Two cases of interparietal inguinal hernias undergoing laparoscopic treatment: a case series.

Interparietal inguinal hernia, an exceedingly rare type of inguinal hernia in which the hernia sac anatomically lies between the tissue layers of the abdominal wall, is difficult to diagnose from physical findings. Given the few reports on interparietal inguinal hernias, this condition has remained fairly unrecognized. Herein, we report the successful imaging and laparoscopic diagnoses as well as repair of an interparietal inguinal hernia. Atypical physical findings and computed tomography data help in the diagnosis of an interparietal inguinal hernia. The laparoscopic approach is useful and feasible for both the diagnosis and treatment of interparietal inguinal hernia.

Unresectable esophageal cancer treated with multiple chemotherapies in combination with chemoradiotherapy: A case report.

BACKGROUND: Definitive chemoradiotherapy (dCRT) using cisplatin plus 5fluorouracil (CF) with radiation is considered the standard treatment for unresectable locally advanced T4 esophageal squamous cell carcinoma (ESCC). Recently, induction chemotherapy has received attention as an effective treatment strategy. CASE SUMMARY: We report a successful case of a 59-year-old female with unresectable locally advanced T4 ESCC treated by two additional courses of chemotherapy with CF after induction chemotherapy with docetaxel, cisplatin and fluorouracil (DCF) followed by dCRT. Initial esophagogastroduodenoscopy (EGD) detected a type 2 advanced lesion located on the middle part of the esophagus, with stenosis. Computed tomography detected the primary tumor with suspected invasion of the left bronchus and 90° of direct contact with the aorta, and upper mediastinal lymph node metastasis. Pathological findings from biopsy revealed squamous cell carcinoma. We initially performed induction chemotherapy using three courses of DCF, but the lesion was still evaluated unresectable after DCF chemotherapy. Therefore, we subsequently performed dCRT treatment (CF and radiation). After dCRT, prominent reduction of the primary tumor was recognized but a residual tumor with ulceration was detected by EGD. Since the patient had some surgical risk, we performed two additional courses of CF and achieved a clinically complete response. After 14 mo from last administration of CF chemotherapy, recurrence has not been detected by computed tomography and EGD, and biopsy from the scar formation has revealed no cancer cells. CONCLUSION: We report successful case with tumor remnants even after DCF and subsequent dCRT, for whom a complete response was finally achieved with two additional courses of CF chemotherapy. Additional CF chemotherapy could be one radical treatment option for residual ESCC after treatment with induction DCF followed by dCRT to avoid salvage surgery, especially for high-risk patients.

Pancreaticoduodenectomy after neoadjuvant chemotherapy for gastric cancer invading the pancreatic head: A case report.

BACKGROUND: Pancreaticoduodenectomy (PD) for advanced gastric cancer is rarely performed because of the high morbidity and mortality rates and low survival rate. However, neoadjuvant chemotherapy for advanced gastric cancer has improved, and chemotherapy combined with trastuzumab may have a preoperative tumor-reducing effect, especially for human epidermal growth factor receptor 2 (HER2)-positive cases. CASE SUMMARY: We report a case of successful radical resection with PD after neoadjuvant S-1 plus oxaliplatin (SOX) and trastuzumab in a patient (66-year-old male) with advanced gastric cancer invading the pancreatic head. Initial esophagogastroduodenoscopy detected a type 3 advanced lesion located on the lower part of the stomach obstructing the pyloric ring. Computed tomography detected lymph node metastasis and tumor invasion to the pancreatic head without distant metastasis. Pathological findings revealed adenocarcinoma and HER2 positivity (immunohistochemical score of 3 +). We performed staging laparoscopy and confirmed no liver metastasis, no dissemination, negative lavage cytological findings, and immobility of the distal side of the stomach due to invasion to the pancreas. Laparoscopic gastrojejunostomy was performed at that time. One course of SOX and three courses of SOX plus trastuzumab were administered. Preoperative computed tomography showed partial response; therefore, PD was performed after neoadjuvant chemotherapy, and pathological radical resection was achieved. CONCLUSION: We suggest that radical resection with PD after neoadjuvant chemotherapy plus trastuzumab is an option for locally advanced HER2-positive gastric cancer invading the pancreatic head in the absence of non-curative factors.

Indirect inguinal hernia containing portosystemic shunt vessel: A case report.

