Complete response and long­term survival after stereotactic body radiotherapy in a patient with liver metastasis from α­fetoprotein­producing gastric cancer: A case report.

α-Fetoprotein (AFP)-producing gastric carcinoma (GC) (AFPGC) is a special subtype of GC that is clinically characterized by a high incidence of liver metastasis and poor prognosis. The present study reported the case of a patient with AFPGC who showed complete response (CR) after stereotactic body radiotherapy (SBRT) for liver metastasis. A 76-year-old male patient underwent total gastrectomy with D2 lymph node dissection for GC. The excised tumor was diagnosed as AFPGC due to the patient's high serum AFP level (3,763 ng/ml) and AFP expression on immunohistochemistry. The patient was diagnosed with liver metastasis two months after the surgery. 18F-fluorodeoxyglucose positron emission tomography indicated that the metastasis was a single recurrent focus. Although the patient underwent seven cycles of chemotherapy with S-1-based regimens, the metastatic tumor showed only a minor response despite the decrease in serum AFP levels. To realize high-quality disease control, SBRT was performed on the liver tumor (total dose of 48 Gy in four fractions). The metastasis showed a significant response two weeks after the completion of SBRT and CR two years later. CR was sustained and the patient survived with no evidence of recurrence 62 months after the diagnosis of liver metastasis. Literature data on the efficacy of radiotherapy for liver metastasis from AFPGC remain scarce. The present case report suggests that SBRT has high efficacy for oligometastatic diseases and may be included as an indication for the treatment of liver metastasis from AFPGC.

Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation.

BACKGROUND/PURPOSE: Postoperative biliary tract complications remain one of the most serious problems facing patients who undergo living-donor liver transplantation. The aim of this study was to analyze the clinical implications of three different methods of biliary reconstruction in left-lobe adult living-donor liver transplantation. METHODS: We retrospectively compared three groups of patients: those who had Roux-en-Y hepaticojejunostomy (HJ; n = 11) biliary reconstruction, those who had duct-to-duct hepaticohepaticostomy (HH) with external stent (n = 11), and those who had HH with a T-tube (n = 6). Median follow-up for each group was 31, 30, and 10 months, respectively. RESULTS: Bile leaks were observed in 45.5% of the patients in both the HJ group and the HH with external stent group. Biliary anastomotic strictures occurred in 9% of the Roux-en-Y HJ patients and in 27.2% of those who had HH with external stent. No biliary complications were observed in the HH with a T-tube group (P = 0.049). CONCLUSIONS: Biliary reconstruction using HH with a T-tube may decrease the incidence of biliary complications. Despite the relatively short follow-up period, these encouraging preliminary results may warrant further studies of this biliary reconstruction technique in left-lobe adult living-donor liver transplantation.

Management of major portosystemic shunting in small-for-size adult living-related donor liver transplantation with a left-sided graft liver.

PURPOSE: We investigated the mechanisms of small-for-size graft syndrome by time-lag ligation, a novel approach to treating major portosystemic shunts in small-for-size adult living-related donor liver transplantation (LRDLT) using left-sided graft liver. METHODS: Five patients with end-stage liver failure and major splenorenal shunting underwent LRDLT using left lobe grafts. The average graft volume to recipient body weight (GV/RBW) ratio was 0.68 +/- 0.14. Two patients underwent time-lag ligation of their splenorenal (SR) shunts on postoperative days (PODs) 8 and 14, respectively. The shunts of the other three patients were untreated. RESULTS: The portal pressures in the first patient who underwent time-lag ligation rose above 300 mmH(2)O and remained there for 2 weeks. Thus, we ligated the SR shunt in the second patient on POD 14, resulting in an increase from 177 mmH(2)O to 258 mmH(2)O, but it decreased again thereafter. In the other three patients, the SR shunt was not ligated because portal blood flow volumes remained sufficient. Total bilirubin levels in the first time-lag ligation patient rose to 16 mg/dl, paralleling the rise in portal pressures. Although they increased after ligation in the second patient, they did not exceed 10 mg/dl. CONCLUSIONS: We recommend time-lag ligation if portal venous blood flow decreases in the early post-transplant period, but not until at least 2 weeks after transplantation. If the portal venous blood flow does not decrease, early postoperative ligation is unnecessary. If there are no major portosystemic shunts, making a portosystemic shunt might decompress excessive portal hypertension. With donor safety priority in LRDLT, novel approaches must be developed to enable the use of smaller donor grafts. We describe a potential means of using left lobe grafts in adult LRDLT.

