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Background/purpose: According to the General rules for the clinical and pathological study of primary liver cancer, compiled by the Liver Cancer Study Group of Japan, ruptured hepatocellular carcinoma (HCC) is classified as stage 4, even if the tumor is small and solitary. We examined the long-term results of elective hepatectomy for the treatment of ruptured HCC., Methods: A first hepatectomy was performed without operative death in 193 patients with HCC. Ten patients had ruptured HCC (ruptured group) and 183 patients had nonruptured HCC (nonruptured group). The extension of HCC was macroscopically classified as stage 1 in 23 patients, stage 2 in 71, stage 3 in 53, and stage 4 in 46., Results: Cumulative survival rates in the ruptured group at 1, 5, and 10 years were 90.0%, 67.5%, and 20.3%, respectively. The cumulative survival rate was lower in patients with stage 4 disease in the nonruptured group than that in patients in the ruptured group (P < 0.05). Cumulative survival rates did not differ significantly between patients in the ruptured group and those with stage 2 or stage 3 disease., Conclusions: Survival rates after elective hepatectomy in patients with ruptured HCC are good, even if the disease is classified as stage 4.

Background/aims: 5-fluorouracil (5-FU)-related metabolic enzymes, including dihydropyrimidine dehydrogenase (DPD), thymidylate synthase (TS), thymidylate phosphorylase (TP), and orotate phosphoribosyl transferase (OPRT) are initial, rate-limiting enzymes in the metabolism of 5-FU. The therapeutic implications of these enzymes in hepatocellular carcinoma (HCC) remain poorly understood. We used a newly developed laser-captured microdissection technique combined with RNA extraction to examine the mRNA levels of 5-FU-related metabolic enzymes in HCC and adjacent liver tissue., Methodology: The study material comprised 43 paired specimens of HCC and adjacent liver tissue. The mRNA levels of 5-FU-related metabolic enzymes were quantified by real-time reverse-transcriptase polymerase chain reaction combined with laser-captured microdissection., Results: The DPD mRNA level in HCC (4.31 +/- 4.21) was lower than that in adjacent liver (6.53 +/- 2.93) (p < 0.001). The TS mRNA level in HCC (3.55 +/- 2.54) was higher than that in adjacent liver (1.90 +/- 0.11) p < 0.001). The TP and the OPRT mRNA levels did not differ significantly between HCC and adjacent liver. The TS mRNA level of HCC with portal invasion (4.47 +/- 2.76) was higher than that of HCC without portal invasion (2.71 +/- 1.96) (p = 0.015). The DPD mRNA level of HCC with septum formation (4.89 +/- 4.82) was significantly higher than that of HCC without septum formation (2.12 +/- 0.61) (p < 0.027). The OPRT mRNA level of poorly differentiated HCC (1.18 +/- 0.49) was lower than that of moderately or well-differentiated HCC (2.42 +/- 1.82) (p = 0.037)., Conclusions: The DPD mRNA level was lower and the TS mRNA level was higher in HCC than in adjacent liver. Our results will hopefully stimulate further investigations designed to optimize the use of 5-FU in patients with HCC.

A case of hepatocellular carcinoma (HCC) causing a major arterioportal (A-P) shunt is reported. The patient exhibited massive ascites and tested positive for hepatitis B surface antigen. An abdominal computed tomography (CT) examination showed a low-density lesion in the left lobe of the liver and an A-P shunt, but no tumor stain was visible. Upper gastrointestinal endoscopy revealed severe esophageal varices. Because the tumor marker level was abnormally high, an HCC causing an A-P shunt in a cirrhotic liver background with severe esophageal varices as a result of portal hypertension was diagnosed. We performed endoscopic variceal ligation to treat the severe esophageal varices and interventional radiology treatment for the A-P shunt and HCC, but the patients condition was unchanged. Because the patients liver function gradually improved, surgical treatment was selected. The patient underwent left hepatectomy. Pathological examination revealed a poorly differentiated HCC in a cirrhotic liver background. The postoperative course was uneventful, and the patient was discharged 2 weeks after the operation. The patient subsequently underwent transcatheter arterial embolization therapy for recurrent HCC in the right lobe of the liver, but the esophageal varices disappeared.

