Current Roles of Ramucirumab in the Sequential Treatment of Unresectable Hepatocellular Carcinoma.

BACKGROUND/AIM: The treatment algorithm for systemic therapies for advanced hepatocellular carcinoma (HCC) has changed dramatically; however, the therapeutic landscape for sequential second-line or later-line treatments, including ramucirumab, remains controversial. This study aimed to investigate the role of ramucirumab for treating HCC. PATIENTS AND METHODS: We retrospectively analyzed data from 17 patients with advanced HCC who received ramucirumab, and 8 of them who received lenvatinib re-administration after ramucirumab treatment failure. RESULTS: The median overall survival of 17 patients treated with ramucirumab was 11.5 months. The median ratios of the 1-month post-treatment α-fetoprotein (AFP) levels and albumin-bilirubin (ALBI) scores to the pre-treatment AFP levels and ALBI scores following ramucirumab treatment were 0.880 and 0.965, respectively. The median ratios of the 1-month post-treatment AFP and ALBI levels to the pre-treatment levels were 1.587 and 0.970 for mALBI grade 1/2a, and 1.313 and 0.936 for mALBI grade 2b/3, respectively. Six of the eight patients who received lenvatinib rechallenge treatment exhibited a decrease in AFP levels one month post-lenvatinib treatment. Deterioration of liver function 3 months post-lenvatinib treatment was noted in five of the eight patients who received lenvatinib rechallenge treatment after ramucirumab. CONCLUSION: Ramucirumab may be equally useful in patients with unresectable HCC who have poor liver function or whose liver function is aggravated by other therapies. Rechallenge treatment with lenvatinib after ramucirumab may be a valid treatment option for HCC.

Spontaneous rupture of splenic hilar lymph node metastasis from hepatocellular carcinoma.

Spontaneous rupture of a primary hepatocellular carcinoma (HCC) is a frequently observed and fatal complication. However, the rupture of lymph node (LN) metastases from HCC is rare. A 79 year-old male with hepatitis B underwent three liver resections for HCC. Two years and 6 months after the last liver resection, enhanced computed tomography (CT) revealed a nodule with a diameter of 3 cm in the lower pole of the spleen. Splenic metastasis of HCC was suspected, and splenectomy was scheduled. During our hospital stay for a urinary tract infection before the scheduled operation, he complained of acute left-sided abdominal pain, and CT showed intra-abdominal hemorrhage due to rupture of the splenic tumor. Emergency splenectomy was performed, and the postoperative course was uneventful. Histopathological examination revealed a poorly differentiated HCC in the lower splenic pole lesion, which contained LN structures. The ruptured lesion was diagnosed as splenic hilar LN metastasis of HCC. Although laparoscopic partial liver resection was performed for intrahepatic recurrence, and atezolizumab plus bevacizumab therapy was administered for peritoneal metastases, the patient was alive 25 months after the splenectomy. Our case suggests that emergency surgery for LN metastatic rupture can achieve hemostasis and lead to improved survival outcomes.

Clinical impact of spacer placement surgery with expanded polytetrafluoroethylene sheet for particle therapy.

BACKGROUND: Spacer placement surgery is useful in particle therapy (PT) for patients with abdominopelvic malignant tumors located adjacent to the gastrointestinal tract. This study aimed to assess the safety, efficacy, and long-term outcomes of spacer placement surgery using an expanded polytetrafluoroethylene (ePTFE) spacer. METHODS: This study included 131 patients who underwent ePTFE spacer placement surgery and subsequent PT between September 2006 and June 2019. The overall survival (OS) and local control (LC) rates were calculated using Kaplan-Meier method. Spacer-related complications were classified according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 5.0). RESULTS: The median follow-up period after spacer placement surgery was 36.8 months. The 3-year estimated OS and LC rates were 60.5% and 76.5%, respectively. A total of 130 patients (99.2%) were able to complete PT. Spacer-related complications of ≥ grade 3 were observed in four patients (3.1%) in the acute phase and 13 patients (9.9%) in the late phase. Ten patients (7.6%) required removal of the ePTFE spacer. CONCLUSIONS: Spacer placement surgery using an ePTFE spacer for abdominopelvic malignant tumors is technically feasible and acceptable for subsequent PT. However, severe spacer-related late complications were observed in some patients. Since long-term placement of a non-absorbable ePTFE spacer is associated with risks for morbidity and infection, careful long-term follow-up and prompt therapeutic intervention are essential when complications associated with the ePTFE spacer occur. TRIAL REGISTRATION: retrospectively registered.

Purse-string suture after ligating by endoloop for closing of the appendiceal stump is an alternative for endostapler in selected cases: A propensity score-matched study.

INTRODUCTION: The closure of the appendiceal stump is a crucial part of a laparoscopic appendectomy, and an endoloop or endostapler is generally used. The endoloop can be more cost effective than the endostapler. However, reports have shown that the endoloop has a higher postoperative abdominal abscess rate than the endostapler in complicated appendicitis. At our institution, we perform a purse-string suture after ligating by endoloop to reduce postoperative abdominal abscess risk. This study aimed to clarify whether this method could reduce the incidence of postoperative abdominal abscess compared with the endostapler. METHODS: Patients with acute appendicitis were classified into the purse-string suture group (n = 149) and the endostapler group (n = 82). Postoperative outcomes were compared after propensity score matching (n = 47). RESULTS: No significant difference was found between the two groups in terms of the patient characteristics and postoperative complications, including abdominal abscess. However, the purse-string suture group had more drain placement and a shorter hospital stay than the endostapler group (P = .04 and P = .02, respectively). In patients with complicated appendicitis, there was less drain placement and a shorter hospital stay in the purse-string suture group than in the endostapler group (P < .01 and P < .01, respectively). This might have reflected the difficulty of the operation. All postoperative abdominal abscesses occurred in complicated appendicitis cases. CONCLUSIONS: Endoloop with additional purse-string suture had a lower incidence of abscess than previous reports of using endoloop alone. Moreover, the postoperative abdominal abscess rate is similar between the two closure methods.

