Long-term outcome of laparoscopic hepatectomy in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: The long-term prognosis for patients with hepatocellular carcinoma (HCC) who undergo laparoscopic hepatectomy has not been well compared with that for patients after open hepatectomy. METHODOLOGY: We analyzed patient survival (PS) and disease-free survival (DFS) of 310 consecutive patients who underwent primary hepatectomy between January 2001 and March 2010. The patients were divided into Group LAP (laparoscopic approach) (n = 24) and Group OPN (with open laparotomy) (n = 286). The median follow-up time was 60.9 months (range, 12.0-123.9 months). RESULTS: The 5-, and 7-year PS rates of Group LAP were 87.9%, and 87.9%, and those of Group OPN were 82.2% and 69.3%, respectively (P = 0.5638). The 5-, and 7-year DFS rates of Group LAP were 47.1%, and 31.4%, and those of Group OPN were 29.4%, and 24.3%, respectively (P = 0.4594). Laparoscopic hepatectomy in patients of Group LAP resulted in a better outcome of blood loss (P = 0.0314), operative time (P < 0.0001), and hospital stay (P = 0.0008). CONCLUSIONS: The long-term outcome of laparoscopic hepatectomy for patients with HCC was identified to be comparable to open hepatectomy with regard to PS and DFS. Laparoscopic hepatectomy is a promising therapeutic option for patients with HCC.

Efficacy of DHMEQ, a NF-κB inhibitor, in islet transplantation: I. HMGB1 suppression by DHMEQ prevents early islet graft damage.

BACKGROUND: Pancreatic islet transplantation (PITx) is an attractive treatment option for restoring appropriate glucose homeostasis in type 1 diabetes patients. Although islet grafts can successfully engraft after PITx, large numbers of islet grafts are required mainly because immune reactions, including inflammation, destroy islet grafts. In these processes, nuclear factor (NF)-κB plays a central role. We hypothesized that the inhibition of NF-κB activation would ameliorate inflammatory responses after PITx and aid successful engraftment. METHODS: To test this hypothesis, a newly developed NF-κB inhibitor, dehydroxymethylepoxyquinomicin (DHMEQ), was used on a syngeneic mouse PITx model. One hundred seventy-five islets from C57BL/6 (B6) mice were transplanted into streptozotocin-induced diabetic B6 mice. The recipient mice were administered DHMEQ for 1, 2, or 3 days after PITx. The underlying mechanisms of DHMEQ on islet graft protection were investigated in an in vitro coculture model of pancreatic islets and macrophages. RESULTS: With a vehicle treatment, only 11.1% of the islet-recipients achieved normoglycemia after PITx. In sharp contrast, DHMEQ treatment markedly improved the normoglycemic rate, which was associated with the suppression of serum high mobility group complex-1 (HMGB1) and proinflammatory cytokines, including tumor necrosis factor-α, monocyte chemoattractant protein-1, macrophage inflammatory protein-1ß, interleukin-1ß, and interleukin-6, after PITx. In a murine macrophage-like cell line, DHMEQ inhibited HMGB1-driven activation and proinflammatory cytokine secretion and further prevented death isolated islets after coculture with these activated macrophages. CONCLUSIONS: Inhibition of NF-κB activation by DHMEQ after PITx reduces the HMGB1-triggered proinflammatory responses and results in engraftment of transplanted islets even with fewer islet grafts.

Efficacy of DHMEQ, a NF-κB inhibitor, in islet transplantation: II. Induction DHMEQ treatment ameliorates subsequent alloimmune responses and permits long-term islet allograft acceptance.

