Management of giant hepatic cysts in the laparoscopic era / 대한외과학회지

PURPOSE: We sought to evaluate the feasibility and outcomes of laparoscopic resection of giant hepatic cysts and surgical success, focusing on cyst recurrence. METHODS: From February 2004 to August 2011, 37 consecutive patients with symptomatic hepatic cysts were evaluated and treated at Dong-A University Hospital. Indications were simple cysts (n = 20), multiple cysts (n = 6), polycystic disease (n = 2), and cystadenoma (n = 9). RESULTS: The median patient age was 64 years, with a mean lesion diameter of 11.4 cm. The coincidence between preoperative imaging and final pathologic diagnosis was 54% and half (n = 19) of the cysts were located in segments VII and VIII. Twenty-two patients had American Society of Anesthesiologists (ASA) classification I and II, and nine had ASA classification III. Surgical treatment of hepatic cysts were open liver resection (n = 3), laparoscopic deroofing (n = 24), laparoscopic cyst excision (n = 4), laparoscopic left lateral sectionectomy (n = 2), hand assisted laparoscopic procedure (n = 2), and single port laparoscopic deroofing (n = 2). The mean fellow-up was 21 months, and six patients (16%) experienced radiographic-apparent recurrence. Reoperation due to recurrence was performed in two patients. Among the factors predicting recurrence, multivariate analysis revealed that interventional radiological procedures and pathologic diagnosis were statistically significant. CONCLUSION: Laparoscopic resection of giant hepatic cysts is a simple and effective method to relieve symptoms with minimal surgical trauma. Moreover, the recurrence is dependent on the type of pathology involved, and the sclerotherapy undertaken.

Prognostic factors for gallbladder cancer in the laparoscopy era / 대한외과학회지

PURPOSE: Hepatobiliary surgery has changed dramatically in recent decades with the advent of laparoscopic techniques. The aim of this retrospective study was to compare survival rates according to stages, adjusting for important prognostic factors. METHODS: A retrospective study of a 17-year period from January 1994 to April 2011 was carried out. The cases studied were divided into two time period cohorts, those treated in the first 9-years (n = 109) and those treated in the last 7-years (n = 109). RESULTS: An operation with curative intent was performed on 218 patients. The 5-year survival rates according to the depth of invasion were 86% (T1), 56% (T2), 45% (T3), and 5% (T4). The number of cases of incidental gallbladder cancer found during 3,919 laparoscopic cholecystectomies was 96 (2.4%). Incidental gallbladder cancer revealed a better survival rate (P = 0.003). Iatrogenic bile spillage was found in 20 perforations of the gallbladder during laparoscopic cholecystectomies, 16 preoperative percutaneous transhepatic gallbladder drainages and 16 percutaneous transhepatic biliary drainages; only percutaneous transhepatic biliary drainage patients showed a significantly lower survival rate than patients without iatrogenic bile spillage (P < 0.034). Chemoradiation appeared to improve overall survival (P < 0.001). Multivariate analysis also revealed that time period, type of surgery, surgical margin, lymphovascular invasion, lymph node involvement, and chemoradiation therapy had significant effects. CONCLUSION: This study found that the prognosis of gallbladder cancer is still determined by the stage at presentation due to the aggressive biology of this tumor. Early diagnosis, radical resection and appropriate adjuvant therapy can increase overall survival.

A Case of Synchronous Esophagus and Stomach Cancer Successfully Treated by Combined Chemotherapy / 대한소화기학회지

Although cases of simultaneous esophagus and stomach cancer have been reported sporadically, there are rare reports of successful treatment using chemotherapy. We report a case of synchronous esophageal and gastric cancer successfully treated using docetaxel and cis-diammineedichloro-platinum (CDDP) combination chemotherapy instead of surgery. A 82-years-old man with anorexia and progressive weight loss was diagnosed with synchronous esophageal and gastric cancer by endoscopy. Both cancers were diagnosed as resectable by the preoperative clinical staging. However, surgery was contraindicated because of severe lung dysfunction. Moreover, he actively refused radiotherapy and endoscopic management. Therefore, the patient was given combined chemotherapy with docetaxel (65 mg/m2) and CDDP (60 mg/m2). The esophageal and gastric lesion completely disappeared on endoscopy, and there were no residual tumor cells on endoscopic biopsy after three cycles of chemotherapy. Metastatic lymph nodes also completely disappeared on the CT scan. The patient received a total of ten cycles of chemotherapy, without severe adverse effects. The patient remained asymptomatic for 18 months after discontinuation of the chemotherapy, without evidence of local recurrence or distant metastasis. Surgery or endoscopic treatment of both esophageal and gastric cancers is desirable, but, if medically inoperable, chemotherapy can be alternative treatment option.

