Efficacy of the Milan criteria as a prognostic factor in patients with colorectal liver metastases

PURPOSE

This study aimed to apply the principles of the "Milan criteria" to patients undergoing hepatic resection for CRLM and to evaluate the efficacy of prognostic factors.

METHODS

The medical records of consecutive patients who underwent curative resection for CRLM from April 2007 to April 2019 were retrospectively reviewed. Time to aggressive treatment failure (TATF) was defined as the time interval from the initial surgery until the first unresectable recurrence or recurrence that could only be treated with doublet or lower dose chemotherapy, or death. The risk factors associated with recurrence-free survival (RFS), TSF, TATF, and overall survival (OS) were evaluated.

RESULTS

On univariate analysis, the Milan criteria significantly predicted long-term OS, TATF, TSF, and RFS. Moreover, the Milan criteria were able to stratify patients with CRLM into distinct prognostic groups with regard to long-term OS, TATF, TSF, and RFS.

CONCLUSIONS

Milan criteria, a simple index, are a factor contributing to all the survival time and are a very important factor in discussing the prognosis of CRLM.

Overexpression of hydroxyproline via EGLN/HIF1A is associated with distant metastasis in pancreatic cancer

For pancreatic cancer, the probability of distant metastasis can help choose the best course of treatment. The aim of this study is to establish the efficacy of hydroxyproline as a biomarker for distant metastasis for pancreatic cancer and to clarify the mechanism of EGLN/HIF1A axis that controls the invasion and metastasis. Metabolites (hydroxyproline) and genes (EGLN2 and EGLN3) were identified by metabolome analysis of the serum with pancreatic cancers with and without distant metastasis. The mechanism of EGLN/HIF1A axis including angiogenesis was examined in pancreatic cancer cells. Hydroxyproline associated with these mechanisms was evaluated to suggest the association with overall survival in pancreatic cancer. Decreased expression of EGLN2 and EGLN3 in pancreatic cancer, via the HIF1A and TGF ß1 pathway, was associated with the induction of angiogenic factors, increased vascular invasion, and poor overall patient survival. Hydroxyproline concentrations were regulated via the HIF1A pathway by EGLN2 and EGLN3, and that increased concentrations of hydroxyproline promote the invasion and metastasis of pancreatic cancer cells. These results suggested that the expression of hydroxyproline through the HIF1A pathway induced by EGLN2 and EGLN3 could be a surrogate marker for treatment and might predict distant metastasis in pancreatic cancer.

Right trisectionectomy for liver metastasis of granulosa cell tumor: a case report and literature review

BACKGROUND

Granulosa cell tumor (GCT) is a type of ovarian sex cord-stromal tumor with low-grade malignancy, which can recur long after primary resection. All reports on GCTs in the liver describe cases of metastases, while there are no previous reports of primary GCTs originating from the liver. We report a case of GCT, with recurrence of liver metastasis long after ovariectomy, which was subsequently resected by a right trisectionectomy.

CASE PRESENTATION

A 76-year-old woman presented with a history of surgical resection of an ovarian tumor performed 30 years previously; no details of the tumor were available. When she was 68 years old, an abdominal ultrasound revealed a small liver mass, which was diagnosed as a hepatic hemangioma with slow growth. Outpatient follow-up was discontinued for 5 years, and the patient was not examined again until the age of 76 years. At this point, the tumor had substantially increased in size, and surgical resection was required owing to suspicion of malignancy. The patient was then referred to our hospital. Contrast-enhanced computed tomography (CT) showed a large tumor, approximately 18 cm in size, occupying the right lobe and medial section of the liver. After percutaneous transhepatic portal vein embolization, a right trisectionectomy was performed. The histopathological findings of the resected specimen showed that the tumor cells had "coffee bean-like" nuclear grooves, which are characteristic of a GCT. Acidophilic non-structural Call-Exner bodies were also observed. Inhibin-α, CD99, and CD56 markers of sex cord-stromal tumors were detected on immunohistological examination; all pathology suggested a GCT. We considered the tumor to be a liver metastasis of a previous ovarian GCT that was resected 30 years prior by ovariectomy. There was no recurrence for > 15 months after the hepatectomy.

CONCLUSIONS

We report a case of a GCT in the liver, which was identified to be a liver metastasis. Right trisectionectomy was subsequently performed for tumor resection. Clinicians should be aware that ovarian GCTs may recur in the liver, and that GCT recurrence may occur long after ovariectomy of the primary ovarian GCT.