BACKGROUND: Long-term graft deterioration remains a major obstacle in the success of pancreatic islet transplantation (PITx). Antigen-independent inflammatory and innate immune responses strengthen subsequent antigen-dependent immunity; further, activation of nuclear factor (NF)-κB plays a key role during these responses. In this study, we tested our hypothesis that, by the inhibition of NF-κB activation, the suppression of these early responses after PITx could facilitate graft acceptance. METHODS: Full major histocompatibility complex (MHC)-mismatched BALB/c (H-2) mice islets were transplanted into streptozotocin-induced diabetic C57BL/6 (B6: H-2) mice. The NF-κB inhibitor dehydroxymethylepoxyquinomicin (DHMEQ) was administered for either 3 or 14 days after PITx. To some PITx recipients, tacrolimus was also administered. Islet allograft survival, alloimmune responses, and in vitro effects of DHMEQ on dendritic cells (DCs) were assessed. RESULTS: With a vehicle treatment, 600 islet allografts were promptly rejected after PITx. In contrast, 3-day treatment with DHMEQ, followed by 2-week treatment with tacrolimus, allowed permanent acceptance of islet allografts. The endogenous danger-signaling molecule high mobility group complex 1 (HMGB1) was elevated in sera shortly after PITx, whereas DHMEQ administration abolished this elevation. DHMEQ suppressed HMGB1-driven cellular activation and proinflammatory cytokine secretion in mouse bone marrow-derived DCs and significantly reduced the capacity of DCs to prime allogeneic T-cell proliferation in vitro. Finally, the DHMEQ plus tacrolimus regimen reverted the diabetic state with only 300 islet allografts. CONCLUSIONS: Inhibition of NF-κB activation by DHMEQ shortly after PITx suppresses HMGB1, which activates DCs and strengthens the magnitude of alloimmune responses; this permits long-term islet allograft acceptance, even in case of fewer islet allografts.

A long-term survival case of adult undifferentiated embryonal sarcoma of liver.

Undifferentiated embryonal sarcoma of the liver (USEL) is a rare malignant hepatic tumor with a poor prognosis that is usually observed in children (aged 6 to 10 years) and rarely seen in adults. We present a case of USEL in a 27-year-old woman with no previous history of the disease. Laboratory tests performed on admission showed that the patient had mildly elevated levels of aspartate aminotransferase, alanine transaminase, alkaline phosphatase, lactate dehydrogenase, and γ-glutamyl transpeptidase. The levels of viral hepatitis and tumor serum markers were all within normal limits. Computed tomography showed a large mass involving the right lobe and the medial segment of the liver. Right trisectionectomy was performed. Microscopically, the tumor was composed of pleomorphic and polynuclear dyskaryotic cells in a myxoid stroma with focal eosinophilic globules and no clear differentiation to muscle. Histological diagnosis showed undifferentiated embryonal sarcoma. Adjuvant therapy with cisplatin, vincristine, doxorubicin, cyclophosphamide, and actinomycin D was initiated. We administered a high dose of etoposide to extract the patient's peripheral blood stem cells and performed radiation therapy and peripheral blood stem cell transplantation. At 5-year follow-up, the patient was alive without any evidence of recurrence. Here, we describe the clinical and histopathological features of USEL as well as the therapeutic options for USEL in adults with this disease.

Effectiveness of using ultrasonically activated scalpel in combination with radiofrequency dissecting sealer or irrigation bipolar for hepatic resection.

BACKGROUND/AIMS: Many kinds of transection devices have been developed but there are very few reports on the effectiveness of using ultrasonically activated scalpel with a hook blade in combination with a thermo-coagulating device for hepatectomy. METHODOLOGY: We studied 533 consecutive patients who underwent hepatectomy for primary disease and for living- related liver transplantation (LRLT) donors preformed using ultrasonically activated scalpel with a hook blade along with a saline-linked radiofrequency dissecting sealer (TL group, n=215) or bipolar cautery with a saline-irrigation system (IB group, n=318). Intraoperative blood loss, operative time, postoperative laboratory data collected over a week and the incidence of postoperative complications were analyzed in accordance with the pre-existing liver conditions. RESULTS: The median operative time required to perform partial hepatectomy and hemihepatectomy in liver tumor cases was found to be significantly shorter in the TL group than in the IB group. There was no significant difference in the amount of blood loss between the 2 groups. Postoperative laboratory data was favorable and the overall complication rate after hepatectomy was 9.01%. CONCLUSIONS: Ultrasonically activated scalpel with a hook blade used in combination with a thermo-coagulation device yielded favorable intra and postoperative outcomes.