Delayed Viral Clearance of Chronic Hepatitis C in Patients after Treatment Failure

Hepatitis C virus (HCV) infection usually progresses to chronic hepatitis, with rare cases of spontaneous viral eradication. We present herein four cases involving patients that were initially declared to have failed to respond to treatments, based on the presence of HCV RNA that was still detectable after completion of the standard treatment for chronic hepatitis C with genotype 2. However, the HCV RNA became undetectable, with a delayed response, after discontinuation of therapy. Two of the four patients were diagnosed as treatment failures after extended treatment, and the other two received no further treatment after the standard treatment. All four patients maintained a sustained virological response during the periodic follow-up after delayed viral clearance.

Efficacy of I-scan Endoscopy in the Diagnosis of Gastroesophageal Reflux Disease with Minimal Change

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of i-scans for the diagnosis of gastroesophageal reflux disease, especially where only minimal change is involved. METHODS: The esophageal mucosa was inspected using an i-scan following conventional white light endoscopy. The examination with iscan was performed under tone enhancement (TE) esophagus (e) mode. Patients with subtle distal esophageal mucosal changes without definite mucosal breaks, such as blurring of Z-line (B), mucosal coarseness (C), hyperemic or purplish discoloration (D), erythema (E), ectopic gastric mucosal islet (I) and mixed type were classified as minimal change. RESULTS: A total of 156 patients were included. Using i-scan endoscopy, the number of minimal change was found to further increase from 94 (conventional endoscopy; 19B, 9C, 29D, 13E, 5I, 19 mixed type) to 109 (i-scan; 15B, 8C, 29D, 16E, 5I, 36 mixed type). And 14 patients who had single type by conventional endoscopy were converted to mixed type after i-scan. Therefore, 29 of 156 patients were upgraded after i-scan, they were account for 19% (p<0.0001; 95% confidence interval, 0.13 to 0.25). CONCLUSIONS: The use of i-scan endoscopy significantly improves the identification of minimal change and helps to identify more precisely the type of minimal change.

Efficacy of I-scan Endoscopy in the Diagnosis of Gastroesophageal Reflux Disease with Minimal Change

BACKGROUND/AIMS: The aim of the study was to evaluate the efficacy of i-scans for the diagnosis of gastroesophageal reflux disease, especially where only minimal change is involved. METHODS: The esophageal mucosa was inspected using an i-scan following conventional white light endoscopy. The examination with iscan was performed under tone enhancement (TE) esophagus (e) mode. Patients with subtle distal esophageal mucosal changes without definite mucosal breaks, such as blurring of Z-line (B), mucosal coarseness (C), hyperemic or purplish discoloration (D), erythema (E), ectopic gastric mucosal islet (I) and mixed type were classified as minimal change. RESULTS: A total of 156 patients were included. Using i-scan endoscopy, the number of minimal change was found to further increase from 94 (conventional endoscopy; 19B, 9C, 29D, 13E, 5I, 19 mixed type) to 109 (i-scan; 15B, 8C, 29D, 16E, 5I, 36 mixed type). And 14 patients who had single type by conventional endoscopy were converted to mixed type after i-scan. Therefore, 29 of 156 patients were upgraded after i-scan, they were account for 19% (p<0.0001; 95% confidence interval, 0.13 to 0.25). CONCLUSIONS: The use of i-scan endoscopy significantly improves the identification of minimal change and helps to identify more precisely the type of minimal change.