Efficacy of Peak Hounsfield Units of the Visceral Fat Area in Predicting Postoperative Complications after Pancreaticoduodenectomy

BACKGROUND

Morbidity following pancreaticoduodenectomy (PD) has been reported to remain high. This study sought to measure the peak Hounsfield units (HUs) of visceral attenuation in patients undergoing PD and to assess the quality of adipocytes by comparing these measurements with perioperative factors.

METHODS

Patients undergoing PD were retrospectively identified (n = 108). Abdominal perimeter, subcutaneous fat area (SFA), visceral fat area (VFA), and peak HU of the VFA were measured. Logistic regression analysis was used to identify independent predictors of postoperative pancreatic fistula (POPF) or complications. Histopathological examination was performed for qualitative diagnosis of the stromal tissue.

RESULTS

The overall rate of POPF was 16%, and severe complications occurred in 23% of the cases. A criterion for peak HU of the VFA only independently predicted POPF (p = 0.007) in the multivariate analysis. A criterion for peak HU of the VFA (p = 0.015) was associated with an increased rate of postoperative severe complications in the univariate analysis. The peak HU of the VFA was significantly correlated with abdominal perimeter (p < 0.001) and VFA (p < 0.001). The peak HU of the VFA was significantly correlated with adipocyte diameter (p < 0.001) and the ratio of stromal connective tissue area around the adipocytes (p < 0.001).

CONCLUSION

The peak HU of the VFA was an independent factor contributing to severe complications, including POPF after PD. It reflects the amount of stromal connective tissue around the adipocytes.

[A Case of Remarkably Effective Chemoradiotherapy for Esophageal Cancer with Multiple Bone Metastasis]

The patient was a 56-year-oldwoman. She presentedto a nearby doctor with a chief complaint of dysphagia andwas diagnosed with esophageal cancer by upper gastrointestinal endoscopy, resulting in a referral to our hospital. Upper gastrointestinal endoscopy revealeda semicircular type 1 lesion 29 to 32 cm from the incisors, andshe was diagnosedwith squamous cell carcinoma by biopsy. Computedtomography (CT)andpositron emission tomography(PET)scans revealedthe enlargement and accumulation of lymph nodes along the lesser curvature of the stomach; thus, she was diagnosed with metastasis. In addition, multiple accumulations were found in the 7th cervical vertebrae as well as in the 1st, 3rd, 4th, and 8th thoracic vertebrae, leading to the diagnosis of bone metastasis. She was finally diagnosed with middle intrathoracic esophageal cancer T2N1M1, Stage Ⅳ; thus, we performedchemorad iotherapy(CRT)with 5-FU andCDDP (FP). The main lesion was markedly reduced in upper gastrointestinal endoscopy after CRT, and no apparent malignancy was found in endoscopic biopsy, so the diagnosis was endoscopic complete response. The CT scan also showed marked reductions in both the main lesion and the lymph nodes. As for the bone metastasis, some areas of bone consolidation remained, but they were diagnosed as partial responses since they were shrunk. Since then, FP has been continuously administeredon a regular basis andit has been about 2 years without any appearance of new lesions or re-exacerbation.

Risk Factors for Life-threatening Grade C Postoperative Pancreatic Fistula After Pancreatoduodenectomy Compared to Grade B

BACKGROUND

The aim of the present study was to investigate risk factors for the development of grade C compared to grade B cases of postoperative pancreatic fistula (POPF).

MATERIALS AND METHODS

Clinicopathological data from 43 patients who developed grade B or C POPF were retrospectively analyzed. The following types of factors were analyzed: Patient-related, surgery-related, and pancreas-related, including the value of the drain amylase and the detection of gram-negative rod bacteria within the first 7 postoperative days (PODs).

RESULTS

Univariate analysis showed that male sex (p=0.0492) and detection of gram-negative rods within the first 7 PODs (p=0.0010) were risk factors for development of grade C POPF. Only detection of gram-negative rods within the first 7 PODs was a significant factor after multivariate analysis (p=0.0027).

CONCLUSION

Sensitive and specific predictive criteria for early detection of grade C POPF should be developed to allow for a management approach appropriately tailored to this condition.

