Propensity Score-Matching Analysis Comparing Robotic Versus Laparoscopic Limited Liver Resections of the Posterosuperior Segments: An International Multicenter Study.

OBJECTIVE: The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments. BACKGROUND: Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature. METHODS: This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias. RESULTS: A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset. CONCLUSIONS: RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR.

Defining Global Benchmarks for Laparoscopic Right Posterior Sectionectomy/H67: An International Multicenter Study.

OBJECTIVE: We aimed to establish global benchmark outcomes indicators for L-RPS/H67. BACKGROUND: Minimally invasive liver resections has seen an increase in uptake in recent years. Over time, challenging procedures as laparoscopic right posterior sectionectomies (L-RPS)/H67 are also increasingly adopted. METHODS: This is a post hoc analysis of a multicenter database of 854 patients undergoing minimally invasive RPS (MI-RPS) in 57 international centers in 4 continents between 2015 and 2021. There were 651 pure L-RPS and 160 robotic RPS (R-RPS). Sixteen outcome indicators of low-risk L-RPS cases were selected to establish benchmark cutoffs. The 75th percentile of individual center medians for a given outcome indicator was set as the benchmark cutoff. RESULTS: There were 573 L-RPS/H67 performed in 43 expert centers, of which 254 L-RPS/H67 (44.3%) cases qualified as low risk benchmark cases. The benchmark outcomes established for operation time, open conversion rate, blood loss ≥500 mL, blood transfusion rate, postoperative morbidity, major morbidity, 90-day mortality and textbook outcome after L-RPS were 350.8 minutes, 12.5%, 53.8%, 22.9%, 23.8%, 2.8%, 0% and 4% respectively. CONCLUSIONS: The present study established the first global benchmark values for L-RPS/H6/7. The benchmark provided an up-to-date reference of best achievable outcomes for surgical auditing and benchmarking.

Impact of Liver Cirrhosis, Severity of Cirrhosis, and Portal Hypertension on the Difficulty and Outcomes of Laparoscopic and Robotic Major Liver Resections for Primary Liver Malignancies.

BACKGROUND: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies. METHODS: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis. RESULTS: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM. CONCLUSIONS: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.

Preliminary comparative study of lower extremity pressure measurements under the conditions using former models and new lithotomy stirrups in rectal cancer surgery.

BACKGROUND: This study aimed to investigate the effect of the use of new lithotomy stirrups-2 on the pressure dispersal on lower limbs, which may lead to the prevention of well-leg compartment syndrome (WLCS) and deep venous thrombosis (DVT), which are the most commonly associated adverse events with laparoscopic and robot-assisted rectal surgery. METHODS: A total of 30 healthy participants were included in this study. The pressure (mmHg) applied on various lower limb muscles when using conventional lithotomy stirrups-1 and new type stirrups-2 was recorded in various lithotomy positions; 1) neutral position, 2) Trendelenburg position (15°) with a 0° right inferior tilt, and 3) Trendelenburg position (15°) with a 10° right inferior tilt. Using a special sensor pad named Palm Q®, and the average values were compared between two types of stirrups. RESULTS: The use of new lithotomy stirrups-2 significantly reduced the pressure applied on the lower limb muscles in various lithotomy positions compared with the use of lithotomy stirrups-1. The most pressured lower limb muscle when using both lithotomy stirrups was the central soleus muscle, which is the most common site for the development of WLCS and DVT. In addition, when using the conventional lithotomy stirrups-1, the pressure was predominantly applied to the proximal soleus muscle; however, when using lithotomy stirrups-2, the pressure was shifted to the more distal soleus muscle. CONCLUSION: These results suggest that the new lithotomy stirrups-2 is useful in reducing the pressure load on leg muscles, especially on the proximal to central soleus, and may reduce the incidence of WLCS and DVT after rectal surgery performed in the lithotomy position. Further clinical studies are needed to determine whether the use of lithotomy stirrups-2 prevents these complications in various clinical settings.

Propensity-score Matched and Coarsened-exact Matched Analysis Comparing Robotic and Laparoscopic Major Hepatectomies: An International Multicenter Study of 4822 Cases.