Lessons learned from 100 initial cases of laparoscopic liver surgery / 대한외과학회지

PURPOSE: Laparoscopic liver resection (LLR) is now widely accepted and is being increasingly performed. The present study describes our experience with LLR at a single center over an eight-year period. METHODS: This retrospective study enrolled 100 patients between October 2002 and February 2010. Forty-six benign lesions and 54 malignant lesions were included. The LLR performed included 58 pure laparoscopy procedures, 18 hand-assisted laparoscopy procedures and 24 hybrid technique procedures. RESULTS: The mean age of the patients was 57 years; among these patients, 31 were over 65 years of age. The mean operation time was 220 minutes. The overall morbidity was 11% and the mortality was zero. Among the 20 patients with simple hepatic cysts, 50% unexpectedly recurred. Among the 41 patients with hepatocellular carcinoma, 21 patients (51%) underwent preoperative radiofrequency ablation therapy or transarterial chemoembolization. During parenchymal-transection, 11 received blood transfusion. The width of the resection margins was under 0.5 cm in 11 cases (27%); 0.5 to 1 cm in 22 cases (54%) and over 1 cm in eight cases (12%). There was no port site seeding, but argon beam coagulation-induced tumor dissemination was observed in two cases. The overall two-year survival rate was 75%. CONCLUSION: This study suggests that the applications for LLR can be gradually expanded when assuring that the safety and curability of LLR are equivalent to that of open liver resection.

Clinical features of gas-forming liver abscesses: comparison between diabetic and nondiabetic patients / 대한간학회지

BACKGROUND/AIMS: Patients with diabetes mellitus (DM) are more likely to have a pyogenic liver abscess with gas formation, which is associated with higher morbidity and mortality. The morbidity and mortality in pyogenic liver abscess are also higher in DM patients than in non-DM patients. This study evaluated the morbidity, mortality, and clinical features in patients with gas-forming liver abscesses associated with DM. METHODS: Among 379 cases of pyogenic liver abscess excluding malignancy from January 2001 through December 2009, 25 patients treated for pyogenic-gas-forming liver abscesses were reviewed retrospectively. We compared the morbidity, mortality, and clinical findings in patients with pyogenic-gas-forming liver abscesses between DM and non-DM patients. RESULTS: Gas formation was present in 25 (6.6%) of 379 cases with pyogenic liver abscess. DM was combined with gas-forming liver abscesses in 19 cases (76%). The most common organism responsible for the gas formation was Klebsiella pneumoniae (82%). Complications were present in 23 cases (92%) of gas-forming liver abscesses, with pulmonary complications (especially pleural effusion) being the most common (n=14, 61%). Four patients (16%) died of sepsis. CONCLUSIONS: Gas-forming liver abscesses are not uncommon in cases of pyogenic liver abscesses and are associated with high morbidity and mortality rates. The clinical manifestations and complications do not differ significantly between DM and non-DM patients.

Predictive Significance of Serum IL-6, VEGF, and CRP in Gastric Adenoma and Mucosal Carcinoma before Endoscopic Submucosal Dissection / 대한소화기학회지

BACKGROUND/AIMS: Endoscopic submucosal dissection (ESD) is commonly used for radical resection of gastric adenoma and mucosal cancer, but there is about 30% of discrepancy rate between the histology of the endoscopic biopsy and that of the resecwas to clarify the clinical significance of IL-6, VEGF, CRP before ESD. METHODS: We investigated the correlation between serum IL-6, VEGF, CRP level and discrepancy rate of gastric neoplastic lesions (10 low-grade dysplasias, 18 high-grade dysplasias, and 25 early gastic cancers). RESULTS: Serum levels of IL-6 in gastric adenoma and mucosal cancer patients were significantly higher than in healthy controls (p<0.05). Especially, serum IL-6 level of high-grade dysplasia patient was significantly higher than low-grade dysplasia and mucosal cancer patients, and the positive rate, sensitivity, and negative predictive value of serum IL-6 levels were higher in high-grade dysplasia patient compared to low-grade dysplasia patient and mucosal cancer patient. Serum levels of VEGF in patients with gastric adenoma and mucosal cancer were significantly higher than healthy controls (p<0.01). Serum levels of CRP in patients with mucosal cancer were significantly higher than in the controls (p<0.05), and the positive rate, sensitivity, and positive predictive value of serum CRP levels were higher in high-grade dysplasia and mucosal cancer patients compared to low-grade dysplasia patient. CONCLUSIONS: Serum levels of IL-6, VEGF, and CRP in patients with gastric neoplastic lesions were significantly higher than healthy controls, especially, serum IL-6 level of high grade dysplasia patient was significantly higher than low-grade dysplasia and mucosal cancer patients.