Background: The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors., Patients and Method: A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia) at our hospital. Five patients who had received laparoscopic hepatectomy (Lap-Hx group) were compared with 5 patients who had undergone open hepatectomy (O-Hx group) in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision, a microwave coagulation device and an ultrasonically activated scalpel were used., Results: Mean patient age was 55.6 +/- 13.9 years in the Lap-Hx group and 51.8 +/- 14.1 years in the O-Hx group. Four patients in the Lap-Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O-Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 +/- 1.5 cm in the Lap-Hx group and 3.0 +/- 1.8 cm in the O-Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap-Hx than in the O-Hx groups(213 +/- 82 vs 247 +/- 97 min; 154 +/- 128 vs 648 +/- 468 ml, p=0.05: and 10.4 +/- 2.3 vs 18.0 +/- 5.1 days, p=0.017), but operating time did not differ significantly., Conclusions: Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors, in particular, hepatocellular carcinoma in the cirrhotic liver.

Background/aims: The effectiveness of intraoperative adjuvant therapy for satellite lesions of nonresectable hepatocellular carcinoma (HCC) was investigated., Methodology: We randomly assigned 30 eligible patients with advanced-stage HCC with multiple intrahepatic lesions who underwent reduction hepatectomy in conjunction with either intraoperative adjuvant therapy (hepatectomy plus microwave coagulonecrotic therapy or radiofrequency ablation) or postoperative adjuvant therapy (transcatheter arterial embolization). The cumulative survival rates were obtained for both groups using the Kaplan-Meier method and compared using the log-rank test. To evaluate whether the intraoperative adjuvant therapy significantly influenced the prognosis, we reviewed changes in clinical factors by multiple regression analysis using the Cox's proportional hazard model. Ap value of less than 0.05 was considered statistically significant., Results: The 3- and 5-year cumulative survival rates in patients who underwent intraoperative adjuvant therapy were 35.7% and 7.7%, while those in patients who underwent postoperative adjuvant therapy were 35.0% and 0%, respectively. The difference was not statistically significant. The level of a-fetoprotein, maximum tumor size, number of tumors, and clinical stage were found to be independent factors affecting survival after diagnosis. Intraoperative adjuvant therapy was not an independent prognostic factor., Conclusions: The survival rates did not differ between the patients who underwent intraoperative adjuvant therapy and postoperative adjuvant therapy for satellite lesions of non-resectable HCC.

Background/aims: We performed a randomized trial to evaluate whether fixation of the greater omentum to the peritoneum prevents delayed gastric emptying and other complications after left-sided hepatectomy., Methodology: Patients undergoing left lateral segmentectomy or left hepatectomy were randomly assigned to a fixation group (n=24) and a non-fixation group (n=25). In the fixation group, the greater omentum was sutured to the peritoneum to prevent the stomach from contacting the cut surface of the liver., Results: Delayed gastric emptying developed in 4 of the patients in the non-fixation group (16%) versus none of the patients in the fixation group. According to univariate analysis, fixation significantly lowered the risk of delayed gastric emptying (p<0.05). The overall morbidity was higher in the non-fixation group (20.0%) than in the fixation patients (8.3%) without significance., Conclusions: Fixation of the greater omentum to the peritoneum decreased the occurrence of delayed gastric emptying following left-sided hepatectomy.

A 73-year-old male with C type liver cirrhosis and poor liver function reserve was diagnosed with hepatocellular carcinoma (HCC)(Segment V, 2 x 2 cm in diameter) and underwent open microwave coagulation therapy (MCT). Ten months later, a movable hard mass about the size of a quail egg was palpable at the left supra-clavicular lymph node (LN)(Virchow's LN) and blood tests revealed an elevated serum alpha-fetoprotein (AFP) level of 26.7 ng/dl. Abdominal and chest CT showed no evidence of recurrence in liver or lung, and no metastases of abdominal LN. Barium and bone scintigraphy revealed no abnormal spots. The affected left supra-clavicular LN was extirpated. The tumor was confirmed to be an LN metastasis from HCC by histopathological examination. After the operation, the patient developed uncontrollable pleural effusion and ascites, and intrahepatic and abdominal LN metastases were visible on abdominal CT with great haste. He died 1.5 months after the LN was extirpated. We herein report a case of HCC treated by MCT which later resulted in a solitary Virchow's LN metastasis in the absence of any abdominal LN or recurrence in the liver or lung.

We report 2 cases of metachronous liver metastases from gastric cancer and 1 case of hepatocellular carcinoma (HCC) that are treated with a hepatic arterial infusion (HAI) to control the progression of local liver tumor. The treatments consist of HAI of epirubicin and mitomycin C plus degradable starch microspheres (DSM) to achieve temporary vascular occlusions. Hepatic resections were not performed in all cases because of the appearance of multiple liver metastases, or the hepatic vascular occlusion in 2 cases of gastric cancer, and the liver damage in the case of HCC. Therefore, HAI with DSM is useful for the evaluation of the hepatic resection in controlling of the local liver tumor.

