. The standard treatment is therefore chemotherapy targeting these clones, however, some patients are ineligible due to liver dysfunction. For these patients, preceding liver transplantation (LT) and following chemotherapy is a possible treatment option. We herein report a 58-year-old man with advanced hepatic AL amyloidosis who was successfully treated using this strategy. Previously reported cases treated with LT for this condition were reviewed, however, the outcomes were not favorable. We additionally investigated potential prognostic factors of this treatment approach to improve the outcome of these patients.

Applicability of enhanced recovery program for advanced liver surgery

BACKGROUND

Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear.

METHODS

We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed.

RESULTS

Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %.

CONCLUSIONS

An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.

Preoperative diagnosis with versus without MRI in resection for hepatocellular carcinoma

PURPOSE

Although MRI has been considered one of the most sensitive diagnostic techniques for hepatocellular carcinoma (HCC), a clear-cut beneficial effect of the use of preoperative MRI remains unclear. We assessed whether preoperative MRI has a beneficial effect on outcomes in patients scheduled to undergo resection of HCC.

METHODS

We evaluated 449 patients with 553 liver tumors. MRI was performed in 349 of these patients, but not in the other 100. Ultrasonography, dynamic CT, and angiography were performed in all patients. Diagnostic abilities and long-term outcomes were compared between patients who did and did not undergo MRI.

RESULTS

The MRI group (349 patients) had 419 liver tumors and the no MRI group (100 patients) had 134 tumors. Preoperatively, the size of the HCC did not differ between the MRI (median, 30 mm; range, 10-205) and the no MRI group (median, 34 mm; range, 10-175; P = .99). The diagnostic accuracy was 98% in the MRI group and 96% in the no MRI group. Recurrence-free survival rates at 5 years were 31% (95% CI, 20.9-42.5) in the no MRI group, compared with 26% (95% CI, 20.1-32.1) in the MRI (P = .45). Overall survival rates at 5 years were 57% (95% CI, 45.6-68.1) in the no MRI group and 60% (95% CI, 53.4-66.8) in the MRI group (P = .64). After analysis by propensity score matching in 100 pairs of patients, recurrence-free survival rates at 5 years were 31% (95% CI, 20.9-42.5) in the no MRI group, compared with 19% (95% CI, 10.3-30.9) in the MRI group (P = .54). Overall survival rates at 5 years were 57% (95% CI, 45.6-68.1) in the no MRI group and 57% (95% CI, 43.2-68.8) in the MRI group (P = .92).

CONCLUSION

MRI seemed to offer no beneficial impact on diagnostic abilities or long-term outcomes after resection for HCC and is thus of questionable value as a routine imaging modality when combined with CT and angiography clinical practice.

Decreased blood loss reduces postoperative complications in resection for hepatocellular carcinoma

BACKGROUND

The correlation between blood loss and the risk of postoperative complications was unclear in patients undergoing resection of hepatocellular carcinoma (HCC).

METHODS

We studied 539 patients who had resection of HCC. Postoperative complications were recorded according to the modified Clavien-Dindo classification. Variables were compared between patients with grade III to V complications and those with no or grade I to II. A spline regression analysis was used to estimate the probability of grade III to V complications.

RESULTS

Among variables, blood loss (P = 0.0001), operating time (P = 0.0001), blood transfusion (P = 0.0001), and tumor size (P = 0.02) differed significantly between patients with grade III to V and those with no or I to II. Multivariate analysis revealed that the factor most strongly related to complications was blood loss (odds ratio 1.68; 95% confidence interval [CI] 1.45-1.96, P = 0.0001). Spline regression analysis showed that an increase in blood loss was accompanied by increase in the risk of complication; when the estimated probability of grade III to V complications exceeded 50% (95% CI 30.0-70.0), the corresponding blood loss was 820 ml.

CONCLUSION

Decrease in blood loss in resection of HCC is accompanied by reduced risk of complications. Surgeons need to minimize blood loss as less as 820 ml.

