Yoshiyuki Fujiwara

The Clinical Significance of Alpha-Fetoprotein mRNAs in Patients with Hepatocellular Carcinoma

Background/Aims: Alpha-fetoprotein (AFP) mRNA-expressing cells are candidates for circulating tumor cells in hepatocellular carcinoma. We analyzed portal vein blood, peripheral blood, and peritoneal lavage samples to detect the presence of AFP mRNA-expressing cells, and explored their relationship with metastasis. Methods: We measured the AFP mRNA expression in 112 sets of portal vein and peripheral blood samples and 61 peritoneal lavage samples that had been obtained during surgery. We estimated the change in the positive ratio of patients with AFP mRNA, the associated background factors, and the rate of recurrence. Results: The change in AFP mRNA positivity in the peripheral blood specimens was remarkable, while that in the portal vein blood and peritoneal lavage samples was similar during hepatectomy. Tumor location was the only factor associated with AFP mRNA positivity. The rate of recurrence was higher in the patients who were positive for AFP mRNA than in those who were negative 9-24 months after hepatectomy. During this limited period, the recurrence rate in the AFP mRNA-positive cases was significantly higher than that in the AFP mRNA-negative cases (p = 0.0472). Postoperative AFP mRNA positivity was not related to very early recurrence (0-9 months) or multicentric liver carcinogenesis (>24 months). Conclusion: AFP mRNA positivity in the peripheral blood was elevated after hepatectomy, and the elevation depended on the tumor location. AFP mRNA positivity might contribute to recurrence-free survival 9-24 months after hepatectomy.

Combined analysis of the pre- and postoperative neutrophil–lymphocyte ratio predicts the outcomes of patients with gastric cancer

PurposeThe neutrophil–lymphocyte ratio (NLR) is a biochemical marker of the systemic inflammatory response and has been associated with prognosis for various types of cancer. This retrospective study investigates the relationship between the pre- and postoperative NLR and the prognosis of gastric cancer patients.MethodsThe subjects were 280 patients who underwent curative surgery for histopathologically diagnosed gastric adenocarcinoma.ResultsThe preoperative NLR was significantly correlated with tumor size, tumor depth, lymphatic invasion, venous invasion, and disease stage. In contrast, there was no correlation between the postoperative NLR and the various clinicopathological variables. Prognosis was significantly worse for patients with a high preoperative NLR than for those with a low preoperative NLR. Prognosis was also significantly worse for patients with a high postoperative NLR than for those with a low postoperative NLR. Furthermore, the prognosis was worse for gastric cancer patients whose pre- and postoperative NLRs were both high. Multivariate analysis indicated that a high pre- and postoperative NLR was an independent prognostic indicator.ConclusionsThe combination of pre- and postoperative NLRs appears to be useful for predicting the prognosis of gastric cancer patients.

Internal supravesical hernia repaired via the anterior approach alone: A case report

Highlights • Internal supravesical hernia is very rare.• Most previous reports performed closure of the hernial sac by open laparotomy.• We could successfully repair intraoperatively-diagnosed internal supravesical hernia by the anterior approach alone.

The attenuation value of preoperative computed tomography as a novel predictor for pancreatic fistula after pancreaticoduodenectomy

PurposePancreatic fistula (PF) is the most serious complication following pancreaticoduodenectomy (PD). This study was performed to identify new clinical factors that may predict the development of PF after PD to improve perioperative management.MethodsSeventy-five consecutive patients who underwent PD from 2012 to 2015 were evaluated. The patients’ perioperative data including the computed tomography (CT) parameters were collected. The minimum, maximum, and mean CT attenuation values (HUmin, HUmax, and HUmean, respectively) were extracted from the pancreatic parenchyma (≥ 100 pixels), and the standard deviation of these values (HUSD) was determined from the slice in which the superior mesenteric and splenic veins were merged. PF was defined as grade B or C according to the International Study Group for Pancreatic Fistula criteria.ResultsThe PF occurrence rate (grade B or C) was 25.3% in 75 patients. A multivariate analysis identified a larger HUSD (odds ratio 3.092; 95% CI 1.018–9.394) and higher amylase concentration in drainage fluid on postoperative day 1 (odds ratio 1.0001; 95% CI 1.00001–1.00022) as significant risk factors for PF.ConclusionsThe HUSD of preoperative CT attenuation values in the pancreatic parenchyma was found to be an independent predictor for PF after PD and it might therefore positively contribute to the perioperative management of PD.