OBJECTIVE: To compare the outcomes between robotic major hepatectomy (R-MH) and laparoscopic major hepatectomy (L-MH). BACKGROUND: Robotic techniques may overcome the limitations of laparoscopic liver resection. However, it is unknown whether R-MH is superior to L-MH. METHODS: This is a post hoc analysis of a multicenter database of patients undergoing R-MH or L-MH at 59 international centers from 2008 to 2021. Data on patient demographics, center experience volume, perioperative outcomes, and tumor characteristics were collected and analyzed. Both 1:1 propensity-score matched (PSM) and coarsened-exact matched (CEM) analyses were performed to minimize selection bias between both groups. RESULTS: A total of 4822 cases met the study criteria, of which 892 underwent R-MH and 3930 underwent L-MH. Both 1:1 PSM (841 R-MH vs. 841 L-MH) and CEM (237 R-MH vs. 356 L-MH) were performed. R-MH was associated with significantly less blood loss {PSM:200.0 [interquartile range (IQR):100.0, 450.0] vs 300.0 (IQR:150.0, 500.0) mL; P = 0.012; CEM:170.0 (IQR: 90.0, 400.0) vs 200.0 (IQR:100.0, 400.0) mL; P = 0.006}, lower rates of Pringle maneuver application (PSM: 47.1% vs 63.0%; P < 0.001; CEM: 54.0% vs 65.0%; P = 0.007) and open conversion (PSM: 5.1% vs 11.9%; P < 0.001; CEM: 5.5% vs 10.4%, P = 0.04) compared with L-MH. On subset analysis of 1273 patients with cirrhosis, R-MH was associated with a lower postoperative morbidity rate (PSM: 19.5% vs 29.9%; P = 0.02; CEM 10.4% vs 25.5%; P = 0.02) and shorter postoperative stay [PSM: 6.9 (IQR: 5.0, 9.0) days vs 8.0 (IQR: 6.0 11.3) days; P < 0.001; CEM 7.0 (IQR: 5.0, 9.0) days vs 7.0 (IQR: 6.0, 10.0) days; P = 0.047]. CONCLUSIONS: This international multicenter study demonstrated that R-MH was comparable to L-MH in safety and was associated with reduced blood loss, lower rates of Pringle maneuver application, and conversion to open surgery.

The double bipolar method for robotic total mesorectal excision in patients with rectal cancer.

Although meta-analyses and systematic reviews have clarified the benefits of robotic surgery, few studies have focused on robotic rectal surgery (RRS) and the use of Endowrist® instruments. Therefore, we evaluated RRS using the double bipolar method (DBM) and compared its short-term outcomes with those of RRS using the single bipolar method (SBM). This study enrolled 157 consecutive patients and all procedures were performed by the same surgeon and recorded through short video clips. We analyzed the patient demographics and short-term clinical outcomes. Although this observational study has several limitations, the console time for total mesorectal excision using the DBM was significantly shorter than that using the SBM. Although the DBM did not demonstrate a specific learning curve, it was a safe and feasible procedure even for patients with advanced disease. Further studies are needed to evaluate the cost-effectiveness of the DBM.

Effectiveness of an immersive virtual reality environment on curricular training for complex cognitive skills in liver surgery: a multicentric crossover randomized trial.

BACKGROUND: Virtual reality (VR) is increasingly used in surgical education, but evidence of its benefits in complex cognitive training compared to conventional 3-dimensional (3D) visualization methods is lacking. The objective of this study is to assess the impact of 3D liver models rendered visible by VR or desktop interfaces (DIs) on residents' performance in clinical decision-making. METHOD: From September 2020 to April 2021, a single-blinded, crossover randomized educational intervention trial was conducted at two university hospitals in Belgium and Italy. A proficiency-based stepwise curriculum for preoperative liver surgery planning was developed for general surgery residents. After completing the training, residents were randomized in one of two assessment sequences to evaluate ten real clinical scenarios. RESULTS: Among the 50 participants, 46 (23 juniors/23 seniors) completed the training and were randomized. Forty residents (86.96%) achieved proficiency in decision-making. The accuracy of virtual surgical planning using VR was higher than that using DI in both groups A (8.43 ± 1.03 vs 6.86 ± 1.79, p < 0.001) and B (8.08 ± 0.9 vs 6.52 ± 1.37, p < 0.001). CONCLUSION: Proficiency-based curricular training for liver surgery planning successfully resulted in the acquisition of complex cognitive skills. VR was superior to DI visualization of 3D models in decision-making. GOV ID: NCT04959630.

Development of a nomogram to predict outcome after liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis.

BACKGROUND & AIMS: Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival. METHODS: Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed. RESULTS: A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm3, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed. CONCLUSIONS: Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes. LAY SUMMARY: Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.

Oncoplastic breast surgery combining partial mastectomy with a triangular skin resection and re-centralization of the nipple-areola.