Dental Pulp Dendritic Cells Migrate to Regional Lymph Nodes

Dendritic cell (DC) migration to regional lymph nodes (RLNs) is an essential step in adaptive immunity, and cell-surface antigens on migrating DCs greatly affect the quality and quantity of subsequent immune responses. Although MHC class II+ DC-like cells exist in the dental pulp, the lineage and function of these cells remain unknown. Here, we identified migratory DCs from the dental pulp after cusp trimming and acid etching in KikGR mice, in which the photoconvertible fluorescent protein changed from green to red upon violet light exposure. Two major cell fractions from the dental pulp had migrated to the RLNs at 16 hrs after cusp treatment, which showed the following lineage markers in the main and second fractions: CD11chighCD11b++Ly6Clow Ly6Glow F4/80+ and CD11cmedCD11b+++Ly6C++Ly6G+++F4/80-, respectively. These lineage markers indicate that the former cells were DCs that had migrated through afferent lymphoid vessels, and the latter were granulocytes recruited via blood circulation. Migratory dental pulp DCs were mature, expressing the highest levels of CD273 (B7-DC) and CD86 co-stimulators and MHC class II. Our results suggest that cariogenic-bacteria-exposed dental pulp DCs migrate to RLNs and there trigger adaptive immune responses.

Palliative enteric bypass for malignant gastric outflow obstruction after pancreaticoduodenectomy in early recurrent pancreatic cancer

BACKGROUND/AIMS

Recurrent pancreatic cancer has a poor prognosis and there are no established therapeutic strategies. We retrospectively studied patients who underwent palliative surgery for recurrent disease with gastric outlet obstruction (GOO) after an initial pancreaticoduodenectomy (PD) for pancreatic cancer.

METHODOLOGY

We retrospectively studied 4 patients who had undergone a bypass operation, including a modified Devine gastrojejunostomy with vertical stomach reconstruction (MDVSR) for GOO to ensure a direct dietary route to the jejunum, thereby, enabling the gastric contents to easily reach the jejunum.

RESULTS

MDVSR was performed in 4 patients, and in addition to the bypass, 1 patient underwent a jejunojejunostomy, and 1 patient an ileocolostomy. The median operative time and blood loss were 123min (range, 95-150 min) and 164mL (range, 115-235 mL). After the second surgery, 2 of 4 patients received chemotherapy (1 patient: gemcitabine + S1, 1 patient: gemcitabine alone). The remaining 2 patients did not receive chemotherapy. The mean survival after the second operation was 145 days (range, 34-386 days).

CONCLUSIONS

Palliative surgery including MDVSR is useful to improve a patient's nutritional state and it is more effective than chemotherapy for treating recurrent disease with GOO after a PD for pancreatic cancer.

Modified duval procedure for small-duct chronic pancreatitis without head dominance

BACKGROUND/AIMS

In the case of small-duct chronic pancreatitis, surgery for pain relief is broadly divided into resection and drainage procedures. These procedures should be selected according to the location of dominant lesion, diameter of the pancreatic duct and extent of the disease. The appropriate procedure for the treatment of small-duct chronic pancreatitis, especially small-duct chronic pancreatitis without head dominance, remains controversial. We developed the modified Duval procedure for the treatment of small-duct chronic pancreatitis without head dominance and determined the efficacy of this procedure.

METHODOLOGY

We retrospectively studied 14 patients who underwent surgical drainage with or without pancreatic resection for chronic pancreatitis with small pancreatic duct (<7mm) without head dominance. These patients were divided into 2 groups; the modified Puestow procedure group and the modified Duval procedure group.

RESULTS

No complications occurred in the modified Duval group. In the modified Puestow procedure group, complete and partial pain relief were observed in 62.5%, and 37.5% of patients respectively. In contrast, complete pain relief was observed in all the patients in the modified Duval procedure group.