We report a case of hepatocellular carcinoma with situs inversus totalis treated by hepatectomy. A 70-year-old asymptomatic female with hepatocellular carcinomas in segments 5, 6 and 8 underwent transarterial embolization in the department of medicine. However, hepatocellular carcinoma in segment 8 relapsed, and she was referred to the department of surgery. Laboratory tests revealed elevation of serum PIVKA2 level (4,690 ng/mL). Angiography revealed tumor stain in segment 8, 3 cm in diameter. No aberrant vessels were detected on angiography. The operator stood on the patient's left, and partial hepatectomy could be performed safety after careful examination of the anatomy. Although aberrant vessels are detected in many patients with situs inversus totalis, operations can be performed safely on them with sufficient understanding of the anatomy.

Background/aims: Resection is the treatment of choice for hepatocellular carcinoma. However, relatively few patients with hepatocellular carcinoma are surgical candidates. The efficacy of a radiologic hepatectomy, achieved by combined embolization of the arterial and portal tumor blood supply, was determined and compared to surgical hepatectomy in a retrospective analysis., Methodology: The records of 32 patients treated for hepatocellular carcinoma between 1989 and 1992 were reviewed. The outcome in 15 patients treated with combined selective segmental portal vein embolization and hepatic artery embolization without hepatectomy (Embolization group) was compared with the outcome in 17 patients who under went curative hepatic resection (Resection group). The recurrence-free and cumulative survival rates were compared in the two groups., Results: Except for a greater number of men in the Resection Group (p=0.03), the demographics and clinical characteristics of the two groups were similar at baseline. There was no patient who died within 30 days of treatment. The recurrence-free survival rates after embolization and resection were 20.8 and 23.4% at 5 years, respectively. The corresponding cumulative survival rates were 23.2 and 51.3%., Conclusions: Combined embolization without hepatectomy may be a viable alternative to curative hepatectomy for selected patients with hepatocellular carcinoma.

Background/aims: We introduced an ultrasonic surgical aspirator with electrosurgical coagulation to increase safety of the liver resections performed for hepatocellular carcinoma., Methodology: This system was evaluated by analyzing the intraoperative blood loss, the duration of hepatectomy, the ischemia time, and the postoperative clinical course and comparing these same parameters with the traditional forceps' fracture method., Results: There was no significant difference in the duration of surgery and the mean liver resection time between the two methods. The mean blood loss by using this system was 2458 +/- 4742 mL and by forceps' fracture method 956 +/- 252 mL. The mean ischemia time was 44.4 +/- 35.9 min by using this system and 23.9 +/- 29.1 min in forceps' fracture method. There was a significant decrease in intraoperative blood loss and ischemia time using the new system. This may decrease postoperative complications., Conclusions: This system may enable all surgeons to perform liver resection easily and safely.

Hepatocellular carcinoma rarely disseminates intraperitoneally. When it does, it usually is considered a terminal event. The successful treatment of complications of peritoneal metastases by surgical resection in a patient with hepatocellular carcinoma is reported. A 63-year-old man with hepatocellular carcinoma in the anterior segment underwent transarterial and portal embolization followed by extended radical hepatectomy. Five years and 8 months later, he presented with an ileus that was secondary to multiple peritoneal metastases that were resected to the extent possible. Eight months later, the patient presented with a second episode of ileus and underwent another operation that included bowel resection. However, pelvic tumors that were unresectable also were present. The patient survived for another 9 months before dying with peritoneal carcinomatosis. Although surgical treatment of peritoneal dissemination of hepatocellular carcinoma is not curative, surgery may improve survival and provide a good quality of life in selected cases.

A 67 year old male with non-resectable hepatocellular carcinoma (HCC) in both lobes and liver cirrhosis was treated with transcatheter arterial embolization and regional chemotherapy. He was doing well for 18 months. He was readmitted for fever, chest pain and multiple pulmonary metastases. During interleukin-2 therapy, he suddenly developed dyspnoea and palpitation, and was in shock. Left-sided haemothorax was confirmed by draining 3 L of fresh blood. In spite of intensive care, he died within 36 h. Autopsy showed that the haemothorax was caused by rupture of one of the metastases in the upper lobe of the left lung, and that the primary HCC was totally necrotic. Survey of the literature failed to find a report of fatal bleeding from a lung metastasis of HCC.