A Case of Autoimmune Pancreatitis Combined with Extensive Involvement of Biliary Tract / 대한소화기학회지

Autoimmune pancreatitis is a distinct disease characterized by the presence of autoantibodies and hypergammaglobulinemia, inflammation of the pancreatic parenchyma, and irregular stricture of the pancreatic duct. The involvement of distal common bile duct is frequently observed, but intrahepatic bile duct involvement is very rare, which seem to have similar feature to primary sclerosing cholangitis. We report a case of the patient with autoimmune pancreatitis combined with extensive involvement of extrahepatic and intrahepatic bile duct, which had a favorable response to steroid therapy.

Primary squamous cell carcinoma of the liver with immunohistochemical evidence / 대한내과학회지

This paper reports a case of primary squamous cell carcinoma (SCC) of the liver. The patient had a large mass between the left lateral segment of the liver and the lesser curvature of the stomach on computed tomography. Ultrasonography-guided fine needle aspiration of the mass was suggestive of a well-differentiated SCC. A left lobectomy of the liver and wedge resection of the stomach were performed. The pathology showed positive immunoreactivity for cytokeratin 19 (CK19), carcinoma-embryonic antigen and high-molecular-weight cytokeratin, and negative immunoreactivity for CK8, CK18 and hepatic-specific antigen

Clinical outcome of pegylated interferon and ribavirin therapy for chronic hepatitis C / 대한간학회지

BACKGROUND/AIMS: The purpose of this study is to elucidate the efficacy and safety of combined peginterferon and ribavirin therapy in Korean patients with chronic HCV infection. METHODS: We retrospectively analyzed the clinical records of 84 patients. Thirty five patients with genotype 1 HCV infection were treated with peginterferon alpha-2a 180 microgram/week and ribavirin 1,000-1,200 mg/day for 48 weeks, and 49 patients with genotype non-1 were treated with peginterferon alpha-2a 180 microgram/week and ribavirin 800 mg/day for 24 weeks. RESULTS: An early virologic response was seen in 87.0% of patients with genotype 1 HCV. An end of treatment response (ETR) was seen in 82.6% and 97.6% of patients with genotype 1 and genotype non-1, respectively. An overall sustained virologic response (SVR) was seen in 53 patients (82.8%) of the 64 patients: in 16 (69.6%) of 23 patients with genotype 1 and in 37 (90.2%) of 41 patients with genotype non-1. An end of treatment biochemical response was seen in 58 patients (90.6%) [genotype 1, 20 patients (87.0%); genotype non-1, 38 patients (92.7%)], and a sustained biochemical response was achieved in 49 patients (76.6%) [genotype 1, 14 patients (60.9%); genotype non-1, 35 patients (85.4%)]. Independent factors affecting an SVR were HCV genotype and the baseline HCV RNA level. CONCLUSIONS: This study shows that a combination therapy of peginterferon and ribavirin is highly effective for chronic HCV infection, producing a high SVR and ETR.

Obstructive Jaundice due to Compression of the Common Bile Duct by Right Hepatic Artery Originated from Gastroduodenal Artery / 대한소화기학회지

Obstructive jaundice by vascular compression is rare. The causative arteries were identified as the right hepatic artery, gastroduodenal artery, cystic artery, proper hepatic artery, and an unspecified branch of the common hepatic artery. Also the venous system, such as enlarging collateral veins in cases of portal hypertension was a causative vessel. Herein, we describe a case of a proximal choledocholithiasis due to compression of the common bile duct by right hepatic artery originated from gastroduodenal artery. Final diagnosis and treatment were achieved through an operation.