CONCLUSIONS

Our modified Duval procedure is useful and should be considered the appropriate surgical technique for the treatment of small-duct chronic pancreatitis without head dominance.

[Case report of transarterial chemoembolization to lymph node metastasis of hepatocellular carcinoma]

We performed transarterial chemoembolization (TACE) on the 67-year-old man who had hepatectomy for hepatocellular carcinoma with hepatitis C, recurrence in the liver and lymph nodes.The metastasis in lymph node did not show a clear increase until dying, and TACE showed the possibility of one treatment method to the metastasis in lymph node of the hepatocellular carcinoma.

Phase I/II study of a fine-powder formulation of cisplatin for transcatheter arterial chemoembolization in hepatocellular carcinoma

AIM

The clinical feasibility of transcatheter arterial chemoembolization (TACE) with fine-powder cisplatin (CDDP) in patients with hepatocellular carcinoma (HCC) has not been investigated. A phase I/II study was conducted to investigate the safety and tolerability of fine-powder CDDP when it was used with lipiodol and gelatin sponge particles for TACE.

METHODS

Fine-powder CDDP emulsified in lipiodol was injected into tumor arteries. Embolization was subsequently performed with gelatin sponge particles. The CDDP dose was started at 45 mg/m(2) (level 1) and increased to 65 mg/m(2) in 10 mg/m(2) increments.

RESULTS

Thirteen patients were enrolled in phase I study since no dose limiting toxicity was observed in any patients, even in seven patients at level 3 (65 mg/m(2)), the recommended dose was 65 mg/m(2). The major adverse event was grade 3 thrombocytopenia, which occurred in 8% of patients. The incidence of hematological toxicities was 15% for leukocytopenia, 84% for thrombocytopenia, and 84% for anemia. Increased serum total bilirubin was observed in 54% and increased aspartate aminotransferase or alanine aminotransferase in all patients. All digestive tract symptoms (nausea 77%, anorexia 84%, vomiting 31%) were grade 2 or lower. Total adverse events were grade 3 or higher in 44%. The response rate in 19 patients who received the recommended dose was 21%.

CONCLUSIONS

TACE with a fine-powder formulation of CDDP at a dose of 65 mg/m(2) is well tolerated in patients with unresectable HCC.

Two cases of primary malignant fibrous histiocytoma of the liver: immunohistochemical expression of ezrin and its relationship with prognosis

Malignant fibrous histiocytoma (MFH) as soft tissue sarcoma would not be especially noteworthy, but primary hepatic MFH reports are extremely rare. Herein, we report ezrin expression in tumor tissues from two primary hepatic MFH cases with different prognoses. Cases 1 and 2 were both women, ages 45 and 70 years, respectively. Case 1 had an 11×10 cm liver tumor in segment (S) 3, and case 2 had two liver tumors, 12×8 cm in S5 and 10×7 cm in S8. Neither had any other systemic tumors. Cases 1 and 2 survived for two year and ten months and for eight and a half months, respectively, after the initial tumor resection. Microscopically, the tumors of these two cases were similar and showed proliferation of atypical cells, including spindle, pleomorphic and multi-nucleated giant cells arranged in storiform, sheet and/or fascicle patterns, with scattered foci of inflammatory cells, indicating MFH. Ezrin expression in tumor tissue from case 1 was sparse, whereas that of case 2 showed strong ezrin expression in many tumor cells. The present results indicate ezrin immunoreactivity in primary hepatic MFH to correlate possible with prognosis, which is consistent with reports on some other types of malignancies.