BACKGROUND: Inguinal hernia repair is one of the most common general surgical operations worldwide. We present a case of indirect inguinal hernia containing an expanded portosystemic shunt vessel. CASE SUMMARY: We report a 72-year-old man who had a 4 cm × 4 cm swelling in the right inguinal region, which disappeared with light manual pressure. Abdominal-pelvic computed tomography (CT) revealed a right inguinal hernia containing an expanded portosystemic shunt vessel, which had been noted for 7 years due to liver cirrhosis. We performed Lichtenstein's herniorrhaphy and identified the hernia sac as being indirect and the shunt vessel existing in the extraperitoneal cavity through the internal inguinal ring. Then, we found two short branches between the expanded shunt vessel and testicular vein in the middle part of the inguinal canal and cut these branches to allow the shunt vessel to return to the extraperitoneal cavity of the abdomen. The hernia sac was returned as well. We encountered no intraoperative complications. After discharge, groin seroma requiring puncture at the outpatient clinic was observed. CONCLUSION: If an inguinal hernia patient has portal hypertension, ultrasound should be used to determine the contents of the hernia. When atypical vessels are visualized, they may be shunt vessels and additional CT is recommended to ensure the selection of an adequate approach for safe hernia repair.

Distal gastric tube resection with vascular preservation for gastric tube cancer: A case report and review of literature.

BACKGROUND: Survival rates in patients with esophageal cancer undergoing esophagectomy have improved, but the prevalence of gastric tube cancer (GTC) has also increased. Total resection of the gastric tube with lymph node dissection is considered a radical treatment, but GTC surgery is more invasive and involves a higher risk of severe complications or death, particularly in elderly patients. CASE SUMMARY: We report an elderly patient with early GTC that had invaded the duodenum who was successfully treated with resection of the distal gastric tube and Roux-en-Y (R-Y) reconstruction. The tumor was a type 0-IIc lesion with ulcer scars surrounding the pyloric ring. Endoscopic submucosal resection was not indicated because the primary lesion was submucosally invasive, was undifferentiated type, surrounded the pyloric ring, and had invaded the duodenum. Resection of distal gastric tube with R-Y reconstruction was safely performed, with preservation of the right gastroepiploic artery (RGEA) and right gastric artery (RGA). CONCLUSION: Distal resection of the gastric tube with preservation of the RGEA and RGA is a good treatment option for elderly patients with cT1bN0 GTC in the lower part of the gastric tube.

Incidentally detected microcystic serous cystadenoma of the pancreas with splenic invasion: a case report and literature review.

Serous cystic neoplasms are relatively uncommon and rarely possess malignant potential. We report a rare case of pancreatic serous cystadenoma with splenic invasion in a female in her 60s. Dynamic contrast-enhanced CT revealed a 3 cm mass in the tail of the pancreas. The lesion showed marked enhancement in the arterial phase on dynamic CT, which extended into the spleen. No cystic components were detected in the pancreatic mass on either magnetic resonance cholangiopancreatography or T 2 weighted imaging. No metastasis or lymph node swelling was detected. Based on the hypervascularity of the tumour, the pre-operative diagnosis was pancreatic neuroendocrine tumour with splenic invasion. The patient underwent laparoscopic distal pancreatectomy with splenectomy. The pathological diagnosis was microcystic serous cystadenoma with locally aggressive features (infiltration into spleen, lymph nodes, and splenic vein). A few cases of pancreatic serous cystadenomas with splenic invasion have been reported; all were symptomatic, with diameters greater than approximately 9 cm. This is the first known case of incidentally detected serous cystadenoma with splenic invasion, reported with detailed imaging findings of dynamic CT and MRI.

A prospective feasibility study of one-year administration of adjuvant S-1 therapy for resected biliary tract cancer in a multi-institutional trial (Tokyo Study Group for Biliary Cancer: TOSBIC01).