Induction of insulin-dependent diabetes mellitus by total pancreatectomy for pancreatic islet transplantation in cynomolgus monkeys.

BACKGROUND/PURPOSE: In order to perform a preclinical trial of pancreatic islet transplantation (PIT) in nonhuman primates, insulin-dependent diabetes mellitus (IDDM) must be induced. Methods for IDDM induction are administration of streptozotocin (STZ) or total pancreatectomy (TP). While STZ-induced IDDM is not always reliable, TP is appropriate for IDDM induction. However, TP is very difficult because of the complex surgical procedure required, necessary confirmation of IDDM, and difficulty in postoperative management. In this study, we tried to establish a reliable IDDM model for PIT in cynomolgus monkeys. METHODS: TP was performed in 5 male cynomolgus monkeys (Macaca fascicularis). This was followed by scheduled measurements of blood glucose, C-peptide levels, insulin levels, oral intake, and insulin requirements. IDDM induction was confirmed by serum C-peptide levels and intravenous glucose tolerance test (IVGTT). Allogeneic PIT was performed 14 days later with immunosuppressive therapy. RESULTS: TP successfully induced IDDM in all animals, confirmed by reduction of fasting serum C-peptide levels. Negative responses of serum C-peptide levels and insulin in IVGTT provided further confirmation of IDDM induction. No mortality or morbidity was encountered in any of the animals. CONCLUSIONS: TP successfully induced IDDM for PIT in cynomolgus monkeys.

[Usefulness of intraoperative fluorescent imaging using indocyanine green for repeated resection of hepatocellular carcinoma].

For recurrent hepatic tumors with treatment history or cirrhosis, small region including extrahepatic tumors that cannot be identified on routine ultrasonography, we used a fluorescent imaging with indocyanine green (ICG) for repeated resection of hepatocellular carcinoma. The patients were consisted of 4 men and 2 women with a mean age of 61.5 (37-66) years. Five cases of intra or extra hepatic tumors could be identified with fluorescent imaging system. Two cases were a local recurrence after TACE, 1 case was a small tumor exited in liver surface, 1 case could be identified the area of vascular invasion of subcutaneous recurrence, and 1 case was a mediastinal small lymph node metastasis of hepatocellular carcinoma. Fluorescent imaging using ICG was considered to be useful for identification of recurrent hepatocellular carcinoma that cannot be identified by a routine ultrasonography.

[A successful case of systemic chemotherapy followed by liver resection for advanced hepatocellular carcinoma with highly vascular invasion and multiple pulmonary metastases].

The prognosis for hepatocellular carcinoma with extrahepatic metastasis or vascular invasion is very poor. We treated a case successfully by combining chemotherapy and liver resection for hepatocellular carcinoma with multiple pulmonary metastases and vascular invasion. A 56-year-old man who complained of abdominal pain in his right side was transported to the hospital by ambulance. Because CT scan revealed the rupture of hepatocellular carcinoma, he underwent emergency transcatheter arterial embolization (TAE). A close examination revealed tumor thrombus in the inferior vena cava and posterior segment of the portal vein branch, with multiple pulmonary metastases. We conducted right hepatic lobectomy and removal of the inferior vena cava tumor thrombus. After the operation, pulmonary metastatic lesions gradually grew larger, so the oral administration of S-1 at 120 mg per day was started. At the end of the first course, the CT scan revealed that multiple pulmonary metastases were significantly reduced, and treatment was maintained until the end of 4 courses. A prolongation of survival could be expected by combining systemic chemotherapy and liver resection for advanced hepatocellular carcinoma such as the present case.

Analysis of risk factors for hyperbilirubinemia occurring after hepatectomy.