Purified eicosapentaenoic acid induces prolonged survival of cardiac allografts and generates regulatory T cells

Fish oil, which is rich in eicosapentaenoic acid (EPA), has been found to have immunomodulatory effects. We examined whether administration of purified EPA affected survival of fully mismatched murine cardiac allografts. Hearts from C57BL/10 (H-2(b)) mice were transplanted into CBA (H-2(k)) recipients treated with one intraperitoneal dose of purified EPA the day of transplantation. Untreated CBA recipients and recipients given 0.1 g/kg of EPA rejected C57BL/10 hearts (median survival time [MST], 8 and 13 days, respectively). With a 1.0 g/kg dose of EPA, graft survival was markedly prolonged (MST >100 days). To determine whether regulatory cells were generated, naïve mice (secondary recipients) underwent adoptive transfer of splenocytes from EPA-treated primary recipients and cardiac allograft transplantation. Adoptive transfer of whole, CD4(+) and CD4(+)CD25(+) splenocytes from EPA-treated recipients induced indefinite survival in secondary recipients. Flow cytometry showed that the CD4(+)CD25(+) cells were Foxp3(+). In reverse transcriptase-polymerase chain reaction (RT-PCR) studies, the expression of peroxisome proliferator-activated receptor gamma (PPARgamma) mRNA was upregulated by EPA treatment. A PPARgamma antagonist abrogated the prolongation of graft survival induced by EPA treatment (MST, 13 days). Thus, in our model, purified EPA induced prolonged survival of fully mismatched cardiac allografts and generated regulatory T cells dependent on PPARgamma activation.

Long-term outcome of laparoscopic deroofing for symptomatic nonparasitic liver cysts

BACKGROUND/AIMS

The use of the laparoscopic procedure for managing symptomatic nonparasitic liver cysts has been documented to be feasible and safe in the short term; however, the long-term outcomes of the procedure have not been well demonstrated. This study was initiated to review the long-term outcomes of this procedure.

METHODOLOGY

Preoperatively, diagnosis was established by ultrasonography (US), computed tomography (CT) scan, and endoscopic retrograde cholangiography or magnetic resonance cholangiographic photograph. The long-term outcomes in 8 patients with symptomatic nonparasitic simple liver cysts treated by laparoscopic deroofing are presented. All patients were followed up, and morphologic evaluation was performed with repeated abdominal US and CT.

RESULTS

All operations could be finished laparoscopically without converting to open laparotomy. Intra- and postoperative complications were not detected. The mean follow-up duration in all cases was 122.5 months (range: 79-149 months). Two patients exhibited morphologic recurrence within 6 months after surgery and required a second treatment.

CONCLUSIONS

From the observation of long-term follow-up, we concluded that laparoscopic deroofing is a useful method for treating symptomatic nonparasitic liver cysts.

Long-term outcome of laparoscopic cystogastrostomy performed using a posterior approach with a stapling device

BACKGROUND

Internal drainage of an acute pancreatic pseudocyst is indicated 6 weeks after its first detection. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Pseudocysts located adjacent to the posterior gastric wall are best drained by pseudocyst gastrostomy. Although the anterior approach for drainage has frequently been reported, reports on the posterior approach are rare.

METHODS

Seven patients underwent laparoscopic cystogastrostomy for pancreatic pseudocysts. The posterior approach that enables the direct visualization of the posterior gastric wall and pseudocyst was used, and the cyst was drained with a needle. After creating a sufficient drainage orifice, the cyst was thoroughly debrided. Cystogastrostomy was performed using the posterior approach with a stapling device. The insertion site of the stapling device closed using a hernia stapler.

RESULTS

Cystogastrostomy was performed using the posterior approach with a stapling device in all patients, without requiring conversion to the anterior approach or open surgery. There were neither operative complications nor late recurrences during the follow-up period (median 65 months).

CONCLUSION

Laparoscopic cystogastrostomy using the posterior approach, which facilitates adequate internal drainage, is a safe and feasible procedure for pancreatic pseudocyst, and it is not accompanied with a risk of recurrence in the long term.

