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Most surgeons perform laparoscopic left lateral sectionectomy (Lap LLS) using the caudo-peripheral approach (C-P approach). However, recently, a cranio-dorsal approach (C-D approach) has been applied to various types of hepatectomy owing to its advantage of preventing split injury. No studies yet have compared the perioperative outcomes of Lap LLS using each approach. Therefore, this study aimed to determine whether the C-D approach is useful for Lap LLS by comparing its perioperative outcomes with the C-P approach. Data of patients who underwent Lap LLS in our institution between 2010 and 2022 for liver tumors were retrospectively collected. We compared the perioperative outcomes of Lap LLS using a conventional C-P approach, which transects hepatic parenchyma in the caudo-peripheral direction and a C-D approach, which transects hepatic parenchyma in the cranio-caudal direction. All surgeries were performed only by board-certified expert surgeons to minimize technical bias. Furthermore, the perioperative procedures employed at our institution remained unchanged throughout the study period. A total of 36 patients were included in the study (C-P approach, n = 25; C-D approach, n = 11). The C-D approach showed a significantly shorter operation time than the C-P approach (median, 225 min vs. 262 min, p = 0.04). In addition, the C-D approach showed significantly lower blood loss than the C-P approach (median, 20 mL vs. 100 mL, p < 0.01). Other parameters, such as morbidity and hospital stay, were comparable between groups. The C-D approach could offer better surgical outcomes than the conventional C-P approach., (© 2023. Italian Society of Surgery (SIC).)

The standard treatment of locally advanced rectal cancer is preoperative chemoradiotherapy(CRT)in Europe and the United States, while that is surgical excision and lateral pelvic lymph node dissection followed by adjuvant chemotherapy in Japan. Recently, total neoadjuvant therapy(TNT), which combines neoadjuvant chemotherapy and preoperative CRT, have been popular. We performed curative excision for initially locally advanced rectal cancer with liver metastasis after TNT. A 61- year-old woman was diagnosed as having rectal cancer with liver metastasis and invasion of the uterus, vagina, bladder, and left ureter. The patient underwent 8 courses of FOLFOX plus bevacizumab, followed by radiotherapy, and totally pelvic excision for the primary tumor. Because of liver metastasis progression, hepatectomy was performed after 6 courses of FOLFIRI plus panitumumab. The patient has been cancer free for 20 months to date. TNT is considered to be an effective strategy for the treatment of large locally advanced rectal cancer.

Background and Aims: Immunotherapy has become the standard-of-care treatment for hepatocellular carcinoma (HCC), but its efficacy remains limited. To identify immunotherapy-susceptible HCC, we profiled the molecular abnormalities and tumor immune microenvironment (TIME) of rapidly increasing nonviral HCC., Approaches and Results: We performed RNA-seq of tumor tissues in 113 patients with nonviral HCC and cancer genome sequencing of 69 genes with recurrent genetic alterations reported in HCC. Unsupervised hierarchical clustering classified nonviral HCCs into three molecular classes (Class I, II, III), which stratified patient prognosis. Class I, with the poorest prognosis, was associated with TP53 mutations, whereas class III, with the best prognosis, was associated with cadherin-associated protein beta 1 (CTNNB1) mutations. Thirty-eight percent of nonviral HCC was defined as an immune class characterized by a high frequency of intratumoral steatosis and a low frequency of CTNNB1 mutations. Steatotic HCC, which accounts for 23% of nonviral HCC cases, presented an immune-enriched but immune-exhausted TIME characterized by T cell exhaustion, M2 macrophage and cancer-associated fibroblast (CAF) infiltration, high PD-L1 expression, and TGF-β signaling activation. Spatial transcriptome analysis suggested that M2 macrophages and CAFs may be in close proximity to exhausted CD8+ T cells in steatotic HCC. An in vitro study showed that palmitic acid-induced lipid accumulation in HCC cells upregulated PD-L1 expression and promoted immunosuppressive phenotypes of cocultured macrophages and fibroblasts. Patients with steatotic HCC, confirmed by chemical-shift MR imaging, had significantly longer PFS with combined immunotherapy using anti-PD-L1 and anti-VEGF antibodies., Conclusions: Multiomics stratified nonviral HCCs according to prognosis or TIME. We identified the link between intratumoral steatosis and immune-exhausted immunotherapy-susceptible TIME., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The effect of hepatic steatosis on the development of colorectal liver metastases (CRLM) remains unknown. This study evaluated the usefulness of fat signal fraction assessed with magnetic resonance imaging (MRI) and the effect of hepatic steatosis on hepatic recurrences following initial hepatectomy for CRLM., Methods: Between January 2013 and December 2019, 64 patients underwent initial hepatectomy for CRLM. The medical records of these patients were reviewed to evaluate the recurrence and survival outcomes., Results: The fat signal fraction was positively correlated with the nonalcoholic fatty liver disease