The treatment of early breast cancer using breast conservation therapy (BCT) commonly ensures local control and acceptable cosmetic results. We herein report a useful technique to obtain symmetry of the breast shape and a level inframammary line and nipple-areola, which achieved excellent results. Six Japanese patients with early breast cancer located on the upper area of the breast were enrolled into this study. A triangle-shaped area of skin was removed together with cancerous and healthy-surrounding breast tissue. Two crescents were designed and de-epithelialized in the directions of 9 o'clock and 3 o'clock. The width of the crescent was decided to be the same as a half or the length of the base of a triangle to be removed. After partial mastectomy, the inner and outer glandular flaps were horizontally sutured. The operations were simple to perform and were not associated with any postoperative complications. Oncoplastic breast surgery combining partial mastectomy with triangular skin resection and re-centralization of the nipple-areola was useful for patients with breast cancer on the upper quadrant area of non-ptotic breasts.

Key components of a hepatobiliary surgery curriculum for general surgery residents: results of the FULCRUM International Delphi consensus.

BACKGROUND: In general surgery residency, hepatobiliary training varies significantly across the world. The aim of this study was to establish an international consensus among hepatobiliary surgeons on components of a hepatobiliary curriculum for general surgery residents. METHODS: A three-round modified Delphi technique was employed. Fifty-two hepatobiliary surgeons involved in general surgery training programs were invited. An initial questionnaire was developed by a group of experts in hepatobiliary and educational research after a systematic literature review. It comprised 90 statements about knowledge, technical skills, attitudes, and postoperative care. Panelists could add or alter items. The survey was delivered electronically and the panel was instructed to score the items based on 5-point Likert scale. Consensus was reached when at least 80% of panelists agreed on a statement with Cronbach's alpha value >0.8. RESULTS: Forty-one (79%) experts have participated. Sixteen panelists are based in Asia, 14 in Europe, and 11 in the Americas. Eighty percent of all proposed skills (81/101) were considered fundamental including knowledge (39/43), technical skills (16/32), attitude (15/15), and postoperative care (11/11). CONCLUSION: An international consensus was achieved on components of a hepatobiliary curriculum. Acquiring broad knowledge is fundamental during residency. Advanced liver resection techniques require specialized hepatobiliary training.

[Postoperative Follow-Up for Stage â ¡ Low Rectal Cancer with Curative Surgery].

We reviewed clinical records of 354 cases with low rectal carcinoma(RC)after curative surgery(stage Ⅱ 149 cases and stage Ⅲ 205 cases). Stage Ⅱ with recurrence(23 cases)were compared with stage Ⅱ without recurrence(126 cases)in clinicopathological items to evaluate the factors affecting recurrence of stage Ⅱ RC, and were compared with stage Ⅲ with recurrence(89 cases)in treatment outcomes to identify the proper follow-up. Multivariate analysis revealed that sex and serum CA19-9 level were affecting factors for recurrence in stage Ⅱ low RC. The local recurrence rate of recurrence cases in stage Ⅱ RC(47.8%)was higher than in stage Ⅲ RC(29.2%). Recurrence was more found by serum tumor marker level in stage Ⅲ RC than in stage Ⅱ RC. Surgery for recurrent diseases was significantly more performed in stage Ⅱ RC(60.9%) than stage Ⅲ RC. Overall survival in stage Ⅱ RC with recurrence was significantly better than in stage Ⅲ RC with recurrence. And the prognosis after recurrence was also better in stage Ⅱ RC than in stage Ⅲ RC. It was thought that proper follow-up mainly by image examination would be effective to improve the prognosis.

Repeat hepatectomy with systemic chemotherapy might improve survival of recurrent liver metastasis from colorectal cancer-a retrospective observational study.

BACKGROUND: Although hepatectomy for metastatic colorectal cancer (mCRC) prolongs survival in up to 40% of people, recurrence rates approach 70%. We used a multidisciplinary approach to treat recurrent liver metastases, including chemotherapy, surgery, and palliative care. On the other hand, development of chemotherapeutic agents is remarkable and improves long-term survival. However, whether chemotherapy and repeat hepatectomy combination therapy improve survival or not is still unclear. The aim of this study was to analyze the outcomes of repeat hepatectomy with systemic chemotherapy for mCRC. METHODS: Following Institutional Review Board approval, we reviewed the records of all patients who underwent hepatectomy for mCRC between 1974 and 2015 at Fujita Health University Hospital. We used the Kaplan-Meier method to estimate overall survival from the first and last hepatectomy in multi hepatectomy cases after 2005 and compared outcomes between groups using the log-rank test. RESULTS: A total of 426 liver resections were performed for mCRC; of these, 236 cases were performed after 2005 (late group). In 118 (50%) cases, the site of recurrence was the liver, 59 (50%) underwent repeat hepatectomy, and 14 cases had ≥ 2 repeat hepatectomies. Overall survival (OS) before and after 2005 was 42.2 and 64.1 months, respectively, with the late group having better OS compared to the early (1974-2004) group. OS for single hepatectomy cases was 83.2 months, for two hepatectomies was 42.9 months, and for three hepatectomies was 35.3 months. In total, 59 patients did not undergo surgery after recurrence with an OS of 28.7 months. Mortality of the second and third repeat hepatectomy was 1.7% and 15.3%, respectively. CONCLUSION: Repeat hepatectomy with systemic chemotherapy for mCRC is feasible and might achieve improved survival in carefully selected patients.