Vertical stomach reconstruction with pancreaticogastrostomy after modified subtotal-stomach-preserving pancreaticoduodenectomy for preventing delayed gastric emptying

Pylorus-preserving pancreaticoduodenectomy (PPPD) yields better results in terms of operative mortality and morbidity and postoperative nutritional state than those obtained after Whipple procedure. However, delayed gastric emptying (DGE) is one of the most troublesome complications of this procedure. We developed a new reconstructive technique-modified subtotal-stomach-preserving pancreaticoduodenectomy (SSPPD) with pancreaticogastrostomy--for preventing DGE. We consider our reconstructive technique to be one of the most favorable procedures for preventing DGE in patients who have undergone pancreaticoduodenectomy with pancreaticogastrostomy.

Pneumatosis cystoides intestinalis after fluorouracil chemotherapy for rectal cancer

Pneumatosis cystoides intestinalis (PCI) is a relatively rare condition characterized by intraluminal gas in the gastrointestinal tract. Several chemotherapeutic agents have been reported to be associated with PCI, although fluorouracil-related PCI is extremely rare. We report a case of a 76-year old man who received adjuvant chemotherapy for rectal cancer with fluorouracil (FU) and leucovorin (LV). After 1 cycle of the treatment, he presented with diarrhea and abdominal pain. Abdominal radiogram revealed the presence of free air under the diaphragm and intramural gas in the intestine. Laparotomy was performed, showing a suspected diagnosis of perforation in the gastrointestinal tract. Intraoperative findings revealed pneumatosis of the intestine without evidence of perforation. He was treated supportively and his symptoms improved. In conclusion, we should consider the possibility of PCI occurring in patients with malignancies during chemotherapy treatment.

[Effective treatment with oral administration of UFT and leucovorin (Uzel) in a patient with liver metastasis and peritoneal dissemination from cecal cancer]

A 70-year-old woman had been diagnosed with advanced cecal cancer with liver metastasis. She had initially undergone a right hemicolectomy for cecal cancer. Although secondary surgery for liver metastasis was performed 2 months after initial surgery, the intra-operative findings showed peritoneal dissemination of diaphragm and ligament teres and liver metastasis, making curative resection impossible. Therefore , combination oral administration of UFT and LV (Uzel) was started (UFT 300 mg/day, LV 75 mg/day, 4 weeks of therapy followed by a 1-week treatment break). Two months after 4 courses, the liver metastasis had markedly diminished and CEA was within the normal range. A good complete response of the liver metastasis was achieved. In conclusion, this treatment was convenient and effective.

[A case of curatively resected AFP producing gastric cancer with massive lymph node metastasis effectively treated by neoadjuvant-chemotherapy of S-1 and CDDP]

A 65-year-old man who had AFP producing gastric cancer with massive lymph-node metastasis was admitted to our institution. Because of bulky lymph-node metastasis, the tumor was considered unresectable. He was treated with neoadjuvant chemotherapy of S-1 and cisplatin (CDDP).S-1 (80 mg/m2/day) was administered for 21 consecutive days followed by 14 days rest as one course,and CDDP (60 mg/m2) was infused over 2 hours on day 8. After 1 course, radiographic examination showed remarkable improvement in the tumor size of the stomach, and computed tomography showed markedly reduced paraaortic lymph node metastasis. However, surgery was performed after 3 weeks,because of the adverse effect of diarrhea grade 3 after one course of the chemotherapy. This is a rare case in which neoadjuvant chemotherapy of S-1 and CDDP may well be an effective treatment for unresectable AFP producing gastric cancer with bulky lymph-node metastasis.

Branch patch reconstruction in living donor liver transplantation: arterialization of grafts with replaced type arteries

We developed a hepatic arterialization technique in living donor liver transplantation. The technique was indicated in patients with a left graft from donors with a right hepatic artery originated from superior mesenteric artery or a right graft from donors with a left hepatic artery from left gastric artery. The donor common hepatic and gastroduodenal arteries were split. On the recipient side, left and right hepatic arteries or branches of the right hepatic artery were split, received patch plasty, and anastomosed with the graft arteries under loupe observation. Livers from 25 donors were procured (16 right livers and 9 left livers) using this technique. There were no vascular complications in the donors. Three recipients died due to infectious disease with arterial patency. The remaining 22 recipients survived without hepatic arterial thrombosis. In limited situations, this technique can be adapted for living donor liver transplantation without increasing donor complications.

