Hirosumi Itoi

Poor prognostic factors of hepatectomy in patients with resectable small hepatocellular carcinoma and cirrhosis

Purpose Some patients with hepatocellular carcinoma (HCC) at an early stage cannot attain long-term survival after hepatectomy. The aim of the present study was to investigate the poor prognostic factors for hepatectomy in patients with resectable small HCC with cirrhosis.Methods We studied 95 patients with cirrhosis with HCC, which consisted of a single tumor 5xa0cm or smaller or two or three tumor nodules each 3xa0cm or less; an absence of extrahepatic metastasis; and an absence of radiological evidence of macroscopic portal vein or hepatic vein invasion. We used Cox’s proportional hazard model to identify risk factors associated with prognosis to determine the contra-indications for hepatectomy in patients with resectable small HCC.Results Preoperative risk factors were: (1) serum AFP concentration of more than 400xa0ng/ml; (2) infiltrative-, massive-, or multinodular-type (multiple) HCC; and (3) the presence of intrahepatic metastasis. Patients who had had more than one of the three preoperative risk factors were poor candidates for hepatic resection, with a 4-year survival of 16.3%.Conclusion If patients with resectable small HCC are diagnosed as having more than one of three preoperative risk factors, they should not receive hepatectomy or should be considered for primary liver transplantation as a therapeutic option for HCC.

Subtotal gastrectomy for cancer located in the greater curvature of the middle stomach with prevention of the left gastric artery.

BACKGROUNDnA novel distal subtotal gastrectomy was performed in 5 patients with macroscopically node-positive gastric cancer located in the greater curvature of the middle stomach. In these patients, total gastrectomy or standard distal subtotal gastrectomy has been typically performed. In these typical gastrectomies, the hepatic and the coeliac branches of the vagi are removed en bloc with the left gastric artery and the whole of the lesser omentum because the lymphatics along the left gastric artery are in the lower stream-regions of lymph flow from the cancer and metastases exist potentially.nnnMETHODSnDuring novel distal subtotal gastrectomy the activated carbon method confirmed that the lymphatics along the ascending branch of the left gastric artery were not in the lower stream-region of lymph flow from the cancer. Then, we preserved the hepatic and coeliac branches of the vagi as well as the ascending branch of the left gastric artery and the upper part of the lesser omentum. The other arteries feeding the stomach were removed with the surrounding lymphatics. In novel distal subtotal gastrectomy the remnant stomach was fed only by the ascending branch of the left gastric artery, while in standard distal subtotal gastrectomy the remnant stomach was fed by the short gastric arteries.nnnCONCLUSIONSnAlthough further examinations are necessary, novel distal subtotal gastrectomy may have superior merit such as good function of gallbladder because of the preservation of the vagal nerve system, compared with total gastrectomy or standard distal subtotal gastrectomy.

Rectal cancer with jumping metastasis to the obturator lymph node only

In May, 1993, we operated upon a 40-year-old woman with lower rectal cancer with jumping metastasis to a solitary right obturator lymph node only. For the rectal cancer with submucosal invasion, we performed low anterior resection with regional lymph node dissection as far as the second group, based on theGeneral rules for clinical and pathological studies on cancer of colon, rectum and anus, 4th edition, of the Japanese Society for Cancer of the Colon and Rectum, including the obturator lymph nodes. Well differentiated adenocarcinoma and mucinous carcinoma were seen in the submucosal invasive front. The risk of obturator metastasis must be considered during operation for rectal cancer.

Investigation on the Surgical Treatment for Multifocal Early Gastric Cancers. Based on the Cell Proliferation Analysis by DNA-cytofluorometry.

私たちの教室で治療した胃癌症例中で多発胃癌は5.6%あるが, 早期胃癌の中では多発のものは8.6%を占めて近年増加傾向にある. この多発早期胃癌は単発早期胃癌と比較して高齢者に多く, 隆起型, 分化型 (高分化腺癌) の頻度が高く, 占居部位は大半が胃体部, 幽門部で幽門側切除が可能であった. 私たちは多発早期胃癌の悪性度評価法として, 各病巣の癌細胞増殖動態を顕微測光法で解析してきた. 予後良, 好例では各病巣のDNAプロイディ・パターンはdiploidで増殖動態は類似し, 病巣間で著差を認めなかった. 一方, 予後不良例ではS-G2期細胞の増加, 多倍体化などの進行胃癌で見られる増殖動態を示し, これらの所見は病巣間でばらつきを示した. したがって, DNAプロイディ・パターンは多発早期胃癌の悪性度の指標になりうると考えられた. また, リンパ節転移の頻度は単発例と差がなく, 単発早期胃癌と同様な進行度評価を適用しうると考えられた.