Tomonori Fujishima

Proposal of a new prognostic model for hepatocellular carcinoma: an analysis of 403 patients

Background: The prognosis of hepatocellular carcinoma (HCC) is highly dependent on tumour extension and liver function. Recently, two new prognostic scoring systems—the CLIP score, developed by Italian investigators and the BCLC score, developed in Barcelona—have been widely used to assess prognosis in patients presenting with hepatocellular carcinoma. Each system has its own relative limitations. Aims: To create a new prognostic scoring system which is simple, easy to calculate, and suitable for estimating prognosis during radical treatment of early HCC. Methods: A total of 403 consecutive patients with HCC treated by percutaneous ablation at the Department of Gastroenterology, University of Tokyo Hospital, between 1990 and 1997 were used as the training sample to identify prognostic factors for our patients and used to develop the Tokyo score. As a testing sample, 203 independent patients who underwent hepatectomy at the Department of Hepato-Biliary-Pancreatic Surgery were studied. Prognostic factors were analysed by univariate and multivariate Cox proportional hazard regression. Results: The Tokyo score consists of four factors: serum albumin, bilirubin, and size and number of tumours. Five year survival was 78.7%, 62.1%, 40.0%, 27.7%, and 14.3% for Tokyo scores 0, 1, 2, 3, and 4–6, respectively. The discriminatory ability of the Tokyo score was internally validated by bootstrap methods. The Tokyo score, CLIP score, and BCLC staging were compared by Akaike information criterion and Harrell’s c index among training and testing samples. In the testing sample, the predictive ability of the Tokyo score was equal to CLIP and better than BCLC staging. Conclusions: The Tokyo score is a simple system which provides good prediction of prognosis for Japanese patients with HCC requiring radical therapy.

Evaluation of transcatheter arterial embolization prior to percutaneous tumor ablation in patients with hepatocellular carcinoma: a randomized controlled trial.

Abstract: Background: Transcatheter arterial embolization (TAE) may reduce the risk of hepatocellular carcinoma (HCC) recurrence when performed before percutaneous tumor ablation (PTA), either percutaneous ethanol injection therapy (PEIT) or radiofrequency ablation (RFA). We conducted a randomized, controlled trial comparing the use of TAE combined with percutaneous ethanol injection therapy (TAE/PEIT) to the use of PEIT only to assess the effects on HCC recurrence and survival. We continued the study after the introduction of RFA and compared TAE combined with RFA (TAE/RFA) with RFA only.

Congenital absence of portal vein with multiple hyperplastic nodular lesions in the liver

Congenital absence of the portal vein is an extremely rare anomaly, in which enteric blood bypasses the liver and drains into the inferior vena cava. A 16-year-old girl was referred to our hospital presenting with liver tumor. Although she had suffered from galactosemia soon after birth, the galactosemia had improved spontaneously 1 year later. Between the ages of 8 and 12 years, chronic hepatitis with a mild elevation of aspartate transaminase (AST) and alanine transaminase (ALT) was observed, but liver tumor had not been detected on computed tomography (CT) in regular medical examinations. However, at age 16, liver tumors, 10 cm in diameter, were found. Abdominal angiography indicated complete absence of the portal vein, suggesting that enteric blood was bypassing the liver and draining into the inferior vena cava. In biopsy specimens obtained under ultrasonographic guidance, liver tumors were confirmed histologically as hyperplastic nodules. In addition to this case report, the clinical features of 25 reported cases of congenital absence of the portal vein are reviewed.

Analysis of factors influencing hepatocellular carcinoma detection : efficient use of computed tomography during arterial portography and during hepatic arteriography

BackgroundThis study was performed to investigate the situations in which computed tomography (CT) combined with arterial portography and hepatic arteriography surpassed dynamic CT in the detection of hepatocellular carcinoma.MethodsComputed tomography combined with arterial portography and hepatic arteriography was performed on 137 patients with chronic hepatitis (92 men and 45 women; mean age, 66.5 years) with hepatocellular carcinoma (HCC) as revealed or suspected by dynamic CT. We analyzed the clinical factors leading to the discovery of additional HCC lesions on CT combined with arterial portography and hepatic arteriography that were undetected by dynamic CT.ResultsComputed tomography combined with arterial portography and hepatic arteriography detected additional HCC lesions that had not been revealed by dynamic CT in 33 of 137 patients. Univariate analysis revealed that in the event of HCC recurrence (vs. primary), multiple HCC lesions detected by dynamic CT (vs. single) and decreased liver function (Child’s classification B/C vs. A) significantly favored the additional detection of HCC lesions. Multivariate logistic regression indicated that recurrence was the strongest predicting factor for finding additional lesions on computed tomography combined with arterial portography and hepatic arteriography.ConclusionsComputed tomography combined with arterial portography and hepatic arteriography is capable of finding additional HCC lesions undetectable by dynamic CT, especially in advanced cases such as HCC recurrence, which may affect the choice of treatment.

Hepatocellular carcinoma depicted as hypoattenuation on CT hepatic arteriography (CTA) and hyperattenuation on CT during arterial portography (CTAP)

We report a 68-year-old man with three nodules of hepatocellular carcinoma (HCC) in a cirrhotic liver; the largest nodule was 3.0cm in diameter. The nodules showed hypoattenuation on computed tomography (CT) hepatic arteriography (CTA) and hyperattenuation on CT during arterial portography (CTAP), indicating that the dominant vascularity of the HCC nodules may have been the portal vein. A biopsy specimen obtained from the nodules showed well differentiated HCC (Edmondson-Steiner grade I). The imaging findings of the nodules on both CTA and CTAP are unusual, in spite of the rather large size, so this seemed suggestive of the hemodynamic properties of relatively large nodules of well differentiated HCC.

