Koichi Doi

Comparison between hepatic resection and radiofrequency ablation as first-line treatment for solitary small-sized hepatocellular carcinoma of 3 cm or less.

It is a matter of debate whether hepatic resection (HR) or radiofrequency ablation (RFA) should be preferred for the treatment of patients with hepatocellular carcinoma (HCC). The aim of this study is to compare the long‐term outcome between HR and RFA in patients with solitary small‐sized HCC.

Intrahepatic dissemination of hepatocellular carcinoma after local ablation therapy.

BACKGROUND/PURPOSE We aimed to clarify the histological features of and risk factors for intrahepatic dissemination after local ablation therapy (LAT) for hepatocellular carcinoma (HCC). METHODS Between April 1992 and December 2005, 192 HCC patients underwent hepatic resection at our department, among whom were 17 patients who had local recurrences after LAT. Eight of these 17 patients had intrahepatic dissemination. The clinical and histological characteristics of these 8 surgically treated patients with intrahepatic dissemination were investigated. RESULTS Histologically, numerous intrahepatic metastases were observed, mainly in the same section as the treated tumor, together with main or sectional portal vein tumor thrombi. Before the ablation therapy, the average tumor diameter was 2.1 cm, and 62.5% of the tumors were adjacent to the main or sectional portal vein. In terms of therapeutic factors, 25% of the patients had a prior needle biopsy and 62.5% had insufficient safety margins. CONCLUSIONS LAT for HCCs (even those less than 3 cm in diameter) adjacent less than 5 mm to the main or sectional portal vein possibly promotes intrahepatic dissemination.

Repeated hepatic resections and radio-frequency ablations may improve the survival of adult undifferentiated embryonal sarcoma of the liver: report of two cases

Undifferentiated embryonal sarcoma of the liver (UESL) in adults, especially over 30 years old, is quite rare. We report two adult UESL patients that one of them survived 62 months and one is now surviving more than 65 months treated with repeated hepatic resections and radio-frequency ablations. Although UESL is an entirely unusual and aggressive tumor, multidisciplinary treatments including repeated hepatic resections and radio-frequency ablations may provide a longer survival.

Heme oxygenase and nitric oxide synthase on tumor growth

Abstract It is well known that heme oxygenase-1 (HO-1) as well as nitric oxide (NO) synthase expressed in tumor cell line and solid tumor. NO may be beneficial to the tumor growth, not only because enhanced vascular permeability in solid tumor is mediated by NO, but because the l -arginine-dependent NO pathway mediates angiogenic activity and vascular endothelial growth factor (VEGF) induces angiogenesis via formation of NO. However, NO has a powerful cytostatic action on tumor cells by inhibiting DNA synthesis and causing oxidative injury. While it has been suggested that induction of HO-1 may provide an important protective response by cells against oxidative damage, HO-1 expression in tumor cells is strongly enhanced by NO donor. Strong induction of HO-1 is observed in solid tumors after occlusion or embolization of the tumor-feeding artery, indicating that ischemic stress which may involve oxidative stress triggers HO-1 induction. In addition, it is of great importance that an HO inhibitor, zinc protoporphyrin IX, suppressed the tumor growth to a great extent. In conclusion, HO-1 expression in the solid tumor may confer resistance of tumor cells to hypoxic stress as well as to NO-mediated cytotoxicity.

Simultaneous total laparoscopic curative resection for synchronous gastric, cecal and rectal cancer: Report of a case

Highlights • Simultaneous total laparoscopic curative resection for synchronous GC, cecal and rectal cancer.• Our ingenious technical attempts can lead to the successful completion of simultaneous total laparoscopic curative resection.• Simultaneous laparoscopic surgery for synchronous GI cancers is a minimally invasive, feasible treatment option.

