Eisuke Adachi

Risk factors for intrahepatic recurrence in human small hepatocellular carcinoma

BACKGROUND/AIMS Postoperative intrahepatic recurrence of human hepatocellular carcinoma is high. Recently, the relationship between proliferating cell activity in the cirrhotic liver and occurrence or recurrence of hepatocellular carcinoma has been reported. METHODS One hundred two resected cases of small hepatocellular carcinoma of < 3 cm in diameter without venous invasion or intrahepatic metastasis were examined to ascertain the factors affecting postoperative intrahepatic recurrence. RESULTS Cumulative intrahepatic recurrence rates at 1, 3, and 5 years after surgery were 12.0%, 57.2%, and 67.6%, respectively. The log-rank test indicated that serum albumin levels of < 3.7 g/dL, alanine aminotransferase levels of more than 54 IU/L, active inflammation in the nontumorous portion, and high proliferating cell nuclear antigen labeling index in the nontumorous portion (> 23.2%) were significant risk factors for recurrence. Tumor factors, including tumor size, histological grade, or alpha-fetoprotein level, were not significant risk factors. Coxs proportional hazard model identified that serum albumin level and alanine aminotransferase level were independently associated with intrahepatic recurrence after hepatectomy. CONCLUSIONS This study suggests that the principal cause linked to either a recurrence or a second new growth of hepatocellular carcinoma in the remnant liver after hepatectomy was the state of the underlying liver parenchyma as well as other tumor factors per se.

Laparoscopic hepatectomy for hepatocellular carcinoma

S. Maehara Background: No reports exist on the role of laparoscopic hepatectomy in the short- and long-term outcomes of patients with hepatocellular carcinoma (HCC). We present our results from using laparoscopic hepatectomy for HCC and discuss the importance of this procedure. Methods: To investigate the role of laparoscopic hepatectomy in the short- and long-term outcomes, 17 patients with HCC who underwent laparoscopic hepatectomy (laparoscopic hepatectomy group) were compared with 38 patients who underwent conventional open hepatectomy (open hepatectomy group) during the same period. Results: No differences in operation time, blood loss, rate of blood transfusion, or incidence of postoperative complications were found between the two groups. The postoperative hospital stay for the laparoscopic hepatectomy group was significantly shorter than for the open hepatectomy group. With long-term prognosis, no difference was found in survival rate and disease-free survival rate between the two groups. No recurrence was found in the stump of the remaining liver after laparoscopic hepatectomy. Conclusions: Laparoscopic hepatectomy has resulted in a better short-term outcome after surgery than conventional open hepatectomy. The long-term prognosis in the laparoscopic hepatectomy group was similar to that in the open hepatectomy group. Therefore, laparoscopic hepatectomy can be a new alternative for treatment of cirrhotic patients with HCC when patients are strictly selected.

Combined hepatocellular and cholangiocarcinoma: Proposed criteria according to cytokeratin expression and analysis of clinicopathologic features

We herein evaluated 36 cases of combined hepatocellular and cholangiocarcinoma (cHCC-CC) (including 29 surgically resected and seven autopsy cases) by the immunohistochemical methods of anticytokeratin antibodies 7 and 19, and then analyzed the clinicopathologic features by comparing cHCC-CC with ordinary hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC). The results indicated that even if mucin production could not be confirmed, nine cases with HCC areas that showed a histological resemblance to CC also showed immunohistological biliary differentiation. Therefore, we advocate that these HCC with biliary differentiation based on an immunohistochemical analysis should thus be included in the criteria of cHCC-CC in broad terms. Regardless of the extent of mucin production, the cHCC-CCs as indicated by an immunohistochemical analysis are considered to have a similar background to that of ordinary HCCs regarding such factors as the average age, male:female ratio, hepatitis B surface antigen (HBsAg) and hepatitis C virus antibody (HCVAb) positivity, alpha-fetoprotein level, and the presence of cirrhosis. However, cHCC-CCs tend to metastasize to many organs and the lymph nodes, and, as a result, have a poor prognosis.