Preoperative human-telomerase reverse transcriptase mRNA in peripheral blood and tumor recurrence in living-related liver transplantation for hepatocellular carcinoma.

BACKGROUND/AIMS: In this study we evaluated the potential role of preoperative h-TERT mRNA expression in peripheral blood as a tool for predicting prognosis and tumor recurrence after living-related liver donor transplantation (LRLDT). METHODOLOGY: The study included patients with unresectable HCC who underwent LRLDT from July 1999 to May 2003. RESULTS: There was no significant difference between the survival curves of those patients who met the Milan criteria and those who did not. However, there was a statistically significant difference (p=0.032) between the survival curves of those patients with positive preoperative h-TERT mRNA expression, and those who either had an initially negative preoperative h-TERT mRNA or who converted from positive to negative after neoadjuvant immunochemotherapy. CONCLUSIONS: In conclusion, the presence or absence of h-TERT mRNA in the peripheral blood may be a useful criterion in evaluating HCC patients for transplantation, as well as a valuable method of assessing anti-tumor therapy and tumor relapse.

Successful surgical treatment for hepatocellular carcinoma and concomitant risky esophageal varices.

BACKGROUND/AIMS: In our frequent encounters with liver cirrhotic patients with hepatocellular carcinoma (HCC) and concomitant risky esophageal varices, we have found that some of them required endoscopic injection sclerotherapy (EIS) and/or surgical treatment for esophageal variceal bleeding due to increased portal venous pressure after aggressive hepatectomy. In this study, we investigated the short-term effect of aggressive hepatectomy accompanied with left gastric venous caval shunt (Inokuchi's shunt) for esophageal varices and postoperative liver function. METHODOLOGY: Four cirrhotic patients with HCC and concomitant risky esophageal varices underwent hepatectomy with Inokuchi's shunt from 1999 to 2001. The mean age was 58.0 +/- 15.3 years old and all patients were classified in Child grade A or B. We investigated hematochemical data and endoscopic findings before and after surgery. RESULTS: One of the patients experienced disappearance of esophageal varices at discharge. In the others, postoperative endoscopy showed disappearance of CRS and reduced sizes of varices. In one patient, hepatic encephalopathy appeared transiently with bleeding from a duodenal ulcer at one month after surgery. However, the patient improved by conservative treatment. Three of the patients have survived well without recurrence of HCC and esophageal variceal bleeding; the remaining patient died from a recurrence of HCC. CONCLUSIONS: Inokuchi's shunt may be sufficiently effective to treat risky esophageal varices associated with resectable HCC and may be safe even if it is undertaken along with a major hepatectomy.

Augmentation of heme oxygenase-1 expression in the graft immediately after implantation in adult living-donor liver transplantation.

Heme oxygenase (HO)-1 is a cytoprotective protein and has recently been identified as a graft survival gene. However, there are little data currently available regarding the expression of HO-1 in human living-related liver transplantation. This is the first report that HO-1 expression is increased in small-for-size liver allografts. We performed biopsies of the graft liver and donor liver left in six patients at four time points during the procedure and studied HO-1 expression by reverse-transcriptase polymerase chain reaction and immunohistochemistry. HO-1 mRNA was expressed at a low level in steady-state liver tissue but was strongly expressed after perfusion of the graft liver. HO-1 expression increased in nonparenchymal cells in the human graft liver. The number of HO-1 positive cells increased threefold by the end of liver transplantation. This study suggests that ischemia-reperfusion injury and excessive shear stress secondary to portal hypertension might augment HO-1 expression in the graft liver.

Important role for macrophages in induction of crescentic anti-GBM glomerulonephritis in WKY rats.