Induction of Indefinite Survival of Fully Mismatched Cardiac Allografts and Generation of Regulatory Cells by Sarpogrelate Hydrochloride

BACKGROUND

At initiation of the immunologic response, platelets rapidly release chemical mediators such as serotonin (5-hydroxytryptamine, [5-HT]) and cytokines. Sarpogrelate hydrochloride (SH), a selective 5-HT2-receptor antagonist, is used to treat patients with peripheral arterial disease. We investigated the effect of SH on the alloimmune response in a murine cardiac transplantation model.

METHODS

CBA mice underwent transplantation of a C57BL/10 heart and received a short course of SH treatment. Survival of the allograft was recorded. An adoptive transfer study was performed to determine whether regulatory cells were generated. Immunohistochemistry studies of intercellular adhesion molecule 1 (ICAM-1), histological, cell-proliferation, and cytokine assessments were performed.

RESULTS

Untreated CBA mice rejected C57BL/10 cardiac grafts acutely (median survival time [MST], 8 days). In mice given 10 mg/kg of SH, all allografts survived indefinitely (MST, >100 days); these mice also had significantly prolonged survival of donor-specific skin grafts but acute rejection of third-party skin grafts. Secondary CBA recipients given not only whole but also CD4 splenocytes from primary SH-treated CBA recipients with C57BL/10 cardiac allograft had indefinite survival of C57BL/10 hearts (MST, >100 days). SH inhibited upregulation of ICAM-1 on endothelial cells in the allografts. Graft acceptance and hyporesponsiveness were confirmed by the histological and cell-proliferation studies, respectively. Production of interleukin-4 and interleukin-10 from splenocytes of SH-treated transplant recipients increased compared to that from splenocytes of untreated recipients.

CONCLUSION

SH induced indefinite survival of fully allogeneic cardiac allografts, generated CD4 regulatory cells, inhibited ICAM-1 expression in the allografts, and upregulated IL-4 and IL-10 production.

Selective cyclooxygenase 2 inhibitor induces indefinite survival of fully allogeneic cardiac grafts and generates CD4+ regulatory cells

BACKGROUND

Selective inhibition of cyclooxygenase 2 has been reported to have not only anti-inflammatory effects but also effects on the immune response. We investigated ability of a cyclooxygenase 2 inhibitor to inhibit alloimmune response in a murine cardiac transplantation model.

METHODS

CBA (H2(k)) mice underwent transplantation of C57BL/10 (H2(b)) hearts. On the day of transplantation, the recipients received either no treatment or single administration of aspirin (a cyclooxygenase 1 and 2 inhibitor) or the selective cyclooxygenase 2 inhibitor NS-398. Naive CBA mice (secondary recipients) underwent adoptive transfer of splenocytes from treated mice with long-surviving grafts (primary recipients) to determine whether regulatory cells developed after NS-398 treatment. Histologic, cell-proliferation, and cytokine studies were also performed.

RESULTS

Untreated CBA mice rejected C57BL/10 cardiac grafts acutely (median survival time, 8 days). The majority of recipients given aspirin rejected their grafts within 20 days (median survival time, 11 days). In mice given NS-398, the majority of the grafts survived indefinitely (median survival time, >100 days). Secondary CBA recipients given CD4+ splenocytes from primary CBA recipients treated with NS-398 also had indefinite survival of C57BL/10 hearts (median survival time, >60 days). Graft acceptance and proliferative hyporesponsiveness were also confirmed by the histologic and cell-proliferation studies, respectively. Production of interleukin 4 and 10 from splenocytes of the recipients treated with NS-398 were significantly higher than that from untreated recipients.

