Dynamic assessment of carcinoembryonic antigen in the first month after liver resection for colorectal liver metastases as a rapid-recurrence predictor.

BACKGROUND: Carcinoembryonic antigen (CEA) is a tumor marker used widely for detecting the recurrence and predicting the prognosis of colorectal cancer. This study investigates the possibility of serial measurement of serum CEA in several weeks after liver resection for colorectal liver metastases (CRLM) in detecting earlier detection of recurrence. METHODS: From 2007 to 2014, CEA levels were assessed at 1 week and at 2-3 weeks after curative-intent liver resection among a total of 240 patients with CRLM. The CEA half-life was calculated and patients were divided into two groups: those with a CEA half-life ≤10 days or normalized (Group S), and those with a CEA half-life >10 days or rising (Group L). RESULTS: The 1-, 3-, and 5-year overall survival rates in Group S versus Group L were 91.3% versus 83.3%, 64.0% versus 41.3%, and 44.2% versus 29.3%, respectively (P = 0.0079). Multivariate analysis revealed that resection of extrahepatic lesions, four or more lesions of liver metastases, and categorization in Group L were independent factors of rapid recurrence within 100 days. CONCLUSION: A CEA half-life >10 days or rising 1 month after curative-intent liver resection was associated with rapid recurrence of CRLM within 100 days. J. Surg. Oncol. 2016;113:463-468. © 2016 Wiley Periodicals, Inc.

Living donor liver transplantation using a graft with periportal fibrosis.

A 57-year-old woman with familial amyloid polyneuropathy (FAP) was scheduled to undergo living donor liver transplantation (LDLT), but the operation was cancelled because the only potential donor had chronic alcohol-related liver disease. One year later, FAP-related neurological symptoms progressed rapidly, and emergency LDLT was planned. The donor's hepatic function had returned to normal range after 1 year of abstinence. The left liver graft volume was equivalent to 37.7% of the standard liver volume (SLV) of the recipient. However, a liver biopsy revealed mild fibrosis (score, F1). LDLT was successfully performed without any complications. The recipient's neurological findings returned to normal. One year after LDLT, the liver graft volume was equivalent to approximately 90% of the SLV, and the fibrosis had improved. LDLT using a graft with a fibrosis score of up to F1 may be an acceptable alternative for recipients with normal hepatic function.

Applicability of enhanced recovery program for advanced liver surgery.

BACKGROUND: Enhanced recovery programs (ERPs) have been developed in various surgical fields and have been shown to accelerate postoperative recovery without increasing the incidence of adverse events. Whether ERP can be safely applied to patients undergoing complex liver surgery with a risk of liver failure remains unclear. METHODS: We created an ERP by rearranging our conventional postoperative treatments and applied this program to patients undergoing major hepatectomy between 2008 and 2013. The ERP elements included greater perioperative education, individualized postoperative fluid therapy, and early mobilization. The success of the ERP was evaluated on postoperative day (POD) 6 based on the criterion of independence from continuous medical intervention with the exception of an abdominal drainage tube. Adherence to each item in the ERP was evaluated, and risk factors for delayed accomplishment were analyzed. RESULTS: Altogether, 200 patients were included, and 165 patients (82.5 %) completed the ERP. Multivariate analyses showed that (1) an age of 65 years or older and (2) a red blood cell transfusion were independent risk factors for delayed accomplishment. The performance of thoracotomy or choledocojejunostomy did not significantly affect accomplishment of the ERP. Oral intake starting on POD 1 was achieved in 179 patients (89.5 %), and termination of intravenous drip infusions on POD 5 was feasible in 72.5 %. CONCLUSIONS: An ERP for major hepatectomy was completed in more than 80 % of the patients. Earlier bowel movement can be challenged. The liquid in-out balance should be adjusted on an individual basis, rather than uniformly, especially for patients over 65 years of age or who required a red blood cell transfusion.

A case of severe bilateral empyema due to Streptococcus pyogenes.

Bilateral empyema is a rare and severe condition and deciding on a treatment is quite difficult. Additionally, infections caused by group A Streptococcus (GAS [Streptococcus pyogenes]) are known to be invasive. We successfully treated without surgery a previously healthy 59-year-old woman with bilateral empyema due to GAS, with repeated drainages, antibiotics, and fibrinolytic therapy. To our knowledge, there have not been any published reports on cases of bilateral empyema due to GAS infection. In rare, severe cases of bilateral empyema caused by organisms such as GAS, physicians managing the condition should consider the overall condition of the patient.

