Yasuo Tsuchiya

Clinicopathological prognostic factors and impact of surgical treatment of mass-forming intrahepatic cholangiocarcinoma.

The clinicopathological characteristics relevant to prognosis after surgical treatment of intrahepatic cholangiocarcinoma (ICC) remain unclear. In this study, the clinicopathological features of 19 patients with mass-forming ICC, the most common form of the disease, were reviewed to analyze prognostic determinants. Two or more segmentectomies of the liver with systematic lymphadenectomy were performed in 18 patients. Resection of the extrahepatic bile duct was performed in 14 patients, and reconstruction of the portal vein was accomplished in 5 patients. Stage IVA or IVB tumors were seen in 13 patients, and lymph node (LN) metastasis was present in 14 patients. The estimated 5-year survival rate after surgery for mass-forming ICC was 28%, with median survival time of 18 months. In univariate analysis, five variables were determined to be significantly correlated with poor survival of patients with mass-forming ICC after surgery. These variables include mass-forming ICC with periductal infiltration, perineural invasion, portal vein invasion, presence of intrahepatic metastasis, and two or more LN metastases. Survival rates of 5 patients without LN metastasis and 6 patients with a single LN metastasis were 80% and 33% at 5 years, respectively, while 8 patients with two or more LN metastasis failed to survive beyond 2 years. Multivariate analysis revealed the presence of intrahepatic metastasis to be an independent prognostic factor of poor survival. Hepatectomy with resection of the extrahepatic bile duct and systematic lymphadenectomy yields a good chance for prolonged survival for patients with mass-forming ICC when the lesion is singular and LN metastasis is limited to a regional LN. Because the presence of intrahepatic metastasis was closely related to a poor prognosis in patients with mass-forming ICC, efficacious chemotherapy would be needed to control development of the lesion.RésuméLes caractéristiques clinicopathologiques influençant le pronostic après traitement des cholangiocarcinomes intra-hépatiq.ues (CIH) ne sont pas claires. Dans cette étude, les caractéristiques clinicopathologiques chez 19 patients porteurs de CIH à forme tumorale, la forme la plus fréquente, ont été analysés à des fins pronostiques. On a réalisé une segmentectomie de deux segments ou plus avec lymphadénectomie systématique chez 18 patients, une résection des voies biliaires extra-hépatiques chez 14 et une reconstruction de la veine porte chez 5 patients. Treize patients avaient une tumeur stade IVA ou IVB; 14 avaient des métastases ganglionnaires. La survie à 5 ans après chirurgie pour CIH à forme tumorale a été de 28%; la médiane de survie a été de 18 mois. En analyse univariée, on a trouvé cinq variables significativement associées à une survie médiocre chez les patients opérés de CIH à forme tumorale. Ces variables sont un CIH avec infiltration péricanulaire, un envahissement perineural, un envahissement portai, la présence de métastases hépatiques, et des métastases de deux ganglions ou plus. La survie de cinq patients sans métastase ganglionnaire et de six patients avec une seule métastase ganglionnaire ont été, respectivement, de 80% et de 33% à 5 ans, alors qu’aucun des huit patients avec deux métastases ganglionnaires ou plus n’a survécu au-delà de deux ans. En analyse multivariée, la présence de métastases intrahépatiques était un facteur indépendant de mauvais pronostic. Une hépatectomie avec résection des voies biliaires extra-hépatiques associée à un curage lymphatique systématique améliore les chances de survie prolongée en cas de CIH à forme tumorale lorsque la lésion est unique et les métastases ganglionnaires sont limitées à un seul ganglion lymphatique régional. Puisque la présence de métastases intrahépatiques est étroitement en rapport avec un mauvais pronostic chez les patients porteurs de CIH à forme tumorale, une chimiothérapie efficace est nécessaire pour contrôler l’évolution.ResumenTras el tratamiento quirúrgico, las características clínicopatológicas pronósticas más importantes para los pacientes con colangiocarcinomas intrahepáticos (ICC) son poco conocidas. En este estudio se revisan las características clínicopatológicas más frecuentes en 19 pacientes con grandes tumores ICC, con objeto de determinar los factores pronósticos más importantes. 18 casos fueron tratados mediante dos o más segmentectomías hepáticas y linfadenectomía sistemática. En 14 pacientes se procedió a la resección y subsiguiente reconstrucción de la vía biliar extrahepática y en 5 de la vena porta. 13 pacientes pertenecían al estadio IV A o IV B y adenopatias metastásicas (LN) se registraron en 14 enfermos. Tras el acto quirúrgico el porcentaje medio estimado de supervivencia a los 5 años fue del 28%, con un tiempo de supervivencia de 18 meses. En pacientes con ICC que cursan con una tumoración macroscópicamente visible y palpable, el análisis univariante detectó 5 variables significativas por lo que a la escasa supervivencia se refiere: tumoración ICC con infiltración periductal, invasión perineural o de la vena porta, existencia de metástasis intrahepáticas y 2 o más adenopatías (LN) metastásicas. La supervivencia a los 5 años de 5 pacientes sin metástasis ganglionares (LN) y con una sola adenopatía metastásica fue del 80% y 33%, mientras que 8 pacientes con dos o más adenopatias metastásicas (LN) no sobrevivieron más de 2 años. El análisis multivariante demostró que las metástasis intrahepáticas constituyen un factor pronóstico independiente, de escasa supervivencia. La hepatectomía con resección de la vía biliar extrahepática asociada a una sistemática linfadenectomia puede, con suerte, prolongar la supervivencia de pacientes con tumores ICC palpables, cuando la tumoración es única y las adenopatias metastásicas son exclusivamente regionales. Dado que la presencia de metástasis intrahepáticas es signo de mal pronóstico, se precisa una eficaz quimioterapia para controlar el desarrollo de este tumor.

