Hideki Miyata

Muscle atrophy as pre-sarcopenia in Japanese patients with chronic liver disease: computed tomography is useful for evaluation

Background/AimThe definition of muscle atrophy (pre-sarcopenia) and its diagnostic criteria have not been well reported. To elucidate the frequency of pre-sarcopenia in chronic liver disease (CLD), we examined clinical features of Japanese CLD patients using abdominal computed tomography (CT) findings.MethodsWe enrolled 988 CLD (736 with naïve hepatocellular carcinoma) and 372 normal control subjects (NCs). The psoas muscle area index [PI, psoas muscle area at the mid-L3 level in CT (cm2)/height (m)2] was calculated using personal computer software. The cut-off level for pre-sarcopenia was defined as less than two standard deviations (SDs) below the mean PI value in the NCs under 55xa0years old [males, 45.6xa0±xa05.7xa0years (nxa0=xa061), 4.24xa0cm2/m2; females, 47.0xa0±xa06.1xa0years (nxa0=xa049), 2.50xa0cm2/m2]. Elderly was defined as 65xa0years or older. Clinical features were retrospectively evaluated.ResultsIn the CLD group (HCV:HBV:HBV and HCV:alcohol:non-HBV and HCVxa0=xa0652:88:7:82:159), pre-sarcopenia was observed in 15.3xa0% of patients with chronic hepatitis (CH), 24.4xa0% of those with liver cirrhosis (LC) Child-Pugh A, 37.7xa0% of those with LC Child-Pugh B, and 37.1xa0% of those with LC Child-Pugh C. A comparison between NC and CH by age (<55, 55–64, 65–74, ≥75xa0years) showed that the frequency of pre-sarcopenia was higher in CH regardless of age (1.8 vs. 3.6xa0%, 3.2 vs. 15.9xa0%, 4.9 vs. 13.4xa0%, 14.3 vs. 20.2xa0%, respectively). PI values showed correlations with BMI (rxa0=xa00.361), age (rxa0=xa0−0.167), albumin (rxa0=xa00.115), and branched-chain amino acids (rxa0=xa00.199) (Pxa0<xa00.01).ConclusionRetrospective evaluate for pre-sarcopenia was easy to perform with CT findings. Nutrition and exercise instruction should be considered for early stage and even non-elderly CLD as well as LC.

Tumor Markers AFP, AFP-L3, and DCP in Hepatocellular Carcinoma Refractory to Transcatheter Arterial Chemoembolization.

Background/Aim: We examined tumor marker levels to assess in more detail transcatheter arterial chemoembolization (TACE)-refractory hepatocellular carcinoma (HCC). Materials and Methods: We enrolled patients treated from 2000 to 2011 for HCC beyond the Milan criteria who had good hepatic reserve function (Child-Pugh A) and no portal vein thrombosis or metastases (n = 154). The modified criteria for being TACE-refractory according to the Liver Cancer Study Group of Japan (m-LCSGJ), from which the tumor marker item was excluded, and the Assessment for Retreatment with TACE (ART) score were used for determining whether the HCC was TACE refractory. α-Fetoprotein ≥100 ng/ml, fucosylated α-fetoprotein ≥10%, and des-gamma-carboxy prothrombin ≥100 mAU/ml were used to define whether tumor markers were positive. We added up the number of positive tumor markers as a prognostic score to assess in more detail the evaluation of TACE-refractory HCC. Results: In order to divide the patients into a refractory and nonrefractory group, the m-LCSGJ criteria [mean survival time (MST) 27.1 vs. 49.9 months; p < 0.001] were superior to the ART score (MST 22.0 vs. 35.1 months; p = 0.051). In the refractory group according to the m-LCSGJ criteria, the patients with a low score of positive tumor markers (<2) after 2 sessions of TACE (n = 36) showed a better prognosis than the others (n = 72) (MST 37.7 vs. 23.2 months; p = 0.014). Conclusion: Patients being nonrefractory according to the m-LCSGJ criteria had a better response, and using the number of tumor markers (≥2) is an easy method for predicting the response to TACE and for a more detailed evaluation of TACE-refractory HCC.

Prognosis and therapy for ruptured hepatocellular carcinoma: Problems with staging and treatment strategy

BACKGROUNDnThere are no clear criteria established for treating a ruptured hepatocellular carcinoma (HCC). To elucidate the clinical features of affected patients, we examined prognosis and therapy choices.nnnMATERIALS/METHODSnWe enrolled 67 patients treated for a ruptured HCC (HCV 44, HBV 5, HBV+HCV 1, alcohol 2, others 15; naïve HCC 34, recurrent 33) from 2000 to 2013, and investigated their clinical background and prognosis.nnnRESULTSnMedian survival time (MST) for all cases was 4 months. For patients who survived for more than 1 year after rupture, the percentages of Child-Pugh C and positive for portal vein tumor thrombosis (PVTT)/extrahepatic metastasis were less than for those who died within 1 year. Child-Pugh classification (A:B:C=14:15:5 vs. 4:9:20, P<0.001) was better, while the percentage of patients with multiple tumors was lower [19/34 (55.9%) vs. 29/33 (87.9%), respectively; P<0.001] in the naïve group. The 1- and 3-year survival rates were better in the naïve as compared to the recurrent group (60.6% and 33.3% vs. 12.6% and 0%, respectively; P<0.01). MST according to modified TNM stage (UICC 7th) calculated after exclusion of T4 factor of rupture, stage I was better than others (22.7 vs. (II) 2.2, (III) 1.2, and (IV) 0.7 months) (P=0.010).nnnCONCLUSIONnIn patients with a ruptured HCC, especially those with a single tumor, and without decompensated liver cirrhosis and PVTT/extrahepatic metastasis, better prognosis can be expected with curative treatment. The present naïve group included more of such cases than the recurrent group, indicating the effectiveness of curative therapy.