Recovery of liver function after the cessation of preoperative chemotherapy for colorectal liver metastasis.

BACKGROUND: Preoperative chemotherapy containing oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) causes histological liver injury and increases postoperative morbidity and mortality in patients with colorectal liver metastasis (CRLM). However, information on the aggravation of liver function and its reversibility is scarce. METHODS: A total of 55 patients who underwent a hepatectomy after receiving FOLFOX and/or FOLFIRI were included in the present study. Indocyanine green tests were repeatedly performed before hepatectomy for monitoring the change of hepatic functional reserve. RESULTS: A significant decrement in the ICG R15 value was observed at 2-4 weeks (12.9%, P = .04), 4-8 weeks (11.4%, P = .01), and 8 or more weeks (11.1%, P = .006) after the last chemotherapy, compared with results documented within 2 weeks (16.8%). However, no significant change was observed among the values obtained at 2-4 weeks, 4-8 weeks, and 8 or more weeks. The individual ICG R15 values at the beginning and end of the cessation period also improved from 17.7% to 11.6% (P = .001). Histological liver injury was associated with larger amounts of operative blood loss but not with morbidity. Neither liver failure nor mortality occurred in the present series. CONCLUSIONS: The hepatic functional reserve, represented by the ICG R15 value, improves during the period after chemotherapy cessation. The present study suggests that chemotherapy cessation for at least 2-4 weeks enables an improvement in the hepatic functional reserve, especially among patients with an abnormal ICG R15 value (> 10%) who have received 6 or more cycles of FOLFOX and/or FOLFIRI.

Characteristics of ectopic pancreas in dynamic gadolinium-enhanced MRI.

The characteristics of jejunal ectopic pancreas in dynamic gadolinium-enhanced magnetic resonance imaging are described in a 40-year-old man with bowel obstruction. The pre-contrast signal intensity and post-contrast enhancement pattern of ectopic pancreas are the same as those of the pancreas.

Prognostic significance of peritoneal washing cytology in patients with potentially resectable gastric cancer.

BACKGROUND/AIMS: The prognostic value of cytological examination of intraoperative washings in potentially resectable gastric cancer is controversial. METHODOLOGY: Between February 1993 and August 2001, clinicopathological features and surgical outcome of 26 consecutive patients with gastric cancer with positive cytological findings of peritoneal washings without peritoneal dissemination were retrospectively analyzed. RESULTS: The overall 1, 2, 3-year survival rates for 26 patients were 69%, 35%, and 0%, respectively. The median survival was 17.5 months. The median survival of patients with curative resection (n=16) and non-curative resection (n=10) was 19 months and 12.5 months, respectively. There was no significant difference in survival between curative resection and non-curative resection (p=0.10). Recurrent disease frequently occurred as peritoneal dissemination (69%). No patient survived for more than 34 months. CONCLUSIONS: Aggressive surgical resections do not provide any survival benefit for gastric cancer with positive cytological findings of peritoneal washings even in the absence of peritoneal dissemination.

Triple cancer in liver, esophagus and urinary bladder: indications and problems of hepatectomy.

In patients with multiple cancers and chronic liver damage, it is difficult to decide on the operative procedures. We describe a 70-year-old man with triple cancer: liver, esophageal and urinary bladder. The patient had the complication of chronic hepatitis C and mild liver damage. He received curative resections of all cancers. In patients with multiple cancers, including hepatocellular carcinoma accompanied by liver damage, the treatment strategy should be decided after clarifying the relationship between the staging of multiple cancers and liver function.

Imaging modality of three-dimensional CT in caudate cholangioma: assessment for resectability.