The Histologic Discrepancy before and after Endoscopic Submucosal Dissection of Gastric Adenoma and Early Gastric Cancer / 대한소화기내시경학회지

BACKGROUND/AIMS: We wanted to investigate of discrepancy rate between the histology of the endoscopic biopsy and that of the resected specimen obtained from the same lesion by endoscopic submucosal dissection (ESD). METHODS: 69 gastric adenomas and 38 early gastric cancers (EGC) that were treated by ESD from July, 2004 to February, 2006 were reviewed to analyze the relation between the histologies of the endoscopic biopsy and the resected specimen. RESULTS: The discrepancy rate between the histology of the endoscopic biopsy and the resected specimen was 40.6% for the gastric adenoma and 23.7% for the EGC. Among the 43 cases of low grade dysplasia, 6 cases (14%) were confirmed as gastric cancer after ESD. CONCLUSIONS: The histologic discrepancy between the endoscopic biopsy and resected specimen was 40.6% for the gastric adenoma and 23.7% for the EGC. Though the endoscopic biopsy may reveal low grade dysplasia, gastric adenoma should be removed by endoscopic mucosal resection because of the histological discrepancy between the endoscopic biopsy and the resected specimen.

The Usefulness of the Endoscopic Findings for Predicting Depth of Invasion in Early Gastric Cancer / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) has been used as a treatment for early gastric cancer (EGC). This study was performed to evaluate the usefulness of the endoscopic findings for diagnosing the depth of invasion in EGC patients. METHODS: We retrospectively analyzed the endoscopic findings of 558 EGC patients who were diagnosed after gastrectomy, EMR or ESD at Dong-A University Hospital between 2000 and 2006, and we divided them into two groups (the mucosa group versus the submucosa group). Nine factors were assessed (Type I or IIa: surface color, surface irregularity, the Yamada type and pitting on the apex; Type IIb: surface color, surface irregularity and marginal definiteness: Type IIc or III: ulcer base irregularity, shape of the converging folds, center of the converging folds and marginal elevation). The tumor size and histologic type were assessed for all the EGCs. RESULTS: Ulcer base irregularity (p=0.005), marginal elevation (p=0.001), and the shape of the converging folds (p=0.018) showed significant correlation with the depth of invasion in type IIc or III EGCs. Tumor size ( <2 cm) showed a significant correlation with mucosal invasion for all the EGCs. CONCLUSIONS: These results support the usefulness of the endoscopic findings for making the therapeutic decision for performing EMR or ESD through predicting the depth of invasion of EGCs.

Evaluation of Predictive Value of Okuda, TNM, CLIP and JIS Staging Systems for Hepatocellular Carcinoma Patients / 대한간학회지

BACKGROUND/AIMS: The aims of this study were to validate the prognostic value of the JIS score for HCC and to compare discriminatory ability and predictive power with other staging systems such as Okuda, TNM and CLIP. METHODS: We analyzed the clinical records of 210 patients who were diagnosed as HCC from 2000 to 2002. Univariate and multivariate survival analyses were done to find out factors to affect survival. To validate prognostic value of those staging systems, survival curve was obtained and analyzed by the Kaplan-Meier's method, and to compare discriminatory ability and predictive power, Homogeneity LR chi-square test and AIC score were used. RESULTS: The median survival was 19.5 months (19.1+/-14.9). The number of patients and 3-year survival rate for those staging systems were Okuda 1(126, 57.7%), 2(63, 9.0%) and 3(21, 0.0%) (p<0.001); TNM I (34, 63.1%), II (71, 59.4%), III (50, 22.4%), IV-A (6, 14.3%) and IV-B (1, 6.5%) (p<0.001); CLIP 0 (79, 68.5%), 1 (39, 34.2%), 2 (36, 16.7%), 3 (25, 20.0%), 4 (18, 5.1%), 5 (9, 11.1%) and 6 (4, 0.0%) (p<0.001) and JIS 0 (26, 78.9%), 1 (65, 65.3%), 2 (43, 21.9%), 3 (40, 25, 8.0%) and 5 (11, 2.0%)(p<0.001) in univariate analysis using Kaplan-Meier analysis. Homogeneity LR chi-square test showed more stratification power in JIS (Okuda, 102.8; TNM, 128.2; CLIP, 148.4 and JIS, 185.6) and AIC score showed superior predictive power in JIS system (Okuda, 1228.5; TNM, 1130.3; CLIP, 1117.1 and JIS, 1093.6). CONCLUSIONS: The proposed JIS system is useful system to predict survival of HCC patients. The discriminate ability of the JIS score is much better than other staging systems and has better prognostic predictive power compared to other staging systems.

