Hideki Saitsu

Results of a pulmonary metastasectomy in patients with colorectal cancer

PurposeThe lung is one of the key sites of hematogenous metastasis in patients with colorectal cancer. A metastasectomy of the lung is reported to improve the prognosis of colorectal cancer. We reviewed our experience in evaluating the surgical outcomes in colorectal cancer patients who have undergone a pulmonary metastasectomy.MethodsA single-center retrospective evaluation of clinical prognostic factors (1996–2008) related to a pulmonary metastasectomy of patients with colorectal cancer was conducted. Fifty-seven consecutive patients in our hospital who had undergone a resection of pulmonary metastasis from colorectal cancer were retrospectively investigated.ResultsThe mean age of the patients who underwent an initial pulmonary metastasectomy was 63.8 years. The average number of pulmonary metastases was 3.8. Pulmonary metastasectomy was performed an average of 1.6 times per head. A total of 32 patients had undergone a liver metastasectomy, and the 5-year survival of these 32 patients was 43.1%. The 5-year survival of the time from first pulmonary metastasectomy was 53.9%. There were no statistical differences with regard to the disease-free interval, interval from primary resection, or the number of pulmonary metastasectomies.ConclusionsA pulmonary resection for colorectal pulmonary metastases is therefore considered to be a favorable treatment for long-term survival even in the presence of liver metastases. Thoracic surgeons should therefore aggressively perform a pulmonary metastasectomy of colorectal cancer.

Validity of FibroScan values for predicting hepatic fibrosis stage in patients with chronic HCV infection

OBJECTIVE:  The aim of this study was to validate the FibroScan system compared with liver histology and serum markers for the diagnosis of hepatic fibrosis. We also tried to determine the cut‐off levels and assess the feasibility of using FibroScan values to predict the fibrosis stage.

Data mining reveals complex interactions of risk factors and clinical feature profiling associated with the staging of non-hepatitis B virus/non-hepatitis C virus-related hepatocellular carcinoma

Aim:  Non‐hepatitis B virus/non‐hepatitis C virus‐related hepatocellular carcinoma (NBNC‐HCC) is often detected at an advanced stage, and the pathology associated with the staging of NBNC‐HCC remains unclear. Data mining is a set of statistical techniques which uncovers interactions and meaningful patterns of factors from a large data collection. The aims of this study were to reveal complex interactions of the risk factors and clinical feature profiling associated with the staging of NBNC‐HCC using data mining techniques.

A new technique of hepatectomy using an occlusion balloon catheter for the hepatic vein

To minimize intraoperative bleeding and allow more accurate resection, we have devised a new technique for hepatectomy. In addition to occlusion of the afferent vessels, we occlude the hepatic vein at the hepatocaval junction using a balloon catheter inserted transhepatically under intraoperative ultrasonic guidance. We have performed eight hepatectomies using this method. A sequence of 15 minutes of vascular occlusion followed by 5 minutes reperfusion was repeated throughout the operation, and the total ischemic time ranged from 45 to 90 minutes. This method greatly decreased intraoperative bleeding without causing significant elevation of the postoperative transaminase or lactic dehydrogenase levels when compared with occlusion of only the afferent vessels or nonischemic resection using a microwave tissue coagulator in patients undergoing equivalent resections. Also, the postoperative prothrombin time recovered to a significantly higher level, and there were no fatal postoperative complications using this method. Our method is useful for systematic hepatic resection along the hepatic vein or for resection of tumor sited at the confluence of the hepatic vein.

Efficacy of surgical treatment using microwave coagulo-necrotic therapy for unresectable multiple colorectal liver metastases