Protoporphyrinogen oxidase is involved in the fluorescence intensity of 5-aminolevulinic acid-mediated laser-based photodynamic endoscopic diagnosis for early gastric cancer

BACKGROUND/AIM Laser-based photodynamic endoscopic diagnosis (LPDED) is a type of endoscopic diagnosis that uses the fluorescence caused by the photochemical reaction that occurs when a fluorescent substance is irradiated by a light of a specific wavelength. Although 5-aminolevulinic acid (5-ALA) can detect early gastric cancer (EGC) during LPDED, there is an unresolved issue of the differences in fluorescence intensity among histopathological types of gastric cancer. Thus, the aim of the present study was to assess whether protoporphyrinogen oxidase (PPOX), involved in the activation of protoporphyrin IX, can affect the fluorescence intensity in EGC. METHODS Thirty-three gastric tumor lesions in 30 patients were assessed by LPDED using a prototype endoscope equipped with a blue laser ray to cause excitation following oral 5-ALA administration. The tumors were then resected by endoscopic submucosal dissection or laparoscopic surgery. PPOX expression was examined immunohistochemically in the excised specimens. To explore the mechanisms of histopathological diversity in PPOX and coproporphyrinogen oxidase (CPOX) expression of EGC, immunohistochemical analysis was performed using 75 surgically resected specimens of diverse EGCs. RESULTS Among the 33 lesions, 26 tumors were detectable by LPDED, whereas seven were undetectable. Between the LPDED-positive and negative groups, there was a significant difference in histopathology. The expression of PPOX was higher in tubular adenocarcinoma (tub) than in signet-ring cell carcinoma (sig). There were significant differences in PPOX and CPOX expression scores of the surgically resected specimens among tub, poorly differentiated adenocarcinoma (por), and sig. CONCLUSION PPOX protein expression could be involved in the fluorescence intensity of LPDED in EGC, possibly reflecting histopathological features.

Prognostic value of postoperative complication for early recurrence after curative resection of hepatocellular carcinoma

BACKGROUND Postoperative complications may adversely affect oncological outcomes. The aim of this study was to evaluate the impact of postoperative complications on early-phase recurrence after curative resection for hepatocellular carcinoma (HCC). METHODS We included 145 HCC patients who underwent initial and curative resection between January 2004 and December 2013. Postoperative complications of grade III or higher based on Clavien-Dindo classification were defined as clinically relevant postoperative complications. Recurrence within two years after hepatectomy was defined as early-phase recurrence. RESULTS Thirty-eight patients (26%) developed postoperative complications. The only predictive factor for postoperative complication was longer operative duration (P = 0.037). The disease-specific survival rate of patients with complication was lower than that of patients without complications (P = 0.015). Early-phase recurrence was observed in 20/38 (53%) patients who suffered postoperative complications and 36/107 (34%) patients with no complications, which was statistically significant (P = 0.039). Multivariate analysis identified four factors contributing to early-phase recurrence: high serum AFP level (P = 0.042), multiple tumors (P < 0.001), poor differentiation (P = 0.036) and presence of postoperative complication (P = 0.039). CONCLUSIONS Postoperative complication is an independent prognostic factor for early-phase recurrence after curative resection of HCC. Close observation of patients with postoperative complications may be a necessary treatment strategy for HCC.

Focal nodular hyperplasia that mimicked a liver metastasis from a soft tissue sarcoma: a case report

BackgroundImaging modalities (computed tomography (CT), ultrasonography, and magnetic resonance imaging (MRI)) have only limited ability to distinguish liver focal nodular hyperplasia (FNH) from metastatic liver tumors. Here, we report a patient who underwent surgery for benign FNH that mimicked a liver metastasis from soft tissue sarcoma (STS).Case presentationA 23-year-old man with a history of several surgeries for metastatic abdominal STS, developed a hepatic tumor accompanying peritoneal STS recurrence. He was diagnosed with a metastatic liver tumor from the STS, based on imaging studies for the hepatic tumor that showed a growing hypervascular lesion and hypo-intensity in hepatic phase on dynamic CT and MRI. However, when the liver and peritoneal tumors were resected, histological diagnosis showed the hepatic tumor to be benign liver FNH.ConclusionsAlthough FNH should be considered as a differential diagnosis for hypervascular hepatic tumors, it has few typical findings, and its appropriate management is controversial. A lesion strongly suspected of being a metastatic liver tumor might require surgical resection.

Resection of rectal cancer resembling submucosal tumor that was preoperatively diagnosed with endoscopic ultrasound-guided biopsy

BackgroundColorectal cancer (CRC) resembling submucosal tumor (SMT; CRC/SMT) is very rare. Because its biopsy is challenging, accurate preoperative diagnosis is also very rare.Case presentationA 55-year-old woman with a high serum carcinoembryonic antigen level underwent a computed tomography colonoscopy, which showed extrinsic rectum compression. A coronal magnetic resonance image showed a 4-cm low-intensity tumor between her rectum and sacrum. Endoscopic ultrasound (EUS) showed a 30-mm low-echoic lesion originating from the rectum. Pathological examination of specimen obtained with EUS-guided fine-needle aspiration biopsy (EUS-FNAB) revealed adenocarcinoma. Immunohistochemical staining showed the tumor to be positive for both CK20 and CDX2 and negative for CK7, indicating that it was a rectal cancer. We performed a laparoscopy-assisted low-anterior resection with dissection of the regional lymph nodes after eight chemotherapy cycles. Macroscopically, tumor was completely covered by normal rectal mucosa, but showed a 2-mm bulge on the mucosa. Histological examination revealed a moderately differentiated adenocarcinoma, mainly located at the subserosal layer and severely invaded to lymphatic and blood vessels. The mucosal layer was not exposed to the cancer components, and her postoperative course was uneventful.ConclusionEUS-FNAB was useful in preoperative accurate diagnosis of this very rare tumor. We also review the literature and discuss CRC/SMT.