BACKGROUND: A crucial role for CD8(+) cells in induction of crescentic anti-glomerular basement membrane (GBM) glomerulonephritis (GN) in WKY rats was demonstrated in studies showing that depletion of CD8(+) cells completely suppressed glomerular accumulation of monocytes/macrophages (Mo/Mphi), crescent formation and proteinuria. Because these studies did not definitively identify CD8(+) cells as the cause of tissue injury, we examined the roles of Mo/Mphi in the development of anti-GBM GN. METHODS: We examined correlations between the amount of urinary protein and the numbers of glomerular CD8(+) cells or Mo/Mphi in rats after administrating different doses of anti-GBM antibody (5.0, 7.5, 10.0 and 25.0 microl/100 g body weight). The roles of Mo/Mphi in induction of GN were examined in animals by depleting Mo/Mphi in the glomerulus. To do this, rats were injected intravenously with liposome-encapsulated dichloromethylene diphosphonate (liposome-MDP) from day 3 to day 7 after anti-GBM antibody injection and they were then sacrificed at day 8. RESULTS: Liposome-MDP treatment significantly reduced the number of ED-1(+) Mo/Mphi accumulated in glomeruli from 32.1 +/- 1.2 to 1.4 +/- 0.3/glomerular cross-section (mean +/- SD, P < 0.01), and the amount of urinary protein from 103.8 +/- 19.8 to 31.8 +/- 15.9 mg/day (P < 0.01), as well as the incidence of crescentic glomeruli from 91.3 +/- 2.7 to 23.3 +/- 7.6% (P < 0.01) at day 8. This treatment also reduced the number of CD8(+) cells accumulating in the glomeruli from 5.4 +/- 0.7 to 0.5 +/- 0.1/glomerular cross-section (P < 0.01). Upregulation of glomerular intercellular adhesion molecule 1 (ICAM-1) and monocyte chemoattractant protein 1 (MCP-1) mRNA expression was suppressed by Mo/Mphi depletion. CONCLUSION: These results indicate that Mo/Mphi play an important role in the induction of crescentic anti-GBM GN and glomerular injury.

Sclerosing encapsulating peritonitis in two patients with liver cirrhosis.

Sclerosing encapsulating peritonitis (SEP) has been reported in a wide variety of patients, including those who have undergone peritoneal dialysis (PD), young adolescent girls, cirrhotic patients after peritoneal-venous shunting (PVS), and patients treated with Beta-blockers. Nevertheless, the etiology of SEP remains obscure. In this article, we report on two patients with severe liver cirrhosis who were diagnosed as having SEP. The association of SEP with liver cirrhosis in patients who have not undergone PVS has previously been reported only rarely. Neither of our two patients had received PD or PVS, and neither had been treated with Beta-blockers, but both had suffered persistent intraabdominal infection. In one patient, we performed therapy combining total enterolysis with the oral administration of prednisolone, at 5 mg/day. The patient recovered and is currently free of symptoms at approximately 15 months after surgery. We believe that SEP may produce complications in cirrhotic patients with persistent intraabdominal infection, and that a combination therapy of surgical and immunosuppressive treatment may be effective for alleviating the small-intestinal obstruction due to SEP.

Living related heterotopic auxiliary partial liver transplantation for extremely small-for-size graft in fulminant liver failure.

Adult living related liver transplantation seeks a balance between donor safety and the need to save the recipient's life. A small-for-size graft is a major obstacle for high-risk patients. We experienced a case of heterotopic auxiliary partial liver transplantation with extremely small-for-size graft for fulminant liver failure. The other reasons why we chose to perform heterotopic auxiliary partial liver transplantation were acute renal failure, subshock state, and a left lobe volume of 24% in the standard liver volume of the donor. Hepatic vein reconstruction was made using an inferior meserteric vein patch graft. Portal vein reconstruction was made using end-to-side anastomosis employing an interposed left external iliac vein. The left hepatic artery of the graft was connected to the distal gastroduodenal artery. The patient was discharged 3 months after transplantation. We would recommend heterotopic auxiliary partial liver transplantation as an optional procedure for patients with severe preoperative conditions or extremely small-for-size graft donors.