Analysis of Endoscopic Sphincterotomy in Patients with Periampullary Diverticulum: according to the Location of the Diverticulum / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic sphincterotomy (EST) involves more complications and medical problems when a periampullary diverticulum (PD) is present. The data about EST for treating a small population of PD patients is controversial and any recent data is rare. The aim of this study is to evaluate the results of performing EST for a large population of PD patients. METHODS: We retrospectively enrolled 178 patients with PD and 178 patients without PD and these patients underwent EST for removal of common bile duct (CBD) stones during the years 2003~2005 at Dong-A University Hospital. We classified PD patients, according to the location of the ampulla and diverticulum, into 3 groups and we considered removal of the CBD stones as success. RESULTS: The success rates of EST in the two groups were similar: 91.0% in the PD group and 98.8% in the control group (p=0.0341). Failures were more frequently observed when the papilla was located inside of the diverticulum than for the other locations (p=0.0341). The complications cholangitis and pancreatitis after EST were similar for the two groups, but bleeding was more frequently observed in the PD group (p=0.0067). CONCLUSIONS: More skill for performing EST is needed to prevent bleeding in PD patients and it is more difficult to remove CBD stones when the papilla was located inside of the diverticulum.

A Case of Giant Brunner's Gland Adenoma Originating from the Gastric Pylorus Associated with Severe Anemia and Intussusception / 대한소화기내시경학회지

Brunner's gland adenoma is characterized by benign proliferation of the normal Brunner's gland, and is a relatively rare disease that accounts for only 10% of benign duodenal tumors. It is usually found in the bulb and second portion of the duodenum, but is rarely found in the pylorus. The clinical manifestations vary from non-specific upper abdominal symptoms to obstruction, intussusception and gastrointestinal hemorrhage. It is a benign lesion but rarely undergoes malignant transformation. Management of Brunner's gland adenoma involves complete removal of the lesion. We experienced a 43-year-old man who had complained of melena and dyspnea on exertion. An esophagogastroduodenoscopy and computed tomography of the upper gastrointestinal tract demonstrated the presence of a 5.5x4.0 cm sized hyperemic and lobulated large mass with hemorrhage that originated from the pylorus and was intussuscepted into the duodenum. Resection of the tumor revealed that it was a Brunner's gland adenoma on a histological examination.

A Case of Giant Brunner's Gland Adenoma Originating from the Gastric Pylorus Associated with Severe Anemia and Intussusception / 대한소화기내시경학회지

Brunner's gland adenoma is characterized by benign proliferation of the normal Brunner's gland, and is a relatively rare disease that accounts for only 10% of benign duodenal tumors. It is usually found in the bulb and second portion of the duodenum, but is rarely found in the pylorus. The clinical manifestations vary from non-specific upper abdominal symptoms to obstruction, intussusception and gastrointestinal hemorrhage. It is a benign lesion but rarely undergoes malignant transformation. Management of Brunner's gland adenoma involves complete removal of the lesion. We experienced a 43-year-old man who had complained of melena and dyspnea on exertion. An esophagogastroduodenoscopy and computed tomography of the upper gastrointestinal tract demonstrated the presence of a 5.5x4.0 cm sized hyperemic and lobulated large mass with hemorrhage that originated from the pylorus and was intussuscepted into the duodenum. Resection of the tumor revealed that it was a Brunner's gland adenoma on a histological examination.

A Case of the Treatment in an Adult with Hepatic Undifferentiated (Embryonal) Sarcoma / 대한간학회지

Undifferentiated embryonal sarcoma is a rare primary malignant neoplasm of the liver. Undifferentiated sarcoma of the liver in adult is an uncommon hepatic tumor of mesenchymal origin, generally considered an aggressive neoplasm with an unfavorable prognosis. We present a case of undifferentiated sarcoma in a 61-year-old woman. CT scan demonstrated a large heterogenous, exophytic growing hepatic mass in the right lobe with pulmonary metastatic nodules. US guided liver biopsy was done and pathological findings of the liver specimen revealed that isolated or grouped round pleomorphic cells and spindle to stellate cells were present. Immunohistochemical stain showed that tumor cells expressed positivity for vimentin and partially positivity or negativity for cytokeratin. She was diagnosed as having undifferentiated sarcoma of the liver. She received seven courses of VAIA chemotherapy by CWS protocols. Chemotherapy was efficacious and the size of the tumor decreased considerably after the treatment. No tumor recurrence for 12 months is noted.