Resection of a pancreatic capillary lymphatic malformation through a partial pancreatectomy: a case report

Background

Pancreatic vascular malformation causes epigastric pain, pancreatitis, portal vein hypertension, bleeding, and rupture. It is a rare disease, with most pancreatic vascular malformations being arteriovenous malformations (AVMs) and the other types of malformations being rare. We report a case of capillary lymphatic malformation (CLM) in the pancreatic uncinate process.

Case presentation

A 74-year-old woman, who presented with complaints of repeated upper abdominal pain, was admitted to our institution. Contrast-enhanced dynamic computed tomography (CT) scan revealed that the tumor in the pancreatic uncinate process had a poor contrast effect in the arterial phase and a small contrast effect in the equilibrium phase, which are suggestive of a benign disease-like vascular malformation. However, we suspected that it could possibly be a malignant tumor because the tumor size tended to increase over time; thus, we decided to perform a surgery. We resected the tumor through a partial resection of the pancreas. Macroscopically, the cut surface of the tumor had a spongioid appearance. Histopathological examination findings showed a mixed shape of small capillaries and lymphatic ducts. The patient was diagnosed with CLM according to the International Society for the Study of Vascular Anomalies (ISSVA) classification, based on the histological appearance and immunostaining findings. The postoperative course of the patient was uneventful.

Conclusions

We reported a case of pancreatic vascular malformation, specifically a CLM, which was completely resected through a partial pancreatectomy.

Surgical Technique of Pancreatic Parenchyma Transection-Delayed Approach (PPTDA) in Hepatopancreatoduodenectomy for Hilar Cholangiocarcinoma

BACKGROUND

The combination of major hepatectomy and pancreatoduodenectomy (PD), that is, a hepatopancreatoduodenectomy (HPD), is the only curative treatment for bile duct cancer with extensive horizontal tumor spread invading both the hepatic hilum and the intrapancreatic bile duct. However, this aggressive procedure remains controversial with regard to the balance between the survival benefit and high risk of mortality and morbidity, especially the risk for postoperative hepatic failure and postoperative pancreatic fistula. Here, we describe the efficacy of a novel modified technique of HPD with delayed division of the pancreatic parenchyma for hilar cholangiocarcinoma, and focus on the surgical technique and the short-term outcomes, with a representative case.

TECHNICAL PRESENTATION

This new surgical technique involves dissection of the pancreatic parenchyma and relevant mesoduodenum at the final step after dissecting the required parts on the inferior side and superior side of the tumor, enabling excision of the resected specimen. This technique described herein can prevent saponification of the resected surface of the pancreas by dissecting the pancreatic parenchyma toward the latter half of the surgical procedure as much as possible. The results suggest that there may also be a relationship between this technique and the prevention of postoperative pancreatic fistula.

CONCLUSION

This new surgical technique of HPD may be able to prevent postoperative pancreatic fistula by performing intraoperative dissection of the pancreatic parenchyma as late as possible, which in turn, may improve the safety of HPD.

Superficial Surgical Site Infection in Hepatobiliary-Pancreatic Surgery: Subcuticular Suture Versus Skin Staples

PURPOSE

Postoperative superficial surgical site infection is a major complication in hepatobiliary-pancreatic surgery. We aimed to compare the efficacy of subcuticular sutures versus staples for skin closure in preventing superficial surgical site infection in hepatobiliary-pancreatic surgery.

METHODS

Consecutive patients who underwent hepatobiliary-pancreatic surgery at our hospital from October 2006 to March 2011 and from April 2012 to March 2015 were reviewed retrospectively. Superficial surgical site infection incidence was evaluated in patients who received subcuticular sutures and those who received staples for skin closure. Propensity score matching analysis was used to adjust bias from confounding factors.

RESULTS

A total of 691 patients were included. Patients with skin staple closures (n = 346) were compared with patients with subcuticular suture closures (n = 345). After a propensity score matching analysis, a significant difference in superficial surgical site infection incidence was found between the skin stapler group (11.3%) and subcuticular sutures group (2.6%). The same comparison was performed by a subgroup analysis and supported this finding in patients after hepatectomy without biliary reconstruction, pancreatoduodenectomy, or open laparotomy surgeries and in patients with body mass index < 25.

CONCLUSIONS

Subcuticular suturing after hepatobiliary-pancreatic surgery was more efficacious in reducing postoperative superficial surgical site infection incidence than staples for skin closure.