Neither hepatitis C virus genotype nor virus load affects survival of patients with hepatocellular carcinoma.

Objective Hepatitis C virus (HCV) genotype and virus load, the strongest determinants of the efficacy of interferon therapy, have been presumed to be associated with risk for hepatocellular carcinoma (HCC). This study was conducted to elucidate whether these two factors are capable of predicting the prognosis of patients with HCC. Methods A total of 371 patients with HCV infection (258 men and 113 women; median age, 66 years; range, 37–88 years) who developed HCC between January 1993 and December 1999 were enrolled. Overall survival and recurrence-free survival were analysed with the Cox proportional hazard regression according to HCV genotype (type 1 versus type 2) and virus load (above versus below 100 kIU/ml). Results Of the 371 patients, 346 received locoregional treatments (ethanol injection, microwave, radiofrequency, or surgery), and 307 achieved complete response as determined by subsequent imaging studies. The remaining 25 patients underwent arterial embolization or chemotherapy. Cox proportional hazard regression showed that neither genotype (P = 0.814) nor virus load (P = 0.958) were significant predictors for survival (P = 0.814 and 0.958, respectively) and recurrence (P = 0.505 and 0.736, respectively). Conclusions Neither genotype nor virus load of HCV affected prognosis of HCC patients.

Percutaneous Ethanol Injection Therapy, Percutaneous Infarction Therapy, and Percutaneous Microwave Coagulation Therapy for Hepatocellular Carcinoma

Nonsurgical treatments play important roles in the treatment of hepatocellular carcinoma. At our institute, more than 90% of new patients with hepatocellular carcinoma have been treated by percutaneous ethanol injection therapy (PEIT) or other percutaneous tumor ablations. Here we describe our experience in those procedures. Between 1985 and 1997, we performed PEIT on 653 patients, and the 1-, 3-, 5-, and 10-year survival rates were 89%, 63%, 38%, and 18%. In 349 patients who had three or fewer lesions and all of whose lesions were 3 cm or less in diameter, the survival rates were 93%, 74%, 47%, and 26% at 1, 3, 5, and 10 years. In percutaneous infarction therapy (PIT), ethanol is injected into the feeding artery, as detected by color Doppler ultrasonography, to cut off the blood flow to the tumor. Successful PIT induces infarction of an area in which the lesion is located. We performed PIT on 18 patients and achieved infarction in 17 of them. PIT is especially useful for a large lesion located in a peripheral portion of the liver. Percutaneous microwave coagulation therapy (PMCT) is a therapy in which heat produced by microwave energy emitted from the inserted electrode destroys the cancer tissue. Using an introducing needle with a scale, a stopper for the electrode, and a guide needle, we performed PMCT on 108 patients. CT scan following the therapy demonstrated complete necrosis of the lesion in 94 cases. Effective mass reduction was accomplished in the remaining 14 cases in which PMCT was used only palliatively. PMCT can surely destroy a certain amount of tissue, although its necrotic area is smaller than that of PEIT. Percutaneous tumor ablation techniques seem useful for hepatocellular carcinoma treatment.

Two-MM reconstructed CT as a routine tool for diagnosis of small hepatocellular carcinoma (HCC)

Aim: The aim of this study was to evaluate the detectability of Hepatocellular carcinoma ( HCC ) by reconstruced CT images with 2 mm interval displayed on the CT monitor . Subjects and methods: Between August 1998 and March 1999, 474 consecutive HCC patients who had chronic liver disease were examined with dual-phase helical CT. 18 patients with the number of nodules exceeding 20 were excluded.therefore 456 patients were enrolled in this study. All of them were performed on a helical CT( Radix Prima; Hitachi Medical, Tokyo) ; Ioparnidol ( 3OOmg/ml,Iopamilon 300; Japan Shering ) was used as the contrast medium and infused into an antecubital vein at a rate of 3mllsec by automatic injector. Scanning was initiated 33 sec after starting injection of contrast medium as a early-phase, and 120 sec as a delayed-phase. Helical CT was performed with a section thickness of 5 mm and a table feed speed of 5-7 mmlsec ; all images ( aroundI50-200 images) were obtained with 2 mm interval, and these were alternately and consecutively displayed on the monitor between early phase and delayed phase in a craniocaudal directon. The reviewer found out HCC nodules paging CT images on the monitor. Results: In 456 patients , 656 nodules were detected by 2mm reconstructed CT; 568 of 656 ( 90% ) were less than 20 mm in diameter. To further characterize the identified nodules in 61 patients, ultrasonography ( SSD-2000; Aloka.Tokyo ) could identify 82 of the1l4 small nodules ( less than 20 mm ) detected by 2mm reconstructed CT. Pathological examination confirmed 62 nodules ( 85% ) of the 73 on which biopsy was performed under the ultrasonography, being malignant. Out of the 114 nodules, 32 small nodules were unidentified by ultrasonography ; 9 nodules were followed up by CT , then natural growth was found in 3, Lipiodol was accumulated in 1 and malignacy was proven by biopsy in 1 nodule within 1-13 month ( Ave. 4.9 Mo ). Conclusion: Two-mm reconstructed CT is a useful to detect small hepatocellular carcinoma as a routine use, and identified nodules could be simply followed , unless otherwise proven malignant.