EXPRESSION OF THE METASTASIS-ASSOCIATED MTA1 PROTEIN AND ITS RELATIONSHIP TO DEACETYLATION OF THE HISTONE H4 IN ESOPHAGEAL SQUAMOUS CELL CARCINOMAS

Metastasis‐associated protein MTA1 and histone deacetylase form a protein complex with histone deacetylase activity that plays an important role in histone deacetylation, alteration of chromatin structure and transcriptional control. The precise role of the MTA1 protein in the malignant progression of human cancers remains unknown, however, especially its overexpression and relationship with histone acetylation/deacetylation in experimental and clinical tumors. The expression levels of MTA1 protein and the acetylation levels of histone H4 were examined in 70 cases of surgically resected esophageal squamous cell carcinomas, using immunohistochemistry. The intensities of immunostaining of MTA1 protein and acetylated histone H4 in carcinoma tissues (Ca) were compared to normal epithelium (N) contained in the same section. Thirty of 70 cases (42.9%) displayed overexpression of MTA1 protein (N < Ca). Cancers overexpressing MTA1 protein invaded deeper into the esophageal wall (p < 0.005) and showed significantly higher degrees of lymph node metastasis (p < 0.01), higher pathological stage, more lymphatic involvement and poorer prognosis (p < 0.05) than the remaining cases. The acetylation levels of histone H4 inversely correlated to the depth of cancer invasion and pathological stage (p < 0.05), and the patients with higher level of histone H4 acetylation had a better prognosis (p < 0.05). Furthermore, immunostaining patterns of MTA1 and acetylated histone H4 were inversely correlated (p < 0.001), demonstrating the relationship of deacetylation of histone H4 in MTA1‐overexpressing carcinomas. In conclusion, the data suggest that the overexpression of MTA1 protein and acetylation level of histone H4 protein, both of which are closely related, might be useful predictors of malignant potential of esophageal squamous cell carcinomas. Thus, strategies involving inhibition of MTA1 function as well as inhibition of histone deacetylation could be novel approaches for the treatment of esophageal squamous cell carcinomas.

Intrahepatic peripheral cholangiocarcinoma: two-phased dynamic incremental CT and pathologic correlation.

To elucidate the characteristic CT findings of intrahepatic peripheral Cholangiocarcinoma, two-phased dynamic incremental CT scans of 20 cholangiocarcinomas in 16 patients were carefully analyzed. Dynamic incremental CT scanning was performed after intravenous administration of 100 ml iodinated contrast medium at a rate of 2 ml/s using a power injector. The CT scans (8–16 sections) were obtained during 45–110 s (early phase) and 6–7 min (delayed phase) after commencement of the injection of the contrast medium. On CT, 55% (11 of 20) of intrahepatic peripheral cholangiocarcinomas appeared hypo-dense in both phases. Most of the tumors (80%) appeared hypodense in the early phase and had increased CT numbers in their delayed images. Lymphadenopathy was observed in 69% (11 of 16) of patients whose main tumors exceeded 3 cm in diameter. All tumors appeared irregular or indistinct. Twenty percent (4 of 20) of the cholangiocarcinomas were difficult to distinguish from hepatocellular carcinomas or hemangiomas.

CD34 expression in endothelial cells of small hepatocellular carcinoma: Its correlation with tumour progression and angiographic findings

The angiogenic process plays an important role in tumour growth and metastasis during hepatocarcinogenesis, but it is still uncertain when the process begins during tumour formation. Forty‐two small hepatocellular carcinomas (HCC) that measured either less than or equal to 2 cm in diameter were studied by comparing the histologic findings with the angiographic findings, and with immunohistochemical expression of endothelial marker QB‐end/10 (QB), a new monoclonal antibody raised against CD34, in the sinusoidal wall. Twenty (91%) of 22 moderately or poorly differentiated HCC revealed a positive reaction for QB, while only eight (40%) of 20 well differentiated HCC demonstrated a positive reaction (P < 0.01). In the tumours showing a ‘nodule in nodule’ appearance, the less differentiated areas were more reactive for QB. Twenty‐three (82%) of 28 QB positive tumours were hypervascular, while only three of 14 (21%) QB negative tumours were hypervascular (P < 0.01) by angiography. All six of the poorly differentiated and 13 (81%) of the 16 moderately differentiated tumours were hypervascular, while only seven (35%) of 20 well differentiated HCC were hypervascular (P < 0.01). These results indicate that as the tumour becomes less differentiated, the QB positive areas become wider and angiography demonstrates hypervascularity. We therefore speculate that the HCC sinusoids acquire the characteristics of capillary and precapillary blood vessels during de‐differentiation from well to moderate, and thus the tumour begins to reveal hypervascularity on angiography. The above process may be correlated with the stepwise progression of HCC.