Ultrasonography screening for hepatocellular carcinoma in Japanese patients with diabetes mellitus

Effective surveillance for hepatocellular carcinoma (HCC) in diabetes mellitus (DM) has not been established. We elucidated the risk factors for HCC in DM patients.

Importance of screening for synchronous malignant neoplasms in patients with hepatocellular carcinoma: impact of FDG PET/CT

Synchronous neoplasms (SNs) are occasionally found in hepatocellular carcinoma (HCC). We examined such cases and the efficacy of 18‐fluoro‐2‐deoxyglucose positron‐emission tomography computed tomography (PET/CT), retrospectively.

Hypophosphatemia in patients with hepatitis B virus infection undergoing long-term adefovir dipivoxil therapy

The purpose of this study was to clarify the frequency of hypophosphatemia and other clinical features in patients with hepatitis B undergoing long‐term therapy with adefovir dipivoxil (ADF).

Early pancreatic volume reduction on CT predicts relapse in patients with type 1 autoimmune pancreatitis treated with steroids

BackgroundType 1 autoimmune pancreatitis (AIP) is clinically characterized by a response to steroid therapy. Despite having a favorable prognosis, AIP has a high relapse rate and factors predicting relapse in AIP patients treated with steroids have not yet been established.MethodsA retrospective chart review was conducted of 32 newly diagnosed type 1 AIP patients who had undergone enhanced computed tomography (CT) pre- and post-steroid therapy.ResultsTen patients experienced relapse. Pancreatic volume was reduced significantly in all patients (pre-treatment volume, 88.5u2009±u200932.9xa0cm3 vs. post-treatment volume, 45.4u2009±u200921.1xa0cm3; Pu2009<u20090.001), although the pre-treatment pancreatic volume did not differ between the relapse and non-relapse groups (92.6u2009±u200910.5xa0cm3 vs. 86.6u2009±u20097.1xa0cm3, Pu2009=u20090.401). However, the post-treatment pancreatic volume was significantly greater in the relapse group than that in the non-relapse group (56.9u2009±u20096.3xa0cm3 vs. 40.2u2009±u20094.2xa0cm3, Pu2009=u20090.008). Similarly, the percent reduction in pancreatic volume was significantly smaller in the relapse group than that in the non-relapse group (36.6u2009±u20094.7xa0% vs. 52.1u2009±u20093.2xa0%, Pu2009=u20090.002). Multivariate analysis identified post-treatment pancreatic volume (HR, 1.04, 95xa0% CI: 1.01–1.08, Pu2009=u20090.010) and percent reduction in pancreatic volume (HR, 0.87, 95xa0% CI: 0.79–0.94, Pu2009<u20090.001) as predictive factors for relapse of type 1 AIP. A post-treatment pancreatic volume of 50xa0cm3u2009<u2009(Pu2009=u20090.009) and a percent reduction in the pancreatic volume of <35xa0% (Pu2009=u20090.004) had a significantly high relapse rate. These data suggest that early pancreatic volume changes after steroid therapy may be a useful prognostic value, because type 1 AIP patients with a high post-treatment pancreatic volume or low pancreatic volume reduction showed significant relapse.ConclusionsEarly pancreatic volume reduction on CT after steroid therapy indicates the therapeutic effects of steroids, and a low decrease in the pancreatic volume may be associated with a limited response that predicts future relapse in patients with type 1 AIP. Reduction of steroids in these cases must be observed carefully with consideration of immunomodulator use.

Validation of Newly Proposed Time to Transarterial Chemoembolization Progression in Intermediate-Stage Hepatocellular Carcinoma Cases