BACKGROUND: Although surgery is the definitive curative treatment for biliary tract cancer (BTC), outcomes after surgery alone have not been satisfactory. Adjuvant therapy with S-1 may improve survival in patients with BTC. This study examined the safety and efficacy of 1 year adjuvant S-1 therapy for BTC in a multi-institutional trial. METHODS: The inclusion criteria were as follows: histologically proven BTC, Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, R0 or R1 surgery performed, cancer classified as Stage IB to III. Within 10 weeks post-surgery, a 42-day cycle of treatment with S-1 (80 mg/m2/day orally twice daily on days 1-28 of each cycle) was initiated and continued up to 1 year post surgery. The primary endpoint was adjuvant therapy completion rate. The secondary endpoints were toxicities, disease-free survival (DFS), and overall survival (OS). RESULTS: Forty-six patients met the inclusion criteria of whom 19 had extrahepatic cholangiocarcinoma, 10 had gallbladder carcinoma, 9 had ampullary carcinoma, and 8 had intrahepatic cholangiocarcinoma. Overall, 25 patients completed adjuvant chemotherapy, with a 54.3% completion rate while the completion rate without recurrence during the 1 year administration was 62.5%. Seven patients (15%) experienced adverse events (grade 3/4). The median number of courses administered was 7.5. Thirteen patients needed dose reduction or temporary therapy withdrawal. OS and DFS rates at 1/2 years were 91.2/80.0% and 84.3/77.2%, respectively. Among patients who were administered more than 3 courses of S-1, only one patient discontinued because of adverse events. CONCLUSIONS: One-year administration of adjuvant S-1 therapy for resected BTC was feasible and may be a promising treatment for those with resected BTC. Now, a randomized trial to determine the optimal duration of S-1 is ongoing. TRIAL REGISTRATION: UMIN-CTR, UMIN000009029. Registered 5 October 2012-Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000009347.

Resection of recurrent hepatocellular carcinoma with thrombi in the inferior vena cava, right atrium, and phrenic vein: a report of three cases.

BACKGROUND: Prognosis for patients with advanced hepatocellular carcinoma with a tumor thrombus in the inferior vena cava or right atrium is extremely poor due to cancer progression, pulmonary embolism, and congestion of the circulatory system caused by right heart failure. Surgical resection of the tumor thrombi may potentially yield better results than non-surgical treatments through prevention of sudden death. However, the benefits of surgical resection in patients with hepatocellular carcinoma and a tumor thrombus extending to the inferior vena cava, right atrium, and potentially in the phrenic vein are unclear. Here, we report three such cases. CASE PRESENTATION: Of the total 136 patients who underwent hepatectomies for hepatocellular carcinoma in our institution, three patients with prior hepatectomies and recurrent hepatocellular carcinoma had tumor thrombi in the inferior vena cava, right atrium, and phrenic vein. Surgical resections were performed, as there was a possibility of sudden death, despite the risk of leaving residual tumor. For all patients, we performed resection of the tumor thrombi in the inferior vena cava and right atrium and combined diaphragm resection. Surgical resection was performed using the total hepatic vascular exclusion technique in all cases. Additional passive veno-venous bypass was also performed in two cases, in which complete tumor resections could not be achieved. The microscopic surgical margins of the combined resected diaphragms were positive in all cases. Progression-free survival was 20.2, 3.8, and 9.5 months for case 1, 2, and 3, respectively. The respective overall postoperative survival was 98.0, 38.9, and 30.9 months. The patients died due to liver cirrhosis, acute heart failure, and hepatocellular carcinoma, respectively. Sudden death did not occur for any of the patients. CONCLUSION: Surgical resections may extend prognosis for patients with recurrent hepatocellular carcinoma with tumor thrombi in the inferior vena cava, right atrium, and phrenic vein, although the indications should be considered carefully.

Prognostic significance of the postoperative level and recovery rate of serum albumin in patients with curatively resected pancreatic ductal adenocarcinoma.

The aim of the present study was to investigate the clinicopathological features and prognostic factors associated with pre- and postoperative serum albumin levels in patients with curatively resected pancreatic ductal adenocarcinoma (PDAC). To achieve this, the data of patients who underwent pancreatectomy for PDAC between January 1995 and March 2016 were retrospectively reviewed, and the pre- and postoperative serum albumin levels at postoperative months (POMs) 3, 6, and 12 were evaluated. The serum albumin recovery rate was also investigated. A total of 196 patients were enrolled in the present study. In the multivariate Cox regression analysis, lymph node metastasis [hazard ratio (HR): 1.65; P=0.022], serum albumin level at POM 12 (≥3.9 g/dl; HR: 0.60; P=0.017), and serum albumin recovery rate at POM 12 (≥1.00; HR: 0.60; P=0.017) were independent prognostic factors for disease-free survival. Lymph node metastasis (HR: 1.79; P=0.013) and serum albumin level at POM 12 (≥3.9 g/dl) (HR: 0.60; P=0.033) were independent prognostic factors for overall survival. These results indicated that the postoperative level and recovery rate of serum albumin are potential biomarkers for predicting the prognosis of patients with curatively resected PDAC. However, further studies are required in order to investigate the survival benefit of increasing postoperative serum albumin levels in these patients.