Gastrointestinal perforation during regorafenib administration in a case with hepatic metastases of colon cancer

Although common side effects of regorafenib include hand-and-foot syndrome and diarrhoea, the incidence of gastrointestinal perforation is reportedly unknown. We describe our experience with the case of a 65-year-old woman treated with regorafenib as a third-line therapy for progressive caecal cancer with multiple hepatic metastases after 4 and 6 courses of systemic mFOLFOX6 + bevacizumab (BV) and FOLFIRI + BV chemotherapy, respectively. The patient used regorafenib for 32 days but visited our hospital with abdominal pain during the second course. She was diagnosed with acute appendicitis and treated conservatively with antibiotics. The abdominal findings did not improve, and a computed tomography evaluation on day 4 of hospitalization revealed free air lateral to the caecal tumour, liver surface, and epigastric region. The patient underwent same-day emergency surgery based on a diagnosis of gastrointestinal perforation with generalized peritonitis. Upon observing digestive fluid leakage into the peri-ileocaecal area and a 5-mm perforation in the appendix, the patient was diagnosed with peritonitis due to gastrointestinal perforation. Ileocaecal resection with D2 debridement was performed, and a colostomy was opened into the ileum and ascending colon. We conclude that our patient developed gastrointestinal perforation during regorafenib therapy and note that clinicians should be aware of this possible complication in patients with a history of prior treatment with BV.

Molecular detection of occult cancer cells in patients with liver tumors treated by local ablation therapy

Abstract Purpose : We aimed to clarify the possibility of hematogenous spreading of cancer cells by microwave coagulation therapy (MCT) and radio-frequency ablation (RFA) for liver cancers. Molecular marker : Carcinoembryonic antigen (CEA) mRNA and melanoma antigen-3 (MAGE-3) mRNA were selected as a genetic marker. PCR method : Blood samples were collected before, during and just after the treatments. Genetic markers were examined using LightCycler reverse transcriptase–polymerase chain reaction (RT–PCR) assay with SYBR Green I. The samples with both positive markers were defined as genetic positive. Molecular metastasis and recurrence : We evaluated peripheral blood samples of 70 patients with liver tumors; 64 hepatocellular carcinomas (HCCs), 1 cholangiocellular carcinoma (CCC), and 5 metastatic liver tumors (MLTs). Genetic positive rates in RT–PCR assay before treatment were 42.2% in HCC, 0% in CCC, and 20% in MLT. Among genetic negative patients before operation, 45% of patients in MCT and 29% in RFA changed to genetic positive as a result of the procedures. Recurrence rates were 55% and 50% in MCT and 43% and 88% in RFA of the patients assessed negative to negative and negative to positive, respectively. Conclusion : Local ablation therapies may promote hematogenous seeding of cancer cells.

Images of the Month: Acute Pancreatitis in Gastric Aberrant Pancreas.

The American Journal of GastroenteroloGy Volume 110 | july 2015 www.nature.com/ajg A 37-year-old woman with a gastric aberrant pancreas on the greater curvature of the middle gastric body presented to our hospital with epigastric pain. Her serum pancreatic amylase levels were slightly elevated (176 IU/l). (Left) Upper gastrointestinal endoscopy detected a submucosal tumor (arrows) with edema of the gastric wall. (Right) Abdominal contrast-enhanced computed tomography revealed an enlarged and enhanced gastric aberrant pancreas with duct structures and edema of the gastric wall around it. The primary pancreas appeared normal.

Repeated recurrence of a gastric gastrointestinal stromal tumor on the chest wall after initial curative resection: Report of a case☆

Highlights • Extra-abdominal recurrence or metastasis of a GIST is very rare.• Furthermore, most GISTs recur during the first 5 years of follow-up and few recur after the first 10 years of follow-up.• We herein report a case of repeated recurrence of gastric GIST involving the chest wall of a patient 11 years after curative resection.

Accelerated cytokine responses of elderly patients result in a significant increase of systemic inflammatory response syndrome and postoperative complications following gastrointestinal surgery

Abstract Objectives : We clarified a distinctive feature of response to surgical stress in elderly patients compared to nonelderly patients. Subjects : Two hundred and ninety-two consecutive patients received elective gastrointestinal surgery. Patients were analyzed for physiological status, cytokine levels, surgical stress parameters and postoperative status of SIRS and complications. Cytokine responses according to patients age : Plasma levels of interleukin 6 (IL-6) fluctuated in higher concentrations in elderly patients. Peak plasma levels of IL-6 were significantly high in patients aged over 75 years in total gastrectomy, over 65 years in pancreaticoduodenectomy and over 60 years in major hepatectomy. Mechanisms of hypercytokinemia in elderly patients : Renal dysfunction caused hypercytokinemia in elderly patients. Hypercytokinemia and SIRS : SIRS was more frequently encountered and continued for a long time in elderly patients, giving us an early sign of postoperative complications. Conclusions : In order to prevent postoperative complications in elderly patients, we must shorten status of SIRS due to excessive hypercytokinemia.