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma.

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

[Study of Skip Metastasis to Lateral Lymph Nodes in Low Rectal Cancer].

We reviewed the clinical records of 302 patients with low rectal carcinoma to evaluate the effectiveness of lateral lymph node(LLN)dissection in cases of skip metastases to the LLN. Patients were divided into 4 groups according to nodal status: group N(133 cases), no metastasis in both the mesorectum lymph node(MLN)and LLN; groupM(100 cases), metastasis in the MLN and no LLN metastasis; group L(15 cases), which was defined as skip metastasis, with no metastasis in the MLN and LLN metastasis; and group ML(54 cases), node metastases in both the MLN and LLN. LLN metastasis was found in 22.8% of all patients, and skip metastasis was found in 10.1%. The recurrence rate in group L(40.0%, 6 cases)was significantly lower than that in group ML(75.9%, 41 cases)and not different from that in group M(43.0%, 43 cases). The initial recurrence sites in group L were the lung(3 cases)and local recurrence(3 cases). In group L, 20.0% had hematogenous recurrence, which was lower than in group ML. There was no significant difference between group L(5-year survival rate: 57.1%)and group M(71.7%)in terms of prognosis. Multivariate analysis revealed that histology was a risk factor for LLN metastasis in lowrectal cancer without MLN metastasis. The positive predictive value of LLN metastasis based on computed tomography was 43.9%. It was believed that LLN dissection was important, especially for non-differentiated cancer, in consideration of skip metastases to the LLN.

[Outcomes of Anal Squamous Cell Carcinoma Treated with Chemoradiotherapy].

We evaluated the effectiveness of chemoradiotherapy(CRT)by reviewing 11 clinicalcases of analsquamous cellcarcinoma( SCC). Radiotherapy(RT)consisted of 40 Gy delivered to pelvic and bilateral inguinal lesions, and a perianal booster dose of 20 Gy in fractions of 2.0 Gy per day, 5 days per week. 5-fluorouracil(5-FU)and mitomycin C were administered twice every 4weeks as standard chemotherapy. On the first day of RT, patients received a single bolus dose of 10mg/m2 mitomycin C, and a continuous 24-hour infusion of 750mg/m2 5-FU for 5 days. One patient with a T3 tumor was orally administered S- 1 during RT because of his poor generalcondition, and 1 patient with a T2 tumor did not receive 1 course of 5-FU and MMC owing to an adverse event. Grade 3 adverse effects occurred in 3 patients, but all 11 patients completed CRT. The anal lesions of 10 patients had complete response after CRT. Recurrence of anal lesions occurred in 4 patients, including 2 patients who were not treated with standard CRT. Of 8 patients who received CR via standard CRT, 2 patients had recurrence of anal lesions more than 60 months after completion of CRT. CRT is believed to be safe and effective for improving the prognosis of anal squamous cell carcinoma; however, sufficient and appropriate follow-up is necessary after complete response.

Clinical outcomes of stage IV colorectal cancer after R0 resection: a multi-institutional retrospective analysis.

BACKGROUND: We analyzed the treatment outcomes after curative surgery for stage IV colorectal cancer to develop outcome-based follow-up protocols and treatment strategies. METHODS: This study was a multi-institutional retrospective analysis of treatment outcomes in patients who underwent R0 surgery for stage IV colorectal cancer. RESULTS: A total of 1133 patients, of whom 837 had recurrence, were included in this study. Recurrence occurred within 12 and 24 months after R0 surgery in 452 (54.0 %) and 652 (77.9 %) patients, respectively. Surgical resection was performed less frequently for recurrence within 12 months of R0 surgery than for recurrence after more than 12 months (p = 0.003). Prognosis was significantly better in patients who had recurrence more than 24 months after R0 surgery than in those who had recurrence within 24 months; this was not only for all patients but also specifically for patients with resection for recurrent disease. Recurrence was less frequent in patients who received preoperative chemotherapy than in patients who did not receive preoperative chemotherapy (p = 0.04). Of significance, fewer patients who received preoperative chemotherapy (57.5 %) had recurrence within 24 months compared with patients who did not receive preoperative chemotherapy (79.8 %) (p = 0.00001). CONCLUSIONS: Intensive follow-up for at least 24 months was considered appropriate for monitoring disease recurrence after R0 surgery for stage IV colorectal cancer. In addition, preoperative chemotherapy contributed to improved outcomes.