Efficacy of Enteral Nutrition by Double Elementary Diet Tube after Pylorus-Preserving Pancreatoduodenectomy.

Nutritional support after pylorus-preserving pancreaticoduodenectomy (PpPD) is still controversial. This study aimed to evaluate the efficacy of enteral nutrition (EN) via the double elementary diet (W-ED) tube after PpPD. One hundred two patients who received EN by the W-ED tube were compared with 52 patients who received total parental nutrition (TPN) previously. Clinicopathological and postoperative features were analyzed among the two groups. Patients with EN by the W-ED tube after PpPD had a lower incidence of postoperative pancreatic fistula than those with TPN. The total protein and albumin levels on discharge in the EN group were significantly higher than those in the TPN group. In the case without complication, decreasing rate of the third lumbar vertebra skeletal muscle area was significantly lower in the EN group. In the cases of soft pancreas, drainage volume by the W-ED tube until four postoperative day was significantly larger in the case without postoperative pancreatic fistula. The W-ED tube offers the advantages of reducing gastrointestinal pressure and enabling reduction of complications after PpPD surgery.

Resection of Hepatic Lesions Perfused by the Cholecystic Vein Using Indocyanine Green Navigation in Patients with cT2 Gallbladder Cancer.

BACKGROUND: Various approaches to hepatectomy have been proposed for cT2 gallbladder cancers (GBC), but the optimal management strategy remains unclear. The aim of this study is to assess the effectiveness of using an indocyanine green (ICG)-based intraoperative navigation system during hepatic resection for cT2 GBC. METHODS: From September 2007 to December 2017, 24 consecutive patients diagnosed with cT2 GBC underwent hepatic resection using ICG navigation. After cannulation of the cholecystic artery, ICG diluted with dissolution liquid was injected and ICG fluorescence illumination was visualized with the HyperEye Medical System. And additional histopathological examination was performed on the most recent 15 of the 24 patients for detection of microscopic liver metastasis. RESULTS: For all patients, the disease-free survival rate was 59.1% at 5 years and overall survival rate was 86.2% at 5 years. Microscopic liver metastasis was detected in the resected liver in 3 (20%) of 15 patients, whose site of liver was S6, S5, and S5, respectively. The weight of the liver resected using ICG navigation was significantly smaller than that of S4a/S5 segmentectomy (P < 0.0001). CONCLUSION: Resected hepatic lesion using ICG imaging was possible to perform hepatectomy including liver micro-metastasis without excess or deficiency. This procedure might be novel intraoperative imaging method to provide valuable information on the optimal surgical approach to cT2 GBC.

Laparoscopic para-aortic lymphadenectomy for colorectal cancer with clinically suspected lymph node metastasis.

INTRODUCTION: The optimal surgical management strategy for isolated para-aortic lymph node (PALN) metastases from colorectal cancer (CRC) remains unclear. However, the complication rates for open approaches remain high. In this study, the outcomes of laparoscopic para-aortic lymphadenectomy in patients with clinically suspected PALN metastasis were evaluated. METHODS: Between April 2013 and April 2018, we performed laparoscopic primary resection and para-aortic lymphadenectomy in 11 patients with advanced colorectal cancer and clinically suspected PALN metastasis. This study was a single-center, retrospective, case series analysis, and the surgical outcomes were reviewed. RESULTS: There were no cases of perioperative mortality, and conversion to open surgery was necessary in only one patient (9%) because of invasion into a rib. One patient (9%) required a blood transfusion. Postoperative complications occurred in three patients, and the morbidity rate was 27% (3/11). Pathologically, PALN metastasis was confirmed in five patients (45%), all of whom received postoperative chemotherapy. The median survival time for all patients was 25 months, and one patient died of recurrence at 25 months after the initial surgery. Two other patients were alive with recurrence after 47 and 36 months, and two patients were alive without recurrence after 17 and 2 months. CONCLUSION: Laparoscopic para-aortic lymphadenectomy for advanced colorectal cancer with clinically suspected PALN is technically feasible and may be beneficial in selected patients. It is necessary to investigate the feasibility of this procedure in a future case series, and information regarding true oncologic outcome will require long-term follow-up.