Laparoscopic anatomical liver resection using indocyanine green fluorescence imaging.

BACKGROUND: Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. METHODS: Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. RESULTS: For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. CONCLUSION: LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections.

[Adjuvant Chemotherapy for High-Risk Stage â ¡ Colon Cancer].

BACKGROUND: This study was designed to clarify effects of postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer. METHOD: The subjects were 99 patients with high-risk Stage Ⅱcolorectal cancer who underwent surgery at our department from October 2013 to March 2018. Patients were classified into adjuvant chemotherapy group and nonadjuvant chemotherapy group. Overall survival(OS)and recurrence-free survival(RFS)were analyzed between the 2 groups. RESULTS: Thirty six patients(36.4%)underwent adjuvant chemotherapy. Adjuvant chemotherapy group were younger(p<0.010), had a better ASA-PS(p<0.010), good preoperative Hb(p<0.010), and preoperative Alb(p<0.010)compared to non-adjuvant chemotherapy group. There was no difference between the 2 groups in the high-risk factors for recurrence. Most patient had an oral medication as for adjuvant chemotherapy. There was no difference in OS and RFS between the 2 groups. CONCLUSION: Postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer did not significantly improve the OS and RFS. Further study is necessary to asses the suitable regimen and patients eligible for chemotherapy.

[Preoperative Chemotherapy with DCF for Advanced Esophageal Cancer].

We conducted a retrospective study to evaluate the efficacy and the problem of the neoadjuvant chemotherapy using DCF for cStage Ⅲ/Ⅳ(squamous cell)esophageal cancer. Eleven patients from January 2017 to December 2018 were enrolled into this study. The median age was 67 years old, male/female ratio was 9:2, performance status was 0 in all patients, and UICC cStage Ⅲ/Ⅳa was 7:4. Cycles of chemotherapy was 2 in 1 patients, 3 in 5 patients and additional 2 courses in 1 patient. Four patients switched to FP therapy after a course of DCF. The efficacy of chemotherapy was evaluated by the clinical response rate, average tumor reduction rate, and histological therapeutic effect rate over Grade 2 which was 63.6%, 48.3%, and 40%, respectively. Neutropenia over Grade 3 was observed in all patients and Grade 4 was observed in 6 patients. In conclusion, preoperative chemotherapy with DCF therapy is useful for the treatment of cStage Ⅲ/Ⅳ(squamous cell) esophageal cancer as long as bone marrow suppression is managed.

Feasibility and Effectiveness of Gastrectomy for Elderly Gastric Cancer Patients.

BACKGROUND/AIM: The benefits of gastrectomy for elderly gastric cancer (GC) patients remain unknown. The aim of this study was to evaluate the validity of gastrectomy. PATIENTS AND METHODS: Patients who had R0 or R1 resection and diagnosed as pathological Stage I-III GC were enrolled in this study. Patients were classified according to age: Elderly group (≥80 years old), non-Elderly group (70-79 years old), Standard group (≤69 years old). RESULTS: As the age raised, the number of comorbidities increased and patients had a worse physical status. Operative procedure and postoperative complications of the Elderly group were similar to that of the non-Elderly group. The overall survival was similar in pathological Stages I and III between the Elderly and non-Elderly groups, while the Stage II Elderly group had shorter overall survival. Also, the Elderly group did not undergo adjuvant chemotherapy compared to other groups. CONCLUSION: Gastrectomy can be performed safely in elderly patients following gastrectomy, survival of elderly patients was similar to non-elderly patients. Therefore, gastrectomy is an acceptable treatment for elderly patients in good condition.

Laparoscopic transabdominal preperitoneal approach for giant inguinal hernias.

BACKGROUND: Many surgical techniques have been developed to treat inguinal hernia. In recent years, the laparoscopic transabdominal preperitoneal (TAPP) approach has been widely performed to repair inguinal hernia. Giant inguinal hernia (GIH) is an extremely rare disease that is a challenge for general surgeons. GIH appears when patients neglect the treatment for many years and it is defined as an inguinal hernia that extends below the midpoint of inner thigh in standing position. According to previous publications, the Lichtenstein tension-free hernioplasty is recommended to repair GIH. In this article, we describe consecutive four cases of GIH repaired via the TAPP approach. METHODS: From April 2015 to March 2017, 200 patients underwent hernioplasty against inguinal hernia at our hospital. Inguinal hernias were treated via the TAPP approach in principle. We performed hernioplasty via the TAPP approach in all 4 patients (2%) who met the definition of Type 1 GIH. Demographic information, maximum diameter of hernia sac, hernia orifice size, and surgical data were obtained. RESULTS: The mean operative time was 135 min. No intraoperative complications were encountered. All patients could walk from postoperative day 1 and were discharged home early, but they all had scrotal seromas. Three patients did not need puncture or drainage, but one of them required puncture. All seromas disappeared within 6 months. There was no recurrence in the 8- to 24-month follow-up. CONCLUSION: The TAPP approach is a feasible, safe therapeutic option that may reduce wound size and pain following surgical treatment of Type 1 GIH.