BACKGROUND: To further improve the outcomes of liver resection, it is important to identify and prevent the causes of the hyperbilirubinemia occurring after hepatectomy and postoperative liver failure. METHODS: Between 2004 and 2009, 591 consecutive patients underwent a hepatectomy at our center. Twenty-two patients who developed hyperbilirubinemia (postoperative total bilirubin over 5 mg/dL) after hepatectomy were classified as Hi-Bi group and another 569 whose total bilirubin did not increase beyond 5 mg/dL were classified as non-Hi-Bi group. RESULTS: A preoperative prothrombin test of less than 80% and a blood loss of more than 1000 mL were identified as independent risk factors for the Hi-Bi group by multivariate analysis. The hyperbilirubinemia of 16 cases improved, while that of 6 cases was prolonged. One of these patients died of liver failure without responding to treatment. The mortality rate for postoperative liver failure in this study was 0.16% (1/591). CONCLUSION: It is important to reduce the length of surgery and intraoperative blood loss to prevent hyperbilirubinemia after hepatectomy. Additionally, decision-making using our algorithm and full examination of the accurate evaluation results, including those for prothrombin time, residual liver function and liver damage, can help reduce the development of hyperbilirubinemia.

Long-term results of hepatectomy for patients with alveolar echinococcosis: a single-center experience.

BACKGROUND: Hepatectomy is the first-line treatment for alveolar echinococcosis (AE) if complete resection is feasible. However, a strategy for the treatment of patients with AE in whom the tumor cannot be resected completely remains to be defined. STUDY DESIGN: Data were retrospectively collected from 188 consecutive patients between 1984 and 2009. Overall survival (OS), progression-free survival (PFS), and risk factors were analyzed in patients classified into 3 groups (group A: complete resection, group B: reduction surgery, and group C: drainage or exploratory laparotomy). RESULTS: In group A (n = 119), the 10-, 15-, and 20-year OS was 98.9%. In group B (n = 63), the 10-, 15-, and 20-year OS was 97.1%, 92.8%, and 61.9%. In group C (n = 6), the 10- and 15-year OS was 50.0% and 33.3%. Patients in groups A and B had better prognoses than those in group C (p < 0.001). In group A, the 10-, 15-, and 20-year PFS was 96.5%, 94.4%, and 94.4%. In group B, the 10-, 15-, and 20-year PFS was 87.1%, 71.6%, and 61.4%. In group C, the 10- and 15-year PFS was 50.0% and 33.3%. Patients in group A had better PFS than those in groups B and C (p < 0.001). Curability was the only independent factor for both OS and PFS by multivariate analysis. CONCLUSIONS: Although the most effective therapy for AE is complete resection, a better prognosis can be achieved by reduction surgery and/or adjuvant albendazole therapy for patients with AE that cannot be completely resected.

Three-dimensional computed tomography scan analysis of hepatic vasculatures in the donor liver for living donor liver transplantation.

Because hepatic vasculatures exhibit variations, a preoperative evaluation of the vascular anatomy and an estimation of the volume of the liver graft are essential for successful adult living donor liver transplantation. Using 3-dimensional (3D) computed tomography (CT), we analyzed the volumetric and anatomical relationship of the hepatic vasculatures of liver grafts. The livers of 223 potential donors were analyzed by 3D CT. Volumetric analysis was performed for each hepatic vein and its tributaries. The anatomy of the portal vein and hepatic artery was assessed along with the biliary system via intraoperative cholangiography in 110 recipients. On the basis of the anatomical presentation of the inferior right hepatic vein (IRHV), the hepatic veins were classified as follows: in type I, the IRHV was absent; in type II, the IRHV was smaller than the right hepatic vein (RHV); and in type III, the IRHV was greater than or equal to the RHV in size. The drainage volume of the middle hepatic vein (MHV) and especially its tributaries in the right lobe increased with the size of the IRHV (P < 0.001). In type III hepatic veins with a large IRHV (17% of the donors), the MHV tributaries had the largest drainage volume in the right lobe (41.2% +/- 11.8%). Furthermore, type III hepatic veins typically exhibited biliary variations in 75% of the donors. No correlation was observed between variations in the hepatic artery and portal vein. In conclusion, a right lobe graft with a large IRHV is accompanied by a large drainage volume via the MHV and by bile duct variations in 17% of livers. Therefore, anatomical and volumetric analysis is important for preoperative evaluations.