Portal Vein Thrombosis Caused by Microwave Coagulation Therapy for Hepatocellular Carcinoma: Report of a Case

Abstract Microwave coagulation therapy (MCT) is one of the treatment modalities for patients with hepatocellular carcinoma (HCC). A 67-year-old man with liver cirrhosis underwent MCT during a laparotomy for a deeply located HCC (2.5 cm in diameter) at the border of the anterior and posterior segments of the right hepatic lobe. Two weeks after MCT, he complained of abdominal fullness. Portal vein thrombosis (PVT) was diagnosed because he had massive ascites and an echogenic mass in the portal vein on abdominal ultrasonography. PVT was successfully treated by fibrinolytic therapy with a selective infusion of urokinase via the superior mesenteric artery (SMA). There have been few reports on PVT as a complication of MCT. Attention should be paid to the possible occurrence of PVT as a critical complication after MCT for liver tumors adjacent to the portal vein. Fibrinolytic therapy via the SMA is thus considered to be an effective approach for PVT after MCT.

Double cancer of the gallbladder and common bile duct associated with an anomalous pancreaticobiliary ductal junction without a choledochal cyst: report of a case.

We report herein the case of a 37-year-old woman found to have double cancer of the gallbladder and common bile duct associated with an anomalous pancreaticobiliary ductal junction (APBDJ) without a choledochal cyst (CC). Abdominal ultrasonography showed an isoechoic mass in the gallbladder, and percutaneous transhepatic biliary drainage tubography revealed incomplete obstruction in the upper portion of the common bile duct and APBDJ. The patient underwent cholecystectomy, partial hepatic resection, pancreatoduodenectomy, and portal vein reconstruction. Pathological examination of the tumors from the gallbladder and bile duct revealed papillary carcinoma and poorly differentiated adenocarcinoma, respectively, and direct continuity was not observed between the tumors. A review of the literature on six cases of multiple primary carcinoma of the biliary tract associated with APBDJ without CC is presented following this case report. Double cancer of the biliary tract was found synchronously in five patients and metachronously in one. Gallbladder cancer showed subserosal invasion in four patients, while bile duct cancer invaded the pancreas in one patient and reached the serosa in two patients. Considering the potential for cancer to arise in the biliary tract and the difficulties associated with monitoring it, cholecystectomy and resection of the extrahepatic common bile duct may be the most appropriate treatment for patients with an APBDJ without a CC.