Characteristic findings of hepatocellular carcinoma : an evaluation with comparative study of US, CT, and MRI

The sensitivity, specificity, and accuracy of ultrasonography (US), dynamic incremented computed tomography (CT) with delayed phase imaging, and magnetic resonance imaging (MRI) with or without Gd-DTPA were studied for detecting the characteristic appearances of hepatocellular carcinomas (HCC): fibrous capsules, fibrous septa, and mosaic appearances. Results were prospectively evaluated in 30 patients who subsequently underwent hepatic lobectomies or segmentectomies. Pathologic evaluations of the resected liver specimens demonstrated fibrous capsules in 20 tumors (66.7%), fibrous septa in 13 tumors (43.3%), and mosaic appearances in 19 tumors (63.3%). The accuracies for fibrous capsules were 71.4% (20 of 28) for US, 81.5% (22 of 27) for CT, and 92.3% (24 of 26) for MRI. The accuracies for fibrous septa were 57.1% (16 of 28) for US, 59.3% (16 of 27) for CT, and 73.1% (19 of 26) for MRI. The accuracies for mosaic appearances were 71.4% (20 of 28) for US, 51.9% (14 of 27) for CT, and 69.2% (18 of 26) for MRI. Gd-DTPA administrated MRI showed higher accuracies than did conventional MRI for all manifestations. In conclusion, the fibrous capsules of HCCs were readily detected by CT and MRI. Gd-DTPA administration demonstrated an advantage in clarifying fibrous capsules, as well as fibrous septa and mosaic appearances.

New technique for the retraction of the liver in laparoscopic gastrectomy.

We developed a new technique for the retraction of the liver using a Penrose drain and a J-shaped retractor, which is both an easy and time-saving method that provides a good view during laparoscopic gastrectomy without damaging the liver.

Significance of modified Glasgow prognostic score as a useful indicator for prognosis of patients with gastric carcinoma

BACKGROUND The significance of the Glasgow prognostic score (GPS), an inflammation-based prognostic score, as an indicator of aggressiveness in gastric carcinoma has not been investigated fully. METHODS Two hundred thirty-two patients with gastric carcinoma were enrolled. Patients who had both an elevated C-reactive protein (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL) were allocated a traditional GPS (TGPS) of 2. Patients who had one of these abnormal values were allocated a TGPS of 1, and patients who had neither were allocated a TGPS of 0. RESULTS There existed a significant difference between the survival of adjacent groups of patients when examined using the TGPS (P = .05 for TGPS 0 vs 1 and P = .006 for TGPS 1 vs 2). Multivariate analysis based on TGPS demonstrated that TGPS (P = .020) and tumor stage (P = .0007) proved to be independent prognostic indicators for worse prognosis. CONCLUSIONS The preoperative measurement of an inflammation-based prognostic score can demonstrate a strict stratification for the prognosis of patients with gastric carcinoma.

Gastric adenosquamous carcinoma producing granulocyte-colony stimulating factor

We report a case of adenosquamous carcinoma of the stomach that produced granulocyte-colony stimulating factor (G-CSF). The patient, who had an admission diagnosis of advanced gastric cancer, had marked leukocytosis without evidence of infection. After leukemia and metastatic leukemoid reaction were excluded by bone marrow examination, a G-CSF-producing cancer was suspected as the cause of the abnormally elevated serum G-CSF level. The resected stomach tumor was histologically diagnosed as adenosquamous carcinoma; positive expression of G-CSF by tumor cells was shown with immunohistochemical detection, which confirmed the preoperative diagnosis. Recurrent disease in the liver and lymph nodes, accompanied by leukocytosis and re-elevation of serum G-CSF, developed just 3 months after the curative gastrectomy and adjuvant chemotherapy. All of the recurrent disease was resected, restoring normal levels of serum G-CSF. The patient survived for almost 2 years after the initial surgery with extensive chemotherapy, including weekly treatment with paclitaxel, before finally succumbing to liver failure secondary to extensive liver metastasis.