The diagnostic value of 99m-Tc GSA scintigraphy for liver function and remnant liver volume in hepatic surgery: a retrospective observational cohort study in 27 patients

Background

The aim was to analyze hepatic hypertrophy after portal vein embolization (PVE) and Associating Liver Partition with Portal vein ligation for Staged hepatectomy (ALPPS) to determine whether clinical circumstances associated with major hepatic resections correlated with remnant growth.

Methods

Data was abstracted from a retrospectively maintained database on 27 patients undergoing hepatic resection followed by PVE and the ALPPS procedure between October 1, 2007 and December 31, 2016. The increasing rate of liver volume and remnant liver LU15 was defined as the percentage-point difference between the liver volume and remnant liver LU15 before and after the intervention or surgery. And correlation between kinetic growth rate (KGR) of liver and future remnant liver volume or remnant liver LU15 was analyzed.

Results

The degree of hypertrophy (DH) of volume and LU15 was significantly greater after ALPPS (volume: 40.3% and LU15: 65.0%) than after PVE (volume: 22.7% and LU15: 48.8%) (P < 0.05). KGR of volume and LU15 was significantly greater after ALPPS (volume: 19.0 cm³/day and 2.00%/day) (LU15: 0.61 /day and 1.82%/day) than after PVE (volume: 3.89 cm³/day and 0.42%/day) (LU15: 0.19 /day and 0.63%/day) (P < 0.001). An inverse correlation between KGR and initial remnant liver volume was observed. And a positive correlation between KGR and LU15 was observed.

Conclusion

Future remnant liver volume and KGR was greater after the ALPPS procedure than after PVE. Liver hypertrophy is related to the expected remnant liver volume and total liver function. This study suggested that total liver function and initial remnant liver volume might be a new indication of hepatectomy after PVE and ALPPS in the case of insufficient remnant liver volume.

[A Case of an Elderly Patient Who Experienced Long-Term Survival after Receiving S-1 for Synchronous Advanced Gallbladder and Stomach Cancer]

The reported patient was a 90-year-old woman with anorexia. She was diagnosed with advanced gallbladder cancer that occurred concurrently with stomach cancer. Subsequent to intestinal bypass surgery, S-1(80mg/day)was administered for 14 days, followed by 7 days of rest for one course. Tumor marker levels returned to normal after 4 months. Computed tomography results indicated that, in regard to the gallbladder cancer, the patient had stable disease after 8 months. In addition, gastroscopy revealed a complete response of the gastric cancer after a year. The patient was able to continue treatment as an outpatient until she experienced aspiration pneumonia. The administration of S-1 was terminated after 4 years and 4 months. Treatment with S-1 monotherapy is considered safe for elderly patients, and has the additional benefit that it is deliverable as an outpatient treatment.

Intermittent transcatheter therapy through a new indwelling catheter system for patients with hepatocellular carcinoma

PURPOSE

This paper describes the technical details of the new indwelling catheter system, which we refer to as System-i, and provides an overview of our experience with this system at our institution.

MATERIALS AND METHODS

The system is implanted via the left brachial artery. The feeding artery of the tumor is catheterized at each treatment, and the system can be used for multiple treatments via more than one feeding artery. Between January 2004 and January 2013, System-i was used to administer 398 treatments in 30 patients with hepatocellular carcinoma (HCC). The technical aspects and outcomes of treatment procedures were evaluated.

RESULTS

Implantation was successful in all cases. System-i was used for a median number of 11 treatments per patient over a median period of 5.7 months, and 71.6 % of all treatments were administered on an outpatient basis.

CONCLUSION

System-i provides an effective and safe method for selective catheterization of feeding arteries for administration of transcatheter arterial chemoembolization or infusion in patients with HCC. Treatment regimens can be individualized without limiting the number of treatments or treatment locations, and patients can be treated on an outpatient basis.

Cryoablation compared with radiofrequency ablation and microwave coagulation therapy for the local control of primary hepatocellular carcinoma