Background/Aim: Determination of failure of transarterial chemoembolization (TACE) for treatment of Barcelona Clinic Liver Cancer stage B (BCLC-B) hepatocellular carcinoma (HCC) has become important because of the development of tyrosine kinase inhibitor (TKI) treatment. We evaluated the usefulness and efficacy of the newly proposed time to TACE progression (TTTP). Patients and Methods: From 2006 to 2016, 192 BCLC-B HCC patients [median age 72 years, male/female ratio = 149/43, Child-Pugh score 5/6/7 = 106/56/30, albumin-bilirubin (ALBI) grade 1/2 = 64/128, Kinki criteria B1/B2 = 64/128] were enrolled. TTTP was defined based on a previous report and first imaging performed 3 months after initial TACE had been used to obtain baseline images. The patients were divided into three groups according to TTTP (<5, 5-10, and ≥10 months; group I, II, and III, respectively). We evaluated the relationship between TTTP and overall survival (OS) as well as the prognostic factors for death. Results: The median number of TACE procedures was 4 (interquartile range 3-7). There was a moderate correlation between TTTP and OS (r = 0.527, 95% CI 0.416-0.622, p < 0.001). The median survival for group I (n = 78), II (n = 49), and III (n = 65) was 24.6, 34.7, and 49.5 months, respectively (group I vs. group II, p = 0.023; group I vs. group III, p < 0.001; group II vs. group III, p = 0.037; Holms method). ALBI grade 2 (HR 1.548, 95% CI 1.004-2.388, p = 0.048), alpha-fetoprotein (>100 ng/mL) (HR 1.540, 95% CI 1.035-2.291, p = 0.033), and TTTP (<5 months) (HR 2.157, 95% CI 1.447-3.215, p < 0.001) were significant prognostic factors for death in multivariate Cox hazard analysis. Conclusion: In patients with reduced TTTP, especially <5 months, it might be difficult to improve prognosis with a repeated TACE procedures. In such cases, reconsideration of the therapeutic strategy might be needed when possible.

Abdominal Ultrasound Findings of Tumor-Forming Hepatic Malignant Lymphoma

Aim/Background: Evaluations of abdominal ultrasonography (US) findings of primary and secondary tumor-forming hepatic malignant lymphoma (HML) have not been adequately reported. In this study, we elucidated US and contrast-enhanced US (CEUS) findings in patients with HML. Materials/Methods: From January 2006 to March 2017, 25 patients with HML were enrolled (primary 7, secondary 18), each of whom was diagnosed pathologically. They were divided into 2 groups based on tumor diameter (cutoff, 30 mm). US imaging findings were retrospectively analyzed. Results: All tumors in patients with a small HML (<30 mm in diameter, small group, n = 14) were revealed as homogeneous hypo-echoic type (100%), with penetrating sign observed in only 1 patient. Tumors in 11 patients in the small group, examined with CEUS, showed homogeneous enhancement in the early vascular phase (91%) and a washout pattern in the portal phase (100%), and they were revealed as defective in the post-vascular phase (100%). In the large group (≥30 mm; n = 11), tumors were revealed as a heterogeneous hypo-echoic lesion in 10 (91%) and penetrating sign was observed in 8 (73%). Dilatation of the distal intrahepatic bile duct by the tumor was observed in 4 patients in the large group. In 7 large group patients examined with CEUS, imaging findings in the early vascular phase varied, with 5 (71%) showing a washout pattern in the portal phase and 5 (71%) revealed as defective in the post-vascular phase. Conclusion: We found that US imaging features of HML differ depending on the tumor diameter.

Efficacy of chemotherapy in elderly patients with unresectable pancreatic cancer: a multicenter review of 895 patients

BackgroundThe efficacy of chemotherapy for unresectable pancreatic cancer has improved. However, it is occasionally difficult to make treatment decisions for elderly patients. We reviewed the outcomes of elderly patients with unresectable pancreatic cancer by using a large cohort and evaluated whether they had received chemotherapy and the reason why.MethodsData for 895 pancreatic cancer patients who were treated using chemotherapy or best supportive care were analyzed considering demographics, clinical stage, treatment, and outcome. Data were analyzed using the chi-square test, Student t-test, or Mann-Whitney U-test, as appropriate. Outcomes were analyzed using the Kaplan-Meier method. Differences in survival were analyzed using the log-rank test.ResultsThe median survival time was significantly shorter in elderly patients (≥65xa0years) than in younger patients (<65xa0years) (181 vs. 263xa0days, Pu2009=u20090.0001). The median survival time of patients treated with chemotherapy was not significantly different between the elderly and the younger group (274 days vs. 333 days, Pu2009=u20090.09), and nor was that of patients choosing best supportive care (84 days vs. 78 days, Pu2009=u20090.83). These results held true even when the age cut-off between younger and elder patients was increased to 70, 75, and 80 years.xa0Elderly patients treated with chemotherapy had a significantly longer median survival time than those choosing best supportive care (274 vs. 86xa0days, Pu2009<u20090.0001); a significantly greater proportion of elderly patients chose best supportive care compared to younger patients (47.8 vs. 25.8%, Pu2009<u20090.0001). The reason for choosing best supportive care was established in 261 elderly patients (82.9%); 133 (51.0%) met the eligibility criteria for chemotherapy, but of these, 78 (58.6%) were not informed about their disease. The treatment preferences of elderly patients were not always considered; they often received only best supportive care per family members preference (Nu2009=u200965, 48.8%) or because the physician based their treatment decision only on the patient’s age (Nu2009=u200968, 51.1%).ConclusionsChemotherapy appears effective for elderly pancreatic cancer patients with unresectable disease, but treatment needs to be optimized to improve prognosis.