[Primary Small Intestinal Cancer-A Clinicopathological Study of Seven Cases].

The clinicopathological features of primarysmall intestinal cancer were assessed retrospectively. Seven patients underwent resection of small bowel cancer in our hospital between June 2011 and January 2019. The mean age of the patients was 62.9 years, and the male to female ratio was 4:3. Five patients were symptomatic, and the correct preoperative diagnosis rate was 28.6%. The average tumor diameter was 5.3 cm, and the median resected intestine length was 25 cm. Histopathological examination revealed that there were 2 patients with poorlydifferentiated tumors and 3 patients with pStage ⅡA, 3 with pStage ⅡB, and 1 with pStage ⅢA disease. Recurrence after surgeryoccurred in 4 patients, including local recurrence in 2 patients and lymph node recurrence in 1 patient. Median survival was 24.5 months. The resected intestinal length was longer and the mesenteric arterydissection was more extensive in survivors than in dead patients. In contrast, the dead patients were older than the survivors and had undifferentiated tumor, ly2/ly3, lymph node metastasis, and recurrence. Moreover, recur- rence occurred in 4 patients who had lymph node metastasis, and/or undifferentiated tumor type, and/or ly2/ly3. An adequate intestinal excision margin along with mesenteric lymph node dissection might be required to improve the survival of patients with primaryintestinal cancer.

[A successful case of living donor liver transplantation performed in 7 hours for sub acute fulminant hepatitis].

Living donor liver transplantation (LDLT) is the ultimate cure for fulminant hepatitis. Successful outcomes rely on the precise evaluation of the reversibility of hepatic encephalopathy, and a swift execution of necessary examination of both the donor and the recipient. The case was a 63-years old woman, presented with fever and loss of appetite. She was hospitalized for acute hepatitis and treated at a nearby hospital. She was transferred to the tertiary hospital for the acute deterioration of her liver function on the 7th day after the emergence of the initial symptoms. On the 10th day, she showed Grade 2 encephalopathy and underwent plasma exchange. She was transported to our hospital for possible LDLT on the 11th day. CT scan on arrival showed severe atrophy of her liver and no definite brain edema despite acutely deteriorating encephalopathy (Grade 3). LDLT was launched after 7 hours from her transport. She was discharged from the intensive care unit on the 6th day and was discharged without severe complications on 42th day after the LDLT.

[A case of successful multi-venous reconstruction using recipient's jugular vein in right lobe-living donor liver transplantation].

In right lobe-living donor liver transplantation (RT-LDLT), hepatic venous reconstruction of the graft is essential to prevent posttansplant graft congestion and have a good outcome. The patient was a 56-year-old man who had decompensated liver cirrhosis secondary hepatitis C with massive ascites, jaundice and hepatic encephalopathy. He underwent LDLT using his son's right lobe graft. Preoperative simulation by 3D-CT volumetry revealed that the right lobe graft needed multi-venous reconstruction for right inferior hepatic vein (RIHV) and middle hepatic venous tributaries. Preoperative CT scan revealed that the recipient had portal venous thrombus and stenosis, which meant that the recipient's explanted portal vein (EPV) was not suitable for the venous reconstruction of the right lobe graft. Therefore, the recipient's internal and external jugular veins (IJV and EJV) were procured for venous reconstruction. The multiple veins of the right lobe graft were reconstructed to have single co-orifice at the backtable, and the co-orifice was anastomosed to inferior vena cava in short time. The recipient discharged on postoperative day 22 with good venous patency. In RT-LDLT unavailable for recipient's EPV, recipient's IJV and EJV grafts are very useful for multi-venous reconstruction.

[The possible role of sorafenib as a part of the multimodal treatment for hepatocellular carcinoma].

The role of sorafenib is unclear in multimodal treatment for hepatocellular carcinoma (HCC). We analyzed patients who underwent multimodal treatment including surgical operation for advanced HCC after administration of sorafenib. A 79- year-old man underwent extended right hepatectomy for Stage III huge HCC. Three years later, multiple recurrences observed in the liver, and an extrahepatic tumor was diagnosed. Peritoneal seeding was suspected, thus we decided to start a sorafenib administration. After 11 months, new intrahepatic lesions were detected, but extrahepatic tumor was unchanged. We considered the extrahepatic tumor was solitary and resectable, and new lesions in the liver were still treatable, then we attempted a surgical treatment with partial hepatectomy and ablation therapy. The tumor was successfully resected, and residual viable tumors were treated by radiofrequency ablation. The patient remains alive without recurrence at 7 months. We could perform a surgical treatment for another 2 patients with sorafenib treatment. These results suggested that there are cases of advance HCC in which multimodality treatment including surgical treatment can be achieved after sorafenib administration.