Conventional preoperative imaging has limited modality and accuracy in primary intrahepatic cholangiocellular carcinoma (ICC) in the caudate lobe (CL). Furthermore, estimating resectability and tumor extension from preoperative imaging is inaccurate. A 60-year-old patient with ICC administrated in our institution requested a second opinion. His lesion was judged unresectable hilar cholangiocellular carcinoma because it had spread widely to the bilateral lobe of the liver as shown by preoperative imaging studies. The irregular shaped mass was located in the para-caval portion of the CL and the size as shown by computed tomography (CT) was 40mm in diameter. The tumor extended close to the common hepatic artery and the right portal branch was involved. The left lobe showed marked atrophy and intrahepatic biliary duct (IHBD) dilatation of the whole liver was observed. The tumor was mainly located in the proximal side of the left lobe and every IHBD were interrupted in the porta hepatis by magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiography. However, the resectability of this tumor could not be determined from these imaging studies. Three-dimensional imaging by multidetector CT (3D-CT) revealed that the tumor involved the left hepatic artery and portal branch whereas the right hepatic artery was intact. The patient was successfully treated in surgery by extending the left lobectomy with en bloc caudate lobectomy. The 3D-CT imaging study was helpful in assessing the resectability in ICC of CL.

A case of anaplastic ductal carcinoma of the pancreas with production of granulocyte-colony stimulating factor.

We report a case of anaplastic ductal carcinoma of the pancreas with production of granulocytecolony stimulating factor in a 46-year-old man. He underwent distal pancreatectomy, total gastrectomy with Roux-en-Y reconstruction and splenectomy. He recovered uneventfully postoperatively and was discharged from hospital on the 22nd postoperative day. Histological examination showed anaplastic ductal carcinoma (giant cell type) of the pancreas. However, three months after the operation, multiple liver metastases were demonstrated by CT scan and the peripheral leukocyte count rose to 81,800/microL. Serum granulocyte-colony stimulating factor concentration was 155pg/mL (normal 5.78-27.5 pg/mL). Therefore, we diagnosed granulocyte-colony stimulating factor-producing pancreatic cancer. Anaplastic ductal carcinoma of the pancreas with production of granulocyte-colony stimulating factor is very rare. Tumors with production of granulocyte-colony stimulating factor are highly malignant, and this patient died of hepatic failure four months after the operation.

Two-dimensional assessment of submillimeter cancer-free margin area in colorectal liver metastases.

The aim of the study is to evaluate the prognostic impact of the extent of submillimeter or zero surgical margin (SubMM) area among the patients who underwent liver resection for colorectal liver metastases (CRLM).The influence of suboptimal margin width of <1 mm on long-term outcome is unclear.A total of 423 liver resections for CRLM were performed at Japanese Red Cross Medical Center between 2007 and 2015. Among them, we identified 235 patients who underwent curative initial liver resection and classified them into 2 groups: R0 (margin: ≥1 mm) and R1 (SubMM). The R1 group was further divided into 2 groups by the extent of SubMM area: small SubMM area (≤4 cm) and broad SubMM area (>4 cm).The median tumor number was 4 (range 1-97), 23% had solitary and 37% had 8 or more number of metastases. With a median follow-up period of 30 months, the overall 1-, 3-, 5-year survival for R0 (n = 72) versus R1 (n = 163) groups were 98.4% vs 87.5%, 75.5% versus 57.1%, and 50.1% versus 36.6%, respectively (P = 0.004). After propensity score analysis allowing for matching the tumor number (<8 vs 8 or more), tumor size, and serum carcinoembryonic antigen level, the DFS and OS were significantly higher in the small SubMM area group (P = 0.024, P = 0.049), respectively.Although wide margins >1 mm should be attempted whenever possible, reducing the extent of SubMM area (≤4 cm) can contribute to better long-term outcome when wide margin is not practicable.

Biologically different subgroups of invasive ductal carcinoma of the pancreas: Dpc4 status according to the ratio of intraductal carcinoma components.

PURPOSE: Among invasive ductal carcinomas of the pancreas (IDCP), there is a morphologically characteristic subgroup accompanied by abundant intraductal carcinoma components (ICCs). With the aim of determining whether ICC-rich IDCP are biologically different from ICC-poor IDCP, the expression status of Dpc4 protein was analyzed. EXPERIMENTAL DESIGN: A total of 43 IDCP was subdivided into two groups: (a). ICC-rich IDCP (ICCs area occupies >or=10% of the entire tumorous area); and (b). ICC-poor IDCP (with <10% of ICCs area). A total of 10 invasive carcinomas derived from intraductal papillary-mucinous neoplasms (ICs from IPMNs) were also analyzed. Each invasive and intraductal carcinoma area was then evaluated for Dpc4 protein status by immunohistochemistry. RESULTS: In a total of 43 IDCP, there were 23 ICC-rich IDCP and 20 ICC-poor IDCP. Dpc4-positive immunostaining was observed in the invasive carcinoma component of ICC-rich IDCP, ICC-poor IDCP, and ICs from IPMN in 18 of 23 (78%), 4 of 20 (20%), and 7 of 10 (70%) cases, respectively. In the intraductal component, positive staining for Dpc4 was found in 20 of 23 (87%), 3 of 7 (41%), and 8 of 10 (80%) cases, respectively. Dpc4 expression was found in both the invasive and ICC components of ICC-rich IDCP, similar to that found in IC derived from IPMN, whereas the expression of Dpc4 was largely diminished in ICC-poor IDCP. CONCLUSIONS: Morphologically distinct subgroups of invasive ductal carcinomas of the pancreas, namely ICC-rich IDCP and ICC-poor IDCP, are also biologically distinguishable as revealed by the differential expression of Dpc4.