Background Five or more colorectal liver metastases (CRLM) are considered marginally resectable and cannot be treated solely by hepatic resection (Hr). This study investigated the long-term effectiveness of surgical treatment using microwave coagulo-necrotic therapy (MCN) and/or Hr for marginally resectable or unresectable multiple CRLM. Methods This study retrospectively analyzed 82 consecutive CRLM patients with ≥5 CRLM who underwent MCN, Hr, or both, at our institution from 1994 to 2012. Presuming all CRLM were resected curatively, virtual remnant liver volume was calculated using preoperative computed tomography or magnetic resonance imaging. Virtual remnant liver volume <30% was defined as unresectable. Patients were divided into marginally resectable (Group Y; n=29) and unresectable (Group N; n=53). Overall and recurrence-free survival were assessed. Results Mean maximum tumor diameter and tumor number were 3.1 and 6.0 cm in Group Y and 3.3 and 11.3 cm in Group N. Surgical methods included MCN (n=16), MCN+Hr (n=9), and Hr (n=4) in Group Y, and MCN (n=28) and MCN+Hr (n=25) in Group N. One- and 2-year recurrence-free survival rates were 38.0% and 22.8% in Group Y, and 18.9% and 3.8% in Group N (P=0.01). However, 1-, 3-, and 5-year overall survival rates of Group N (86.8%, 44.6%, and 33.7%, respectively) were similar to those of Group Y (82.8%, 51.4%, and 33.3%, respectively; P= not significant each). Conclusion MCN may improve survival for patients with unresectable multiple CRLM, similar to that in patients with marginally resectable multiple CRLM.

Adenocarcinoma of the liver with osteoclast-like giant cells

To the Editor: A giant cell tumor of the bone is a common tumor characterized by proliferation of giant cells, which are surrounded by mononuclear cells. Osteoclast-like giant cell tumors (OCGTs), histologically similar to giant cell tumors of bone, have been described in several extraskeletal sites. There have been at least 40 reports describing approximately 60 occurrences of OCGTs in the pancreas, whereas only 16 liver tumors have been reported. In the present study, the clinicopathological characteristics of an adenocarcinoma of the liver with osteoclast-like giant cells (OCGCs) were examined. A 73-year-old woman presented at a neighborhood clinic with right hypochondrial pain of 3 months. A computed tomography (CT) scan revealed multilocular cystic lesions with a 14-cm diameter that occupied the right hepatic lobe. Iodine contrast further revealed a heterogeneously delayedenhanced solid component in the multilocular cystic lesion that had partially invaded the septum of cysts. The connection between cystic components and intrahepatic bile ducts was not evident in the magnetic resonance imaging (MRI) or magnetic resonance cholangiopancreatography. Further extensive diagnostic procedures showed no evidence of another tumor or metastases. Laboratory examinations revealed elevated levels of carcinoembryonic antigen (CEA; 218.3 ng/mL), CA19-9 (14 132 IU/mL), and DUPAN-2 (550 IU/mL), whereas the levels of α-fetoprotein (AFP; 3.7 ng/mL) and the protein induced by vitamin-K absence II (PIVKA-II; 12 mAu/mL) increased. Tests for hepatitis B surface antigen and hepatitis C virus antibody were negative. As preoperative examinations indicated that the tumor in the liver was the primary occurrence, a curative extended right hepatectomy was performed. Pathological gross findings revealed that the tumor in the right liver measured 145 × 83 mm and consisted of cystic portions containing mucinous fluid with or without hemorrhages and whitish solid portions located among or adjacent to the cysts (Fig. 1a). The tumor showed invasive growth into non-tumorous areas of the liver. Microscopic findings revealed that the tumor consisted of two distinct histological components (e.g. an adenocarcinoma and pleomorphic mononuclear cell component). The adenocarcinoma mainly lined the cystic lesions forming irregular papillae or fused glands (Figs 1b,2a). Nuclear atypia was evident and cellular polarity was disturbed. In addition, invasive proliferation was observed with a MIB-1 index of 20%.

The Efficacy of Continued Sorafenib Treatment after Radiologic Confirmation of Progressive Disease in Patients with Advanced Hepatocellular Carcinoma

Background Whether radiologically detected progressive disease (PD) is an accurate metric for discontinuing sorafenib treatment in patients with hepatocellular carcinoma (HCC) is unclear. We investigated the efficacy of sorafenib treatment after radiologic confirmation of PD in patients with advanced HCC. Methods We retrospectively analyzed HCC patients treated with sorafenib at Kyushu Medical Center. Six of the 92 patients with radiologically confirmed PD were excluded because they were classified as Child-Pugh C or had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥3; 86 patients were ultimately enrolled. Results Among the 86 patients, 47 continued sorafenib treatment after radiologic confirmation of PD (the continuous group), whereas 39 did not (the discontinuous group). The median survival time (MST) in the continuous group after confirmation was 12.9 months compared with 4.5 months in the discontinuous group (p <0.01). The time to progression in the continuous group after confirmation was 2.6 months compared with 1.4 months in the discontinuous group (p <0.01); it was 4.2 months and 2.1 months in patients who had received sorafenib ≥4 months and <4 months, respectively, before confirmation (p = 0.03). In these subgroups, the post-PD MST was 16.7 months and 9.6 months, respectively (p < 0.01). Independent predictors of overall survival after radiologic detection of PD were (hazard ratio, confidence interval): ECOG PS <2 (0.290, 0.107–0.880), Barcelona Clinical Liver Cancer stage B (0.146, 0.047–0.457), serum α-fetoprotein level ≥400 ng/mL (2.801, 1.355–5.691), and post-PD sorafenib administration (0.279, 0.150–0.510). Conclusion Continuing sorafenib treatment after radiologic confirmation of PD increased survival in patients with advanced HCC. Therefore, radiologically detected PD is not a metric for discontinuation of sorafenib treatment in such patients.