Long-term survival with extended lateral lymphadenectomy for lateral lymph node recurrence after laparoscopic abdominoperineal resection for rectal adenosquamous carcinoma: a case report.

The patient was a 54-year-old female who presented with the chief complaint of melena. Lower gastrointestinal endoscopy detected a type 1 tumor extending from the anal canal to the rectum. CT did not detect any distant metastasis. Proximal D3 lymphadenectomy with laparoscopic abdominoperineal resection was performed for stage IA rectal cancer. In the histopathological examination, the tumor was identified as stage IIIa adenosquamous carcinoma. Although the patient underwent postoperative adjuvant chemotherapy with S-1, a recurrent left lateral lymph node tumor was detected on CT and PET 12 months later. The patient underwent the treatment with mFOLFOX + bevacizumab for 6 months. However, the tumor continued to progress, and therefore, extended lateral lymphadenectomy was performed 21 months after the first surgery. The patient did not undergo postoperative adjuvant therapy and is alive without recurrence 90 months after the first surgery and 70 months after the reoperation. Adenosquamous carcinoma of the rectum is a rare histological type of colorectal cancer for which there is no effective treatment besides surgical resection, and its prognosis is known to be worse than that of adenocarcinoma. Since there has been no report of long-term survival after extended lateral lymphadenectomy for recurrent lateral lymph node tumors following surgery for adenosquamous carcinoma of the rectum, herein, we report the case with a review of the literature.

Erratum: Publisher Correction to: Severe adverse events due to dihydropyrimidine dehydrogenase deficiency in a Japanese patient with colon cancer taking capecitabine: a case report.

[This corrects the article DOI: 10.1007/s13691-018-0334-1.].

Severe adverse events due to dihydropyrimidine dehydrogenase deficiency in a Japanese patient with colon cancer taking capecitabine: a case report.

Fluoropyrimidine has been commonly used not only in unresectable cases of metastatic colorectal cancer, but also in adjuvant therapy. Dihydropyrimidine dehydrogenase (DPD) is an enzyme encoded by the DPYD gene, which is responsible for the rate-limiting step in pyrimidine catabolism and breaks down more than 80% of standard doses of 5-fluorouracil (5-FU) and capecitabine, an oral prodrug of 5-FU. The lack of enzymatic activity increases the half-life of the drug, resulting in excess drug accumulation and toxicity which may lead to life-threatening side effects. There have been several published case reports about DPD deficiency in patients with colorectal cancer in Western countries. However, case reports of DPD deficiency in Japanese patients with colorectal cancer are rare because measuring DPD activity is not covered by public medical insurance in Japan, and it is not examined in our daily clinical practice currently. Therefore, we think that it is important to accumulate such case reports for further understanding. This report describes the case of a Japanese patient with colon cancer who experienced severe side effects while taking capecitabine, due to DPD deficiency. A 68-year-old man with ascending colon cancer underwent curative laparoscopic right hemicolectomy. Because final pathologic staging was Stage IIIa, standard adjuvant chemotherapy with capecitabine (3600 mg/body/day, days 1-14, every 3 weeks) was started on postoperative day 50. After 2 weeks, he started to experience Grade 3 diarrhea and was admitted to the hospital on postoperative day 66. On day 70, the patient had Grade 4 febrile neutropenia. Antibiotics and granulocyte-colony-stimulating factor were administered until his blood tests recovered to the normal degree. After 1 week of diarrhea, antidiarrheal agents were administered, and the patient gradually recovered. During the occurrence of diarrhea, specimen cultures were negative for infection. He was discharged on day 21 of the hospital stay. DPD deficiency was suspected, and 2 weeks later the DPD activity of the peripheral blood mononucleocytes was examined. The result was 10.3 U/mg protein which was remarkedly low (reference range 22.6-183.6 U/mg protein), and DPD deficiency was diagnosed. We always must consider the possibility of DPD deficiency in patients who experience severe side effects while taking capecitabine.