The roles of platelet-activating factor and endothelin-1 in renal damage after total hepatic ischemia and reperfusion.

BACKGROUND This study was designed to verify the involvement of platelet-activating factor (PAF) in renal damage associated with hepatic ischemia and reperfusion (HIR) injury through the release of endothelin (ET)-1 and to determine the modulating effect of a specific PAF receptor antagonist on these insults in rats. METHODS Male rats pretreated with either normal saline as a vehicle (NS group) or intravenous TCV-309, a PAF receptor antagonist (TCV group), were subjected to 120 min of total hepatic ischemia under an extracorporeal portosystemic shunt. Plasma aspartate transaminase, creatinine, blood urea nitrogen, and ET-1 levels and the relative renal wet weight were determined under nonischemic conditions and at 1, 3, and 6 hr of reperfusion after hepatic ischemia. Changes in mean arterial blood pressure and renal tissue blood flow measurements in the kidney were determined throughout the experiment. RESULTS Increased plasma aspartate transaminase, creatinine, blood urea nitrogen, and ET-1 levels and the relative renal wet weight after HIR in the NS group were significantly suppressed by TCV-309 pretreatment. Mean arterial blood pressure and renal tissue blood flow after HIR in the TCV group were significantly improved when compared with those in the NS group. These effects resulted in attenuation of structural hepatic and renal damage with the improvement of 7-day survival (62%). CONCLUSIONS The present study demonstrates that renal damage as well as critical liver injury is produced after reperfusion following 120 min of total hepatic ischemia. A PAF receptor antagonist may be therapeutically useful to protect against these types of damage via indirect modulation of plasma ET-1 levels.

Impact of endothelin-1 on microcirculatory disturbance after partial hepatectomy under ischemia/reperfusion in thioacetamide-induced cirrhotic rats

BACKGROUND Endothelin (ET)-1 contributes to hepatic ischemia and reperfusion (HIR) injury in normal liver. This study was conducted to clarify the role of ET-1 in HIR injury in cirrhotic state. MATERIALS AND METHODS Using thioacetamide-induced cirrhotic rats with spontaneous portosystemic shunt, we determined the changes in plasma aspartate aminotransferase (AST) levels, plasma and hepatic ET-1 values, 7-day survival rates, and hepatic oxygen saturation (SO(2)) by time-resolved spectroscopy as an indicator of hepatic microcirculation under intermittent or continuous total hepatic ischemia with subsequent partial hepatectomy. RESULTS Hepatic ET-1 levels in cirrhotic rats were significantly higher than those in noncirrhotic rats. Plasma and hepatic ET-1 levels at 1, 3 and 6 h of reperfusion after intermittent hepatic ischemia were significantly lower than those after continuous hepatic ischemia. In cirrhotic animals subjected to intermittent hepatic ischemia, the elevation of plasma AST levels at 1, 3 and 6 h of reperfusion and the decline in hepatic SO(2) at the end of 60-min hepatic ischemia and after reperfusion were significantly suppressed when compared with those subjected to continuous hepatic ischemia. Pretreatment with a nonselective endothelin receptor antagonist in continuous hepatic ischemia significantly ameliorated plasma AST levels and hepatic SO(2) values with less hepatic sinusoidal congestion, resulting in an improvement in the 7-day survival rate. CONCLUSIONS Continuous hepatic ischemia in the cirrhotic liver has disadvantages relating to microcirculatory derangement with more ET-1 production in partial hepatectomy. In liver surgery, pharmacological regulation of ET-1 production may lead to attenuation of reperfusion injuries for ischemically damaged cirrhotic liver.