Long-Term Survival Following Treatment with Antineoplastons for Colon Cancer with Unresectable Multiple Liver Metastases: Report of a Case

We report a case of survival for nearly 8 years after treatment of unresectable multiple liver metastases from colon cancer, using microwave ablation and the nontoxic antitumor agent, the antineoplastons. A 72-year-old man diagnosed with adenocarcinoma of the ascending colon and 14 bilateral liver metastases underwent a right hemicolectomy combined with microwave ablation of six metastatic liver tumors. We also decided to give antineoplastons to inhibit metastatic tumor growth and recurrence. Antineoplaston A10 was given intravenously, followed by oral antineoplaston AS2-1. Computed tomography scans done 1 and 4 years after the initial diagnosis showed recurrent tumors in S4 and S7, respectively. The patient underwent a second and a third microwave ablation of the recurrent tumors, and has survived for nearly 8 years without suffering any serious adverse effects. He is currently free from cancer. This case report demonstrates the potential effectiveness of the nontoxic antitumor agent, the antineoplastons, for controlling liver metastases from colon cancer.

Surgical Results of Pancreatoduodenectomy for Disease in the Pancreatic Head Region

Between January 1965 and September 1995, 330 patients underwent pancreatoduodenectomy in our institution. In 249 cases, we performed the Child method of reconstruction after pancreatoduodenectomy. Of these patients, 299 underwent pancreatoduodenectomy because of malignant disease and 19 died in the hospital after the operation; the mortality rate was 5.8%. We must be aware of certain complications after pancreatoduodenectomy, especially anastomotic leakage of the pancreatiocojejunostomy. It 16 cases of pancreatic fistula, 7 patients died of this complication. Five-year survival rates of patients with carcinoma of the pancreas, bile duct, and papilla of Vater were 17.3%, 19.7%, and 56.2%, respectively. In cases of carcinoma of the papilla of Vater with no lymph node involvement, the 5-year survival rate was 64.9%; for cases with lymph node involvement, it was 40.0%. Many more strategies must be developed to obtain a better outcome in cases of carcinoma of the pancreas and bile duct. The most important need is to prevent metastasis of carcinoma to the liver in these patients.

Long-Term Maintenance of Complete Response after Sorafenib Treatment for Multiple Lung Metastases from Hepatocellular Carcinoma.

Sorafenib is an effective treatment for unresectable hepatocellular carcinoma (HCC) characterized by disease stabilization. However, the response rates are very low (<9%), and a complete response is rarely achieved. We report an extremely rare case of a HCC patient with multiple lung metastases treated with sorafenib who achieved a complete response for a long period. A 77-year-old woman was diagnosed with chronic hepatitis C in 1990. In 2007, a HCC detected in the liver was treated with percutaneous ethanol injection therapy. Subsequently, recurrence of HCC in the liver was treated with microwave coagulonecrotic therapy in 2010. In April 2011, a computed tomography (CT) scan revealed innumerable multiple metastases spread diffusely in both lungs. Tumor marker levels were extremely high [α-fetoprotein (AFP) 76,170 ng/ml, lens culinaris agglutinin-reactive fraction of AFP 7.5%, des-γ-carboxyprothrombin (DCP) 63,400 mAU/ml]. Sorafenib was administered at a reduced dose of 400 mg/day because of old age. Four months after sorafenib treatment, AFP and DCP had decreased to within normal levels, and the multiple lung metastases had disappeared. Currently, sorafenib is administered at a reduced dose of 400 mg/day, and the complete response has been maintained for 48 months.