Perioperative management of hepatic resection toward zero mortality and morbidity: analysis of 793 consecutive cases in a single institution.

BACKGROUND: The mortality rates associated with hepatectomy are still not zero. Our aim was to define the risk factors for complications and to evaluate our perioperative management. STUDY DESIGN: Between 2001 and 2008, 793 consecutive patients (547 men and 246 women; mean age ± SD, 56.1 ± 14.9 years) underwent hepatectomy without gastrointestinal resection and choledocojejunostomy at our center. Of these patients, 354 (44.6%) were positive for the hepatitis B virus surface antigen and/or the hepatitis C virus antibody. We categorized 783 (98.7%) patients as Child-Pugh class A. Major resection (sectionectomy, hemihepatectomy, and extended hemihepatectomy), was performed in 535 patients (67.5%) and re-resection in 81 patients (10.2%). RESULTS: The median operative time was 345.5 minutes and median blood loss was 360 mL. The rate of red blood cell transfusion was 6.8%. The morbidity rate was 15.6%. Reoperations were performed in 19 patients (2.4%). The mean postoperative hospital stay was 18.4 ± 10.4 days. The in-hospital mortality rate was 0.1% (1 of 793 patients; caused by hepatic failure). The independent relative risk for morbidity was influenced by an operative time of more than 360 minutes, blood loss of more than 400 mL, and serum albumin levels of less than 3.5 g/dL, as determined using multivariate logistic regression analysis. CONCLUSIONS: Shorter operative times and reduced blood loss were obtained by improving the surgical technique and using new surgical devices and intraoperative management, including anesthesia. Additionally, decision making using our algorithm and perioperative management according to CDC guidelines reduced the morbidity and mortality associated with hepatectomy.

Cytoplasmic expression of CD133 is an important risk factor for overall survival in hepatocellular carcinoma.

CD133 antigen has been used to identify cancer stem cells in several solid tumor types, including hepatocellular carcinomas (HCCs). The aim of this study was to investigate whether the expression and subcellular localization of CD133 correlated with the clinicopathological factors, recurrence, and survival in HCC patients. Tissue specimens from 136 HCC patients who underwent curative primary hepatectomy between 2000 and 2005 were collected and immunohistochemically analyzed for CD133 expression. Positive immunohistochemical results and subcellular localization of CD133 were determined, and the correlation between CD133 expression and clinicopathological factors of HCC patients were evaluated. CD133-positive tumor cells were observed in 30 (22.1%) cases. Cytoplasmic and membranous expressions were observed in 22 (16.2%) and 20 (14.7%) of the CD133-positive cases, respectively. Positive cytoplasmic expression of CD133 was found to be associated with the overall survival of HCC patients, especially in stage III and IVA HCC patients (p=0.0092). Univariate analysis revealed that pre-operative serum albumin, alpha-fetoprotein (AFP) levels, tumor size, portal venous invasion, and cytoplasmic CD133 expression were important risk factors in HCC. Multivariate analysis revealed that among the factors related to tumor aggressiveness, cytoplasmic expression of CD133 showed the most significant association with overall survival, although the difference was not statistically significant (p=0.0681). Cytoplasmic expression of CD133 was a significant risk factor for the overall survival of HCC patients. Patients with stage III and IVA HCC showing positive cytoplasmic expression of CD133 are more likely to have a worse prognosis.

Donor pretreatment with DHMEQ improves islet transplantation.