[Results of Neoadjuvant Chemoradiotherapy for Rectal Cancer with Invasion to the Adjacent Organs].

We reviewed the clinical records of 14 cases who received neoadjuvant chemoradiotherapy(CRT)to evaluate the clinical effectiveness of the CRT for T4b rectal cancer. The preoperative radiotherapy consisted of 40-50 Gy delivered in fractions of 1.8-2.0 Gy per day, 5 days per week. A treatment with intravenous 5-fluorouracil, or oral tegafur-uracil(UFT)with l-leucovorin, or oral S-1, or capecitabine or intravenous irinotecan with oral S-1, was administered during radiotherapy. One patient died due to pelvic abscess at 69 days after CRT. Complete response(CR)or partial response(PR)was observed in 8 cases, 1 month after CRT. Curative surgery was performed in 10 patients. Among 10 patients who underwent curative surgery, both urinary and anal function were preserved in 5 patients. Although no lymph node metastasis was found in 9 patients of 10 patients who underwent curative surgery, recurrence was found in 5 patients, and local recurrence was found in 4 of these patients. Recurrence occurred in all patients who had recurrence within 1 year. Preoperative CRT was expected to be an effective treatment to improve the resection rate and prognosis for T4b rectal cancer. However, it was thought that it was necessary to be careful about local recurrence, especially within 1 year after surgery.

[Treatment Outcome of Anal Squamous Cell Carcinoma Treated with Radical Chemoradiotherapy].

We reviewed the clinical records of 7 patients with anal squamous cell carcinoma(SCC)to evaluate the effectiveness of radical chemoradiotherapy(CRT). The radiotherapy(RT)consisted of 40 Gy delivered to the pelvis and bilateral inguinal lesions, and a perianal booster dose of 20 Gy, in fractions of 2.0 Gy per day, 5 days per week. 5-fluorouracil(5-FU)and mitomycin C(MMC)were administered 3 times every 4weeks as standard chemotherapy. On the first day of RT, 750mg/m2 of 5-FU in the form of a continuous 24-hour infusion, for 5 days was administered. On the first day of chemotherapy, 10mg/ m2 of MMC was also administered as a single bolus infusion. One patient with a T3 tumor was administered oral TS-1 during RT because of advanced age. In the CRT group, there was 1 case each of T1 and T3, and the others were T2. Grade 2 adverse effects occurred in 5 patients, and Grade 3 in 2, but completion of CRT was achieved in all 7 patients. All patients had a complete response in the anal lesion after CRT. Three patients, including those with the T3 tumor treated with TS-1, developed recurrence of the anal lesion. Two patients with T2 tumors, who were treated with CRT comprising 5-FU and MMC, developed recurrence of the anal lesion more than 60 months after CRT. CRT is expected to be a safe and effective treatment to improve the prognosis for anal squamous carcinoma; however, sufficient and appropriate follow-up is necessary after a complete response.

Treatment of hepatocellular carcinoma with Child-Pugh C cirrhosis.

BACKGROUND: In most guidelines, no other interventional therapy but liver transplantation is recommended for the treatment of hepatocellular carcinoma (HCC) with Child-Pugh C cirrhosis (CP-C). However, in Japan, patients were sometimes treated with expectation of benefit. SUMMARY: A workshop was conducted to explore the state of treatments for CP-C HCC in Japan. After the workshop, a questionnaire on therapies was given to the panelists. Clinical data of 769 patients with CP-C HCC from 8 hospitals as well as analyses of data collected by the Liver Cancer Study Group of Japan (LCSGJ) consisting of 1,344 CP-C HCC cases were presented. Patients who underwent liver transplantation were excluded. In total, 424 out of the 769 patients (55.1%) from the 8 hospitals and 537 out of 828 CP-C HCC cases (64.8%) from the LCSGJ data received interventional therapies, such as local ablation and transcatheter arterial chemoembolization. All panelists agreed that there was a subgroup of CP-C patients who benefitted from the locoregional therapies. The major goals for the therapies were to prevent HCC rupture and avoid obstruction of major vessels by tumor growth, which can lead to a sudden deterioration of the patients' condition. Patient liver function and tumor stage are both important factors for the decision to undergo treatment; however, the inclusion criteria for the treatments varied among the centers. Key Message: There exists a subgroup of CP-C patients who benefit from interventions for HCC.