Treatment of hepatocellular carcinoma with a portal vein tumor thrombus and pulmonary metastases of rectal cancer with microsatellite stability using atezolizumab plus bevacizumab.

Herein, we report the successful treatment using atezolizumab plus bevacizumab of a patient with hepatocellular carcinoma (HCC) with a portal vein tumor thrombus and multiple pulmonary metastases from rectal cancer with microsatellite stability. This patient developed rectal cancer with synchronous pulmonary metastases and HCC. After resecting the primary lesion of the rectal cancer, transcatheter arterial chemoembolization was performed for the HCC. Drug therapy was planned for multiple pulmonary metastases of rectal cancer; however, the early development of recurrent HCC with portal vein tumor thrombus had to be highly prioritized, and atezolizumab plus bevacizumab was introduced. Following the disappearance of the recurrent HCC lesion, the metastatic pulmonary nodules shrunk into scar-like spots. The treatment for both HCC and pulmonary metastases of rectal cancer were considered to result in clinical complete response.

Ultrasound-guided lung biopsy with coaxial technique: pleural contact length affects the occurrence of pneumothorax after first puncture.

PURPOSE: To assess prebiopsy characteristics influencing the occurrence of pneumothorax after first puncture of ultrasound (US)-guided lung biopsy with coaxial technique. MATERIALS AND METHODS: From January 2007 to September 2018, 180 peripheral lung lesions in 174 patients who underwent B-mode US-guided lung biopsy with coaxial technique at single institution were included in this study. Technical success was defined as the ability to make a diagnosis using the acquired sample with/without an adverse event of pneumothorax. Statistical analyses of prebiopsy characteristics were performed to identify the most important cutpoint and to evaluate the effect on diagnostic accuracy. RESULTS: Of the 180 lesions (mean size, 37 mm ± 26.2; mean pleural contact length, 38.2 mm ± 34.4), technical success rate was 97.2% (175/180 lesions) and diagnostic accuracy rate was 91.6% (165/180 lesions). Pneumothorax occurred immediately after first puncture for seven of 180 lesions. Classification and regression tree analysis and Fisher's exact test showed the proportion of the pneumothorax immediately after first puncture was higher in lesions with pleural contact length less than 9.78 mm (p = 0.002). No significant difference was shown between the pneumothorax and non-pneumothorax after first puncture in technical success and final diagnosis success rate. CONCLUSION: Pleural contact length affects the occurrence of pneumothorax after first puncture of US-guided lung biopsy with coaxial technique.

Complications in hepatic arterial infusion chemotherapy: retrospective comparison of catheter tip placement in the right/left hepatic artery vs. the gastroduodenal artery.

PURPOSE: To compare the complication rates associated with hepatic arterial infusion chemotherapy (HAIC) for unresectable hepatocellular carcinoma (HCC) using two different catheter tip locations, the right/left hepatic artery (group 1) and the gastroduodenal artery (group 2). METHODS: Between April 2001 and March 2015, 88 patients (group 1, n = 36; group 2, n = 52) with unresectable HCC, underwent HAIC via a transfemorally placed infusion catheter. The incidence of complications related to catheter placement (including hepatic arterial occlusion, catheter dislocation, non-target embolization and port-catheter system infection) as well as catheter patency and patient survival were evaluated. RESULTS: The technical success rate was 100%. The overall complication rate was 17% (15/88 patients). The specific complications were as follows: hepatic artery occlusion, n = 1 (group 2, n = 1), gastroduodenal ulcer, n = 6 (group 1, n = 2; group 2, n = 4); catheter dislocation, n = 1 (group 2, n = 1); port-catheter system infection, n = 3 (group 2, n = 3); and bleeding at the puncture site, n = 4 (group 1, n = 1; group 2, n = 3). CONCLUSIONS: The complication rates in groups 1 and 2 did not differ to a statistically significant extent.

Left lobe graft poses a potential risk of hepatic venous outflow obstruction in adult living donor liver transplantation.