BACKGROUND: Currently, pancreatic islet transplantation to achieve normoglycemia in insulin-dependent diabetes mellitus (IDDM) requires two or more donors. This may be due to the inability to transplant functionally preserved and viable islets after isolation. Islets have already been subjected to various harmful stresses during the isolation process leading to apoptosis. One of the intracellular signaling pathways, the transcription factor nuclear factor-kappaB (NF-kappaB)-related pathway, is relevant to the mechanism of beta-cell apoptosis in isolated islets. We attempted to prevent islet apoptosis during isolation by a novel NF-kappaB inhibitor, dehydroxymethylepoxyquinomicin (DHMEQ). MATERIALS AND METHODS: DHMEQ was injected intraperitoneally into donor mice 2 h prior to isolation. NF-kappaB activation, the functioning of isolated islets, apoptosis after isolation, and cytokine- and apoptosis-related genes were analyzed. After 160 equivalents of islets were transplanted into diabetic mice, graft survival and function were evaluated. RESULTS: Intra-islet NF-kappaB was activated immediately after isolation, and DHMEQ inhibited NF-kappaB activation without deterioration of islet function. DHMEQ significantly prevented apoptosis by inhibiting caspase 3/7 activities and down-regulated Bax, a pro-apoptotic gene. Donor pretreatment with DHMEQ significantly improved engraftment in syngeneic islet transplantation in mice, thus preserving insulin contents in the graft liver, as assessed by functional and histologic analyses. CONCLUSIONS: DHMEQ is a promising agent in islet transplantation because it protects islets from apoptosis during isolation stress. Donor pretreatment with DHMEQ can significantly affect the success of islet engraftment.

[A successful case of S-1 chemotherapy for bilateral pulmonary recurrence of hepatocellular carcinoma long after hepatectomy].

The treatment for hepatocellular carcinoma with distant metastasis remains unclear. We experienced a successful case of S-1 chemotherapy for bilateral pulmonary recurrence of hepatocellular carcinoma following hepatectomy after gaining chemoresistance through pretreatment. A 62-year-old man underwent extended right hepatectomy for hepatocellular carcinoma occupying the whole right lobe. CT scan 15 months after hepatectomy revealed bilateral multiple pulmonary recurrence. Pharmacokinetic modulation chemotherapy (PMC) was performed after treatment of UFT, and stable disease status for 24 months was achieved. Pulmonary metastatic lesions gradually became larger, so oral administration of 100 mg per day of S-1 was followed by stable disease status for 9 months. The present case suggests that S-1 chemotherapy may be useful for hepatocellular carcinoma with distant metastasis.

The impact of anatomical resection for hepatocellular carcinoma that meets the Milan criteria.

BACKGROUND: The aim of this study was to analyze the impact of anatomical resection for hepatocellular carcinoma (HCC) that meets the Milan criteria. METHODS: Between 1990 and 2006, 322 consecutive patients with HCC who met the Milan criteria underwent curative resection (R0) and were classified into two groups: Group A (patients with a single HCC, with a tumor diameter of 5 cm or less) and Group B (patients with multiple tumors, no more than three tumor nodules, each with a diameter of 3 cm or less). Patient survival (PS), recurrence-free survival rates (RFS), and risk factors were analyzed. RESULTS: Univariate analysis revealed that in Group A, anatomical resection was the significant factor related to PS, while anatomical resection was that related to RFS. Multivariate analysis showed that in Group A, anatomical resection was a significant favorite factor associated with PS and RFS. Univariate analysis for Group B revealed that anatomical resection was the significant factor related to PS, while that related to RFS was the anatomical resection. Multivariate analysis showed that anatomical resection was a significant favorite factor for only RFS in Group B. CONCLUSION: Anatomical resection improved the surgical outcome of the patients with HCC which met the Milan criteria.

Risk factors for portal vein complications in pediatric living donor liver transplantation.

BACKGROUND: Portal vein (PV) complications in pediatric living donor liver transplantation (LDLT) are often asymptomatic in the early stages after transplantation and can be serious enough to lead to graft failure. There have been few reports on risk factors for PV complications in LDLT. The aim of this study is to investigate the influence of hepatic inflow upon PV complications and to predict patients at risk for these complications. MATERIAL/METHOD: From 1997 to 2008, 46 pediatric patients underwent LDLT at our center. Portal venous and hepatic arterial flows and PV diameter were analyzed. RESULTS: PV complications were identified in seven patients (15.2%) and occurred at a younger age and lower weight. As a result of appropriate treatment, none of the patients suffered graft failure. Analysis of the 46 patients and 27 patients under two yr of age identified smaller PV diameter in recipient and larger discrepancy of PV diameter as risk factors. Portal venous flow tended to be low, in contrast to hepatic arterial flow, which tended to be high. CONCLUSION: PV size strongly influences PV complications. Other factors such as younger age, low portal venous flow, and high hepatic arterial flow may be risk factors for PV complications.