CONCLUSIONS

In our model administration of cyclooxygenase 2 inhibitor induced indefinite survival of fully mismatched cardiac grafts and generated CD4+ regulatory cells. Cyclooxygenase 2 inhibitor could warrant consideration for use as an immunomodulating agent in clinical transplantation.

Various Costimulatory Pathways Are Essential for Induction of Regulatory Cells by Intratracheal Delivery of Alloantigen

BACKGROUND

We previously reported that intratracheal delivery of alloantigen induced regulatory cells in a mouse heart transplantation model. We investigated the roles of costimulatory pathways in the induction of regulatory cells by intratracheal delivery of alloantigen.

METHODS

CBA (H-2k) mice were pretreated with intratracheal delivery of splenocytes (1 x 10(7)) from C57BL/10 (H-2b) mice and administration of monoclonal antibodies (mAb) specific for programmed death (PD)-1 and its ligands, programmed death-ligand (PD-L)1 and PD-L2, CD70, CD134 ligand (CD134L), CD153, CD137L, or receptor activator of nuclear factor-kappaB (NF-kappaB) (RANK). Seven days later, naive CBA mice underwent adoptive transfer of splenocytes (5 x 10(7)) from the pretreated CBA mice and transplantation of C57BL/10 heart.

RESULTS

Adoptive transfer of splenocytes from CBA mice that had been pretreated with intratracheal delivery of C57BL/10 splenocytes significantly prolonged the survival of C57BL/10 allograft (median survival time [MST], 68 days) as compared with adoptive transfer from untreated CBA mice (MST, 12 days). Concomitant administration of control immunoglobulin (Ig)G, anti-PD-L2 mAb, or anti-CD137L along with intratracheal delivery did not significantly affect the prolongation (MST, 72, 68, and 65 days, respectively). In contrast, anti-PD-1, anti-PD-L1, anti-CD70, anti-CD134L, anti-CD153, or anti-RANK mAb abrogated the prolongation induced by adoptive transfer from the pretreated mice with intratracheal delivery (MST, 18, 17, 16, 14, 10, and 18 days, respectively).

CONCLUSION

The PD-1/PD-L1, CD27/CD70, CD134/CD134L, CD30/CD153, and tumor necrosis factor (TNF)-related activation-induced cytokine (TRANCE)/RANK interactions are independently required for generation of regulatory cells by intratracheal delivery of alloantigen.

Effects of Immunosuppressants on Induction of Regulatory Cells After Intratracheal Delivery of Alloantigen

BACKGROUND

We previously reported that intratracheal delivery (ITD) of alloantigen generated regulatory cells in mice. Here, we examined the effect of various doses of conventional immunosuppressants (FK506, cyclosporine A, azathioprine, mycophenolate mofetil, and rapamycin) on inducing regulatory cells in our model.

METHODS

CBA mice (primary recipients) were given C57BL/6 splenocytes by ITD and either no additional treatment or various doses of an immunosuppressant. Seven days later, splenocytes from these mice were adoptively transferred into naive secondary CBA recipients that underwent C57BL/6 cardiac grafting the same day.

RESULTS

Adoptive transfer from primary recipients given ITD of splenocytes alone induced prolonged allograft survival in secondary recipients (median survival time [MST], 50 days), suggesting that regulatory cells were generated. When ITD of alloantigen was combined with daily administration of 0.1 mg/kg FK506 or 0.2 mg/kg rapamycin, graft survival was similarly prolonged (MST 55 and 50 days, respectively). When combined with 20 or 40 mg/kg MMF or 0.4 mg/kg rapamycin, the majority of recipients demonstrated indefinite survival (MST, >100 days in all groups). When ITD of alloantigen was combined with 0.3, 0.5, or 1.0 mg/kg FK506; 5, 10, or 25 mg/kg cyclosporine A; or 1.0 or 2.0 mg/kg azathioprine, allografts were rejected acutely (MST 7-13 days).

CONCLUSION

Generation of regulatory cells by ITD of alloantigen was facilitated by mycophenolate mofetil and high doses of rapamycin but abrogated by cyclosporine A, azathioprine, and high doses of FK506. Low doses of rapamycin and of FK506 did not interfere with generation of regulatory cells.