The role of oxysterol binding protein-related protein 5 in pancreatic cancer.

The expression of oxysterol binding protein-related protein (ORP) 5 is related to invasion and a poor prognosis in pancreatic cancer patients. ORP5 induced the expression of sterol response element binding protein (SREBP) 2 and activated the downstream gene of sterol response element. ChIP using SREBP2 antibody revealed that histone deacetylase 5 (HDAC5) was one of the downstream genes of SREBP2. The effect of HMG-CoA reductase inhibitors (statins) were analyzed according to the expression level of ORP5. The invasion rate and growth was suppressed in cells that strongly expressed ORP5 in a time- and dose-dependent manner, but had less effect in cells weakly expressing ORP5, suggesting that when the potential of invasion and growth relies on the cholesterol synthesis pathway, it becomes sensitive to HMG-CoA reductase inhibitor. Furthermore, HDAC inhibitor, tricostatin A, induced the expression of phosphatase and tensin homolog as well when ORP5 was suppressed or the cells were treated with statin. Treatment with both statin and tricostatin A showed a synergistic antitumor effect in cells that highly expressed ORP5. Therefore, in some pancreatic cancers, continuous ORP5 expression enhances the cholesterol synthesis pathway and this signal transduction regulates phosphatase and tensin homolog through HDAC5 expression. This is the first report to detail how the signal transduction of cholesterol synthesis is related to cancer invasion and why statins can suppress invasion and growth.

[A five-year survived case of more than 5 cm colorectal liver metastases treated with intraoperative microwave coagulation therapy].

A 54-year-old man underwent Hartmann's operation for rectal cancer in October 2003. Diagnostic images showed a single liver tumor in segment 7 of the liver in March 2004. He had a non-B, non-C cirrhosis. Liver damage was defined as B and ICG retention rate after 15 minutes was 54%. Platelet count was 7x10(4)-11x10(4)/mm3 and PT activity was 59%. The S7 tumor size was 6.5 cm in diameter, and we planned a partial resection of the liver. Intraoperative histological diagnosis of needle biopsy showed a metastatic adenocarcinoma from rectal cancer. Because of tuberculous peritonitis, it was difficult to control oozing from dissected plane. Therefore, we changed the method of operation from a partial resection to microwave coagulation therapy (MCT). To avoid a deteriorating liver function, we did not perform any adjuvant chemotherapy. He is alive without recurrence for five years after surgery. Nevertheless metastatic liver tumor is more than 5 cm and in cirrhotic liver, if the tumor located superficial parenchyma, MCT may have a possibility to be a curative treatment.

[Local ablation therapy for hepatocellular carcinoma (HCC) on the liver surface: radio-frequency ablation aimed at tumor marginal pre-ablation under endoscopic surgery].

RFA for the hepatocellular carcinoma localized on the surface of the liver tends to have some complications such as bleeding, an ejection of tumor and a heat injury to other internal organs even if percutaneous RFA seemed to be done easily. Therefore, we should first choose the RFA treatment under endoscopic (either laparoscope or thoracoscope) surgery for the hepatocellular carcinoma localized on the surface of the liver. Moreover, a direct central puncture should be avoided from the viewpoint of securing a margin, prevention of bleeding and rise in the intratumorale pressure. Now, we selected the unique operation method of RFA: First, the tumor is confirmed under the endoscope, and the tumor range is marked with the endoscopic echo. Second, several times of RFA applied to the tumor surroundings are done, and the margin is secured with avoiding a direct central puncture. If tumor diameter is over 2.5 cm, central ablation of the tumor is considered to be necessary, we can directly puncture the center of the tumor without bleeding since the tumor already has the congelation by surrounding heat effect. We have done RFA by this way for 29 patients with HCC since April 1st, 2004. The complications such as a heat injury to the neighboring organ could be well prevented. An enough margin of ablation about 1 cm around the tumor was confirmed by the postoperative CT image. There was no local recurrence during the average observation period of 290 days, and a severe post operative complication has not occurred. The average of hospitalized period after the operation was about 10 days. Therefore, pre-surrounding ablation preceding central puncture under the endosope for hepatocellular carcinoma on the liver surface is a feasible technique.