Liver transplantation for hepatocellular carcinoma: the Japanese experience.

Despite the wide spectrum of selection criteria used by living donor liver transplantation (LDLT) centers in Japan, LDLT for hepatocellular carcinoma (HCC) can achieve an acceptable outcome comparable to the outcome for deceased donor liver transplantation (DDLT) for HCC. One of the most crucial considerations in liver transplantation for HCC is the advent of expanded criteria that allow more patients with HCC to receive the organs and offer similar or even better results compared to the Milan of UCSF criteria. Expanded criteria for HCC are proposed from three single-center and one multicenter study in Japan. These criteria are based on the independent predictors for outcome derived from the analyses of the pretransplant factors and explant pathology. The beneficial effect of those proposed criteria can be predicted by the inclusion rates of the patients compared to the Milan or UCSF criteria in the same cohort and the outcome for those included patients. While application of the UCSF criteria increases the inclusion rate compared to the Milan criteria by 5-10%, these proposed criteria increase the inclusion rates by 5-54% compared to the Milan criteria. The higher inclusion rates compared to the application of the Milan criteria are achieved by criteria including tumor markers, either AFP or PIVKA II or both. Inclusion of tumor markers in addition to parameters of tumor morphology might be the key to establish the best criteria for liver transplantation for HCC.

Alveolar echinococcosis of the liver in children.

BACKGROUND/PURPOSE: Alveolar echinococcosis of the liver (AEL) is a zoonosis that is distributed in cold regions of the northern hemisphere. The disease is mostly found in adults and rarely in pediatric patients because it tends to be slow growing. PATIENTS AND METHODS: Ten Japanese pediatric patients (under 15 years old) with AEL have been operated on in Hokkaido University Hospital from January 1936 to June 2008. We examined these children and revealed the characteristics of AEL. RESULTS: The patients included three males and seven females whose mean age was 10.9 years old, ranging from 7 to 15. The length of follow-up was from 3 months to 33 years (median 19 years). Six cases were picked up by mass screening; nine cases who underwent hepatectomy are still alive and one case whose tumors were unresectable died of liver failure. CONCLUSION: Our cases indicate that some AEL pediatric patients advanced rapidly, so early detection is imperative. Thus, screening examinations are essential for children in contaminated areas and, if a liver tumor is found on a screening examination and diagnosed as AEL, complete radical resection should be performed.

[A study of cirrhotic patients with hepatocellular carcinoma and huge splenomegaly who received treatment for hepatocellular carcinoma with concomitant splenectomy].

Treatment for hepatocellular carcinoma (HCC) with advanced cirrhosis, especially with hypersplenic thrombocytopenia, will be very difficult. Then we evaluated usefulness of concomitant splenectomy with treatment for patients with HCC, severe cirrhosis and huge splenomegaly. The preoperative mean platelet (Plt) count was 4.6 × 10(4)/µL and the mean longest diameter of spleen on CT was 143.0 mm. The mean Plt count on postoperative days 14 and 28 was 23.1 × 10(4)/µL (p=0.005) and 16.1 × 10(4)/µL (p=0.01), respectively and improved significantly compared with preoperative one. A white blood cell count and serum albumin also improved significantly on postoperative days 14 and 28, respectively. Treatment for recurrent HCC after splenectomy was preformed 2.4 times per patient (transarterial chemoembolization 13 times and radiofrequency ablation 4 times/7 patients). Now 5 patients are alive and the mean survival period was 17.3 months (range 8-38 months). It maybe said that concomitant splenectomy for cirrhotic patients with HCC and huge splenomegaly who need to receive a treatment for HCC was useful in our study, because those patients could receive a treatment for recurrent HCC repeatedly, and that probably contributes to the improvement of prognosis.