Interleukin-10 but not Transforming Growth Factor-β is Essential for Generation and Suppressor Function of Regulatory Cells Induced by Intratracheal Delivery of Alloantigen

BACKGROUND

We previously reported that intratracheal delivery of alloantigen-induced regulatory cells in mouse heart-transplantation model. Here, we investigated roles of interleukin (IL)-10 and transforming growth factor (TGF)-beta in induction and effector phases of the regulatory cells.

METHODS

CBA mice were pretreated with intratracheal delivery of C57BL/10 splenocytes and administration of neutralizing anti-IL-10 or anti-TGF-beta monoclonal antibody (mAb). Seven days after the pretreatment, naive CBA mice (secondary recipients) were given adoptive transfer of splenocytes from the pretreated mice and underwent heart grafting from C57BL/10 mice. To determine roles of these cytokines in the effector phase of the regulatory cells, anti-IL-10 or anti-TGF-beta mAb was administered weekly into the secondary recipients after the adoptive transfer.

RESULTS

Adoptive transfer of splenocytes from CBA mice that had been pretreated with intratracheal delivery of C57BL/10 splenocytes significantly prolonged the survival of C57BL/10 allograft (median survival time [MST] 68 days) as compared with adoptive transfer from untreated CBA mice (MST 12 days). In the induction phase, anti-IL-10 mAb abrogated development of the regulatory cells that afforded prolonged allograft survival in the secondary recipients (MST 20 days), whereas anti-TGF-beta mAb did not abrogate it (MST 88 days). In the effector phase, anti-IL-10 mAb abrogated prolonged allograft survival afforded by adoptive transfer of the regulatory cells in the secondary recipients (MST 27 days), whereas anti-TGF-beta mAb did not abrogate suppressor function of the regulatory cells (MST 53 days).

CONCLUSION

IL-10 but not TGF-beta was required for generation and suppressor function of the regulatory cells induced by intratracheal delivery of alloantigen.

Syenergistic effect of 15-deoxyspergualin with costimulation blockade on alloimmune response

INTRODUCTION

A virally induced alloreactive memory seems to represent a potent barrier to tolerance induction but the combination of 15-deoxyspergualin (DSG), an inhibitor of NFkB translocation, with costimulation blockade (CB)-based chimerism as an induction regimen can overcome a preformed anti-donor memory response. In this study, we investigate the ability of DSG with CB to inhibit a naive alloimmune responses.

METHODS

A BALB/c (H-2d) skin or heart was transplanted into a C57BL/6 (H-2b) recipient treated with anti-CD154 mAb (MR1; 500 mcg/d on days 0, 2, 4, 6) alone, DSG (5 mg/kg/d, days 0 to 7) alone, or both agents. Proliferation of alloreactive T cells after each treatment was also examined using a graft-versus-host disease (GvHD) model using the fluorescent dye CFSE.

RESULTS

Treatment with DSG alone induced prolonged survival of the cardiac allografts (median survival time [MST]: 97.5 days). MR1 alone induced indefinite survival of cardiac allografts, although at 150 days after transplantation, the histology showed changes characteristic of chronic rejection, including interstitial fibrosis, infiltration of mononuclear cells, and intimal hyperplasia in coronary vessels. Combined treatment with DSG and MR1 induced donor-specific unresponsiveness in all recipients, graft histology showed only minimal infiltration. Treatment with DSG and MR1 also significantly prolonged the survival of skin allografts (MST: 31 days) compared with that of DSG or MR1 alone (MST: 17 and 14 days, respectively). In the GvHD model assessed with CFSE, the combined treatment was the more effective to suppress proliferation of alloreactive T cells while DSG alone inhibited proliferation more than MR1 alone.

CONCLUSION

DSG potentiates anti-CD154 therapy to suppress the alloimmune response.