Predicting hepatic failure with a new diagnostic technique by preoperative liver scintigraphy and computed tomography: a pilot study in 123 patients undergoing liver resection.

BACKGROUND: A novel index, total liver LU15, has been identified as a surrogate marker for liver function. We evaluated the ability of preoperative remnant liver LU15 values to predict postoperative hepatic failure. METHODS: Preoperative risk factors for postoperative hepatic failure and remnant liver LU15 were evaluated in 123 patients undergoing liver resection for several diseases from September 1st, 2007 to December 1st, 2016. We calculated the remnant liver LU15 value from the total liver LU15 value and the functional remnant liver ratio. Risk factors for postoperative hepatic failure was determined by univariate and multivariate analysis. RESULTS: Hepatic failure grade B/C developed postoperatively in six patients of seven patients within Makuuchi criteria / without criteria for remnant liver LU15. Operative time (p = 0.0242) and criteria for remnant liver LU15 (p = 0.0001) were prognostic factors for hepatic failure according to the univariate analysis. And criteria for remnant liver LU15 (p = 0.0009) was only prognostic factor by multivariate analysis. CONCLUSION: Based on the findings form this pilot study, it appears that patients with a remnant liver LU15 value of 13 or less may have a high risk of postoperative hepatic failure.

Anastomotic Leakage Using Linear Stapling Device with Pre-attached Bioabsorbable Polyglycolic Acid Felt After Laparoscopic Anterior Resection.

AIM: Many studies have evaluated the risk factors for anastomotic leakage after laparoscopic anterior resection. In this study in order to increase the tightness of anastomoses and prevent bleeding from their staple lines, a linear stapler with pre-attached bioabsorbable polyglycolic acid (PGA) felt was used for rectal transection, and the short-term surgical outcomes were evaluated. PATIENTS AND METHODS: A prospective registry of 62 patients with rectosigmoidal or rectal carcinoma who initially underwent laparoscopic anterior resection using PGA felt for rectal transection was reviewed. RESULTS: The overall frequency of anastomotic leakage was 1.6% (1/62), and none of the patients developed postoperative staple line bleeding or other adverse events related to the use of PGA felt. CONCLUSION: The frequency of anastomotic leakage was relatively low, and therefore the use of a linear stapler with pre-attached bioabsorbable PGA felt might reduce the risk of adverse events related to anastomosis, especially anastomotic leakage.

[Long-Term Survival of a Gastric Neuroendocrine Carcinoma Patient with Extra-Regional Lymph Node Metastases].

A 56-year-old man with advanced gastric tumor in the pyloric antrum had multiple lymph node metastases(lymph nodes #5, 6, 8, and 13), as revealed by abdominal computed tomography(CT).The patient was diagnosed with coexisting clinical Stage III A gastric cancer(cT2[SS], cN2, cM0)with concomitant malignant lymphoma.Distal gastrectomy, D2 lymph node dissection, and resection of lymph node #13 were performed.Histopathological findings indicated that both the primary tumor and lymph node metastases were neuroendocrine carcinomas.Adjuvant chemotherapy with S-1 was administered; however, follow-up CT after 6 months revealed local recurrence around the celiac artery.Therefore , the chemotherapy regimen was changed to irinotecan and cisplatin.A clinical complete response was obtained after 6 chemotherapy courses and maintained for up to 45 months.The patient is alive at 60 months after the operation.

Increased expression of HOXB9 in hepatocellular carcinoma predicts poor overall survival but a beneficial response to sorafenib.

At advanced stages of hepatocellular carcinoma (HCC), the multikinase inhibitor sorafenib is the only effective treatment. Surrogate markers that predict the biological and clinical efficacy of sorafenib may help tailor treatment on an individual patient basis. In the present study, the clinical significance of the expression of HOXB9, a transcriptional factor, in HCC was assessed. Increased HOXB9 expression in HCC was found to be positively correlated with the expression of angiogenic factors, increased vascular invasion and was found to be associated with poor overall patient survival. Sorafenib treatment effectively suppressed the expression of angiogenic factors and activation of the Raf/MEK/ERK pathway in HOXB9-expressing HCC cell lines. Consistent with these findings, HCC patients, whose cancer expressed high levels of HOXB9, exhibited increased overall survival upon sorafenib treatment. Collectively, these results suggest that HOXB9 expression in HCC could be a surrogate marker for a beneficial response to sorafenib treatment.