286

Background: Although cryoablation (Cryo) has been advocated as an effective local treatment for hepatocellular carcinoma (HCC), data are lacking regarding its outcomes in comparison with radiofrequency ablation (RFA) and microwave coagulation therapy (MCT). The aim of this study was to clarify the benefits and disadvantages of each modality for primary HCC. Methods: We reviewed outcomes of 120 patients with primary HCCs (< 5cm) who underwent local treatment (Cryo: n = 55 and RFA/MCT: n = 65) between 1998 and 2011. The primary endpoint was local recurrence free survival (LRFS). The secondary endpoints were complication rates and the length of hospital stay. Results: Age, sex, Child-Pugh score, and background liver disease were identical between both groups. The Cryo group had larger tumors (mean ± standard error tumor size: Cryo 2.55 ± 0.75 cm vs. RFA/MCT 1.96 ± 0.72cm, p < 0.001). The LRFS was higher in the Cryo group than in RFA/MCT group (2270.0 ± 240.8 days vs. 1940.7 ± 269.5 days: p = 0.116). The Cox proportional hazards multivariate analysis revealed that Cryo as the treatment of choice was an independent predictive indicator of improved LRFS (HR, 0.403 [95% CI: 0.202−0.807], P = 0.010). On the contrary, tumor size (for each 1 cm increase, HR, 1.635 [95% CI: 1.038–2.574], p = 0.034) and Child-Pugh score ≥ 6 (HR, 2.166 [95% CI: 1.179 – 3.979], p = 0.013) were negative prognostic factors for LRFS. Subgroup analysis showed that the LRFS for tumors ≤ 2 cm was similar between the 2 groups. However, if the tumor size was greater than 2 cm, the LRFS of the Cryo group was superior to RFA/MCT (2400.0 ± 287.4 days vs. 1177.9 ± 366.5 days: p = 0.004). The complication rates (Cryo 10.9% vs. RFA/MCT 10.8%: p = 0.980) and the length of hospital stay (9.45 ± 5.33 days vs. 9.52 ± 5.90 days: p = 0.947) were similar in both groups. No mortality was observed in the entire cohort. Conclusions: Cryo provides significantly higher chance of local control for primary HCCs compared with RFA/MCT, particularly if the tumor size exceeds 2 cm. Associated risks are at least equivalent to those of RFA/MCT even in patients with marginal to poor liver function. Cryo is a promising local ablative option in an era of rising incidence of HCC.

Inhibition of superoxide generation and of increase in intracellular Ca2+ concentration by zinc in rat neutrophils stimulated with zymosan

The effect of Zn2+ on the O2- generation and change in intracellular Ca2+ concentration ([Ca2+]i) of rat peritoneal neutrophils was studied. Zymosan (serum-treated zymosan (STZ))-induced O2- generation was inhibited by Zn2+ at concentrations as low as 10 microM. A large amount of the inhibition was observed in the absence of extracellular Ca2+ but the inhibition could not be restored by increasing the extracellular Ca2+ concentration, indicating that Zn2+ does not necessarily inhibit the O2- generation competitively with extracellular Ca2+. In the absence of extracellular Ca2+, Zn2+ inhibited STZ-induced transient increase in [Ca2+]i in the concentration range that evoked a marked inhibition in the O2- generation. On the other hand, Zn2+ did not inhibit significantly STZ-induced uptake of 45Ca2+ from extracellular medium by the cells. From these results, it is suggested that Zn2+ inhibits STZ-induced release of Ca2+ from intracellular storage sites, resulting in the suppression of the activation mechanism of neutrophils.

Enhancement of zymosan-induced respiratory burst of rat neutrophils by lead in vitro

The effect of Pb2+ on serum-treated zymosan (STZ)-induced O2 consumption of rat peritoneal neutrophils was studied. Pb2+ was found to mimic effectively the enhancing action of Ca2+ on the O2 consumption depending on the concentration up to about 80 microM. However, at concentrations over 80 microM, Pb2+ inhibited the O2 consumption. The enhancing effect of Pb2+ on the O2 consumption was further examined using the intracellularly Ca2(+)-depleted neutrophils. Pb2+ also enhanced the O2 consumption of the Ca2(+)-depleted cells as effectively as Ca2+. The Pb2(+)-enhanced O2 consumption of the Ca2(+)-depleted cells was inhibited by N-(6-aminohexyl)-5-chloro-1-naphthalene-sulfonamide (W-7) based on its calmodulin antagonistic action. The effect of Pb2+ on the activity of activator-deficient 3',5'-cyclic nucleotide phosphodiesterase (PDE), a calmodulin-dependent enzyme, was examined. Pb2+ activated PDE as effectively as Ca2+ only in the presence of calmodulin. The Pb2(+)-activated PDE activity was also inhibited by W-7 only in the presence of calmodulin. These results indicated that Pb2+ could replace Ca2+ in the activation process(es) of the respiratory burst, suggesting a possible involvement of calmodulin in the enhancing mechanism of the O2 consumption by Pb2+.