Volume reduction surgery for advanced hepatocellular carcinoma.

PURPOSE: The aim of this study was to evaluate the prognostic impact of reductive surgery on the survival of patients with advanced hepatocellular carcinoma (HCC). METHODS: Eligible patients had a main tumor greater than 10 cm in diameter with multiple intrahepatic metastases (>5 nodules), and good liver function (Child-Pugh class A), but no tumor thrombus in the main portal vein. The main tumor was surgically removed but the metastases were not removed and were treated with repeated transcatheter hepatic arterial chemo-embolization (TAE). RESULTS: From Jun 1997 to May 2003, 13 patients (median age 61 years, range: 48-74) were prospectively enrolled. The median diameter of the main tumor was 14 cm (range 11.5-18.0). No major surgical complications were observed and the median hospital stay was 12 days (range 7-20). The first TAE was performed 1 month after hepatectomy in all patients and was repeated for median of 5 (range: 1 to 16) times. Complete remission was observed in two patients. One patient had recurrence afterwards but another patient survived 41 months without recurrence. Three patients survived more than 3 years. The overall 1-, 3-, and 4-year survival rates of the 13 patients were 67.7%, 40.6%, and 40.6%, respectively. CONCLUSIONS: Volume reduction surgery followed by TAE might prolong the survival of patients with a large HCC and intrahepatic metastases, especially those with a main tumor on the right side.

Prognostic factors for poor survival after repeat hepatectomy in patients with colorectal liver metastases.

BACKGROUND: The recurrence rate for colorectal liver metastases after repeat hepatic resection is high, and selection criteria for repeat hepatectomy are still controversial. METHODS: Clinical data of patients undergoing repeat hepatectomy for metastatic colon cancer were reviewed retrospectively and compared with those of initial hepatectomy and other treatments to determine criteria for repeat hepatectomy and to confirm its efficacy. RESULTS: For 22 patients who underwent repeat hepatectomy, no mortality and an 18% morbidity rate were observed. The 3-year survival rate after repeat hepatectomy was 49%. The only poor prognostic factor after repeat hepatectomy was a serum carcinoembryonic antigen level greater than 50 ng/mL before initial hepatectomy. The prognosis for patients who underwent repeat hepatectomy and had shown high carcinoembryonic antigen levels before initial hepatectomy was approximately equal to that for the patients who received systemic chemotherapy or hepatic arterial infusion for unresectable tumors in the remnant liver. CONCLUSION: Repeat hepatectomy for colorectal liver metastases can be performed safely and appears to be as effective as initial hepatectomy. However, for patients with a carcinoembryonic antigen level greater than 50 ng/mL before the initial hepatectomy, repeat hepatic resection alone may not be as effective, and a new strategy is needed.

Prognostic value of cytologic examination of peritoneal washings in pancreatic cancer.