Hepatic venous outflow obstruction (HVOO) is a critical complication after living donor liver transplantation (LDLT). This study aimed to evaluate the incidence of HVOO and the risk factors for HVOO in adults. From 2005 to 2015, 430 adult LDLT patients (right lobe [RL] graft, 270 patients; left lobe [LL] graft, 160 patients) were enrolled and divided into no HVOO (n = 413) and HVOO (n = 17) groups. Patient demographics and surgical data were compared, and risk factors for HVOO were analyzed. Furthermore, the longterm outcomes of percutaneous interventions as treatment for HVOO were assessed. HVOO occurred in 17 (4.0%) patients. The incidence of HVOO in patients receiving a LL graft was significantly higher than in those receiving a RL graft (8.1% versus 1.5%; P = 0.001). The body weight and caliber of hepatic vein anastomosis in the HVOO group were significantly lower compared with the no HVOO group (P = 0.02 and P = 0.008, respectively). Multivariate analysis revealed that only LL graft was an independent risk factor for HVOO (OR, 4.782; 95% CI, 1.387-16.488; P = 0.01). Among 17 patients with HVOO, 7 patients were treated with single balloon angioplasty, and 9 patients who developed recurrence were treated with repeated interventions. Overall, 6 patients underwent stent placement: 1 at the initial procedure, 3 at the second procedure for early recurrence, and 2 following repeated balloon angioplasty (≥3 interventions). These 6 patients experienced no recurrence. Overall graft survival was not significantly different between the HVOO and no HVOO groups (P = 0.99). In conclusion, the use of a LL graft was associated with HVOO, and percutaneous interventions were effective for treating adult HVOO after LDLT. Liver Transplantation 22 785-795 2016 AASLD.

Long-Term Outcome of Percutaneous Biliary Interventions for Biliary Anastomotic Stricture in Pediatric Patients after Living Donor Liver Transplantation with Roux-en-Y Hepaticojejunostomy.

PURPOSE: To retrospectively evaluate long-term outcomes of percutaneous transhepatic biliary drainage (PTBD) followed by balloon dilation and placement of an internal drainage tube for anastomotic stricture in pediatric patients who underwent living donor liver transplantation (LDLT) with Roux-en-Y hepaticojejunostomy (RYHJ). MATERIALS AND METHODS: Fifty-two patients (23 male, 29 female; median age, 5 y) with anastomotic biliary stricture were treated with PTBD followed by balloon catheter dilation and long-term placement of an internal drainage tube, which was removed upon cholangiographic confirmation of free flow of bile into the small bowel. Clinical success, tube independence rate, risk factors of recurrent biliary stricture, and patency rates were evaluated. RESULTS: Thirty-nine patients (75%) had no stricture recurrence. Of 13 patients (25%) with recurrence, six were treated again with the same percutaneous biliary interventions and showed no further recurrence. Clinical success was noted in 43 of 52 patients (83%). Drainage tubes were removed from 49 patients (94%). Multivariate logistic regression analysis indicated that serum alanine aminotransferase level > 53 IU/L at discharge after the initial series of percutaneous biliary interventions was a significant risk factor for recurrent biliary stricture (P = .002). Kaplan-Meier analysis showed 1-, 3-, 5-, and 10-year primary and primary assisted patency rates of 75%, 70%, 70%, and 68%, and 94%, 92%, 88%, and 88%, respectively. CONCLUSIONS: PTBD followed by balloon dilation and internal drainage may be an effective treatment for anastomotic biliary stricture after pediatric LDLT with RYHJ.

[A case of leptomeningeal melanomatosis presenting with right abducens nerve palsy].

A 39 year-old man was admitted to this hospital because of severe headache and vomiting. He had been suffering from lumbago about one month previously, and diplopia ten days previously. The neurological examination revealed disturbance of right eye abduction, no nuchal rigidity. The cerebrospinal fluid (CSF) at the time of admission included erythrocytes (1,490/µl), white blood cell (62/µl) and increased level of protein (531 mg/dl), but no malignant cells were detected. He was treated as meningitis. Cranial magnetic resonance imaging (MRI) demonstrated heterogeneous intensity lesion in the left maxillary sinus and gadolinium enhancement of diffuse meninges and cranial nerves. Spine MRI showed gadolinium enhancement of lumbar spinal meninges and the cauda equina. Biopsy of the lesion in the left maxillary sinus was performed. The pathological findings demonstrated malignant melanoma. Because malignant cells were also observed in CSF, we diagnosed this case as leptomeningeal melanomatosis. Leptomeningeal carcinomatosis should be suspected when headache accompanied with pleomorphic clinical manifestations.