HYPOTHESIS: Findings from cytologic examination of peritoneal washings affect the staging, prognosis, and management of pancreatic cancer. DESIGN: Retrospective review. SETTING: Tertiary care center. PATIENTS: A total of 151 patients with invasive ductal adenocarcinoma of the pancreas and without distant metastases or ascites, as determined by preoperative radiologic examinations, underwent peritoneal washings. Based on intraoperative findings, patients were subdivided into 3 groups according to the extent of cancer spread: 65 were assigned to a resectable group, 53 to a locally advanced group, and 33 to a visible metastases group. MAIN OUTCOME MEASURES: Survival and peritoneal metastases-free survival. RESULTS: The incidence of positive cytologic findings was 23.8% (36/151). Positive rates increased significantly with disease progression (P<.001). In the resectable group, survival and peritoneal metastases-free survival were significantly shorter for patients with positive vs negative cytologic findings. In the remaining 2 groups, no differences were observed between patients with positive vs negative cytologic findings in survival or peritoneal metastases-free survival. In patients with positive cytologic findings without visible metastases, survival and peritoneal metastases-free survival were significantly better in the locally advanced group undergoing chemoradiotherapy than in the resectable group. CONCLUSIONS: Positive peritoneal cytologic findings are not independent factors that determine survival and peritoneal metastases-free survival; rather, they are associated with advanced disease. In patients with visible metastases, cytologic factors are not correlated with survival or peritoneal recurrence. In patients without visible metastases, chemoradiotherapy may be beneficial for those with positive cytologic findings.

Aggressive surgical treatment for T4 gastric cancer.

Surgical treatment for locally advanced gastric cancer remains controversial, and many still question the benefits of extended resection. The aim of this study was to evaluate the effectiveness of combined resection of the involved organs with regard to survival in patients with gastric cancer. Between 1993 and 2000, among the 1638 patients with gastric cancer who underwent gastrectomy, 82 were found to have evidence of adjacent organ spread at laparotomy. A retrospective analysis of these patients was performed. Curative resections were carried out in 50 patients, whereas noncurative resections were performed in 32 patients. The 5-year survival rate in the group undergoing curative resection was 36.9%. The survival rate in the R0 group was significantly higher than the survival rate for patients undergoing noncurative resections. There was no significant difference in survival rates between patients with pT3 cancer and those with pT4 cancer. Seventy-one patients were pathologically proved to have lymph node metastasis, and the survival rate for patients with a lymph node ratio greater than 0.2 was lower than that in other groups. In multivariate analysis, peritoneal dissemination, lymph node ratio, and histologic findings were the predictors of survival. Patients with T4 gastric carcinoma, even with lymph node metastasis, might have benefited from aggressive surgery with curative intent.

Survival benefits of portal vein resection for pancreatic cancer.

BACKGROUND: The efficacy of portal vein resection for pancreatic cancer is controversial. METHODS: Eighty-one consecutive patients with pancreatic cancer undergoing surgical resection were retrospectively analyzed. The clinicopathological findings and relationship between portal vein resection and survival were investigated. RESULTS: Thirty-three patients with pancreatic cancer underwent pancreatic resection with portal vein resection. Histological examination revealed that 17 patients had definite invasion to the portal vein (group 1) and 16 patients had no invasion (group 2). Forty-eight patients with pancreatic cancer underwent pancreatic resection without portal vein resection (group 3). There were no significant differences in survival rates (P = 0.437) between patients with portal vein resection and patients without portal vein resection. However, patients in group 1 had a significantly (P = 0.021) worse prognosis as compared with those in group 2. Despite aggressive surgical resection, the surgical margin was positive in 35% of patients in group 1 as compared with 13% of patients in group 2 and 21% of patients in group 3. CONCLUSIONS: Patients undergoing portal vein resection for pancreatic cancer had a prognosis similar to patients without portal vein resection. Negative microscopic invasion to the portal vein was significantly associated with improved survival.

Clinical characteristics of hepatocellular carcinoma with an extensive lymph node metastasis at diagnosis.

Lymph node metastasis is reported to occur only rarely in patients with hepatocellular carcinoma (HCC). However, we have encountered patients with HCC with extensive lymph node metastases. Here we report the clinical characteristics of HCC associated with extensive lymph node metastasis at diagnosis. Ten patients with HCC in whom extensive lymph node metastases were observed at the initial medical examination were studied. The degree of disease progression was documented with ultrasonography and dynamic computed tomography. Primary liver lesions were classified in the following three types according to imaging characteristics: type A, massive type with portal vein tumor thrombus; type B, multinodular, nonencapsulated type; and type C: multinodular, encapsulated type. In patients with types A and B HCC, a large number of lymph node metastases was observed, whereas a small number of isolated metastases was observed in patients with type C. All patients with types A and B HCC died within 7 months (median survival, 4 months), whereas those with type C survived for 4 years or more after treatment with transcatheter arterial chemoembolization and surgery. A relationship exists between the type of primary HCC lesions and the pattern of lymph node metastasis. Long-term survival may be expected for patients with isolated lymph node metastases.