activity score and liver-spleen ratio. Recurrence following the initial hepatectomy was observed in 48/64 patients, and hepatic recurrence was observed in 30/64 patients. The fat signal fraction was significantly higher in patients with hepatic recurrence after initial hepatectomy. The hepatic recurrence rate was 69.2% in patients with fat signal fraction ≥ 0.0258, which was significantly higher than that in patients with fat signal fraction < 0.0258. Hepatic recurrence-free survival rate was significantly higher in patients with fat signal fraction < 0.0258 than in those with fat signal fraction ≥ 0.0258. Multivariate analyses revealed that fat signal fraction ≥ 0.0258 was an independent risk factor for hepatic recurrence., Conclusion: The fat signal fraction assessed with MRI was significantly associated with hepatic recurrence following initial hepatectomy for CRLM., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Advanced hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) has the worst prognosis among all phenotypes. This trial aims to evaluate whether treatment with durvalumab, alone or in combination with tremelimumab, plus particle therapy is a safe and synergistically effective treatment in patients with advanced HCC and MVI., Methods and Analysis: This phase Ib, multicentre (two sites in Japan), open-label, single-arm, investigator-initiated clinical trial will assess durvalumab monotherapy in combination with particle therapy (cohort A) and that of durvalumab plus tremelimumab in combination with particle therapy (cohort B) for patients with advanced HCC with MVI. Cohort A will receive 1500 mg durvalumab every 4 weeks. Cohort B will receive 1500 mg durvalumab every 4 weeks in principle and 300 mg tremelimumab only on day 1 of the first cycle. Carbon-ion radiotherapy will be administered after day 8 of the first cycle. The primary endpoints are rates of any and severe adverse events, including dose-limiting toxicities (DLTs); secondary endpoints are overall survival, 6-month survival, objective response, 6-month progression-free survival and time to progression. Patients are initially enrolled into cohort A. If cohort A treatment is confirmed to be tolerated (ie, no DLT in three patients or one DLT in six patients), the trial proceeds to enrol more patients into cohort B. Similarly, if cohort B treatment is confirmed to be tolerated (ie, no DLT in three patients or one DLT in six patients), a total of 15 patients will be enrolled into cohort B., Ethics and Dissemination: This study was approved by the ethics committees of the two participating institutions (Chiba University Hospital and National Institutes for Quantum (approval number: 2020040) and Radiological Science and Technology, QST Hospital (approval number: C20-001)). Participants will be required to provide written informed consent. Trial results will be reported in a peer-reviewed journal publication., Trial Registration Number: jRCT2031210046., Competing Interests: Competing interests: SO has received honoraria from Bayer, Eisai, Eli Lilly and Chugai Pharma and research funding from Bayer, Eisai, Eli Lilly and AstraZeneca. NK has received honoraria from Bayer, Eisai, Eli Lilly and Chugai Pharma and research funding from Bayer, Eisai and Eli Lilly., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Creating a good surgical visual field is one of the most important factors for performing a successful surgery. Here, we introduce a useful technique for creating a good liver parenchymal visual transection plane during laparoscopic partial hepatectomy and compare the perioperative outcomes of our current technique with those of conventional techniques., Methods: We reviewed the data of patients who underwent laparoscopic partial hepatectomy between July 2016 and December 2020. The current technique for creating transection planes was first applied in our department in April 2019. The patients were divided into conventional (forceps) and current (silicone ring) technique groups, depending on the surgical technique., Results: Twenty-eight and 12 patients underwent laparoscopic partial hepatectomy using the conventional and current techniques, respectively, when the difficulty level-as determined by IWATE criteria-was low. Although the tumor size was significantly larger (median: 22.5 vs. 15 mm, P=0.04) in the current technique group, the estimated intraoperative blood loss was significantly lower (median: 50 vs. 100 mL, P=0.01), and the median surgical margin was significantly longer (median: 7 vs. 3 mm, P=0.02). There were no significant between-group differences in surgical time (median: 344 vs. 240 min, P=0.14), postoperative hospital stay duration (median: 11 vs. 9.5 d, P=0.051), and the incidence of complications (P=0.63)., Conclusion: We believe that the technique involving the use of a silicone ring can result in better surgical outcomes as it provides a good visual hepatic transection plane during laparoscopic partial hepatectomy., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The clamp crushing method and the use of the Cavitron ultrasonic surgical aspirator (CUSA) are widely accepted techniques for hepatic parenchymal transection. The actuator-driven pulsed water jet (ADPJ) with high tissue selectivity is a new technology that was shown as a safe transection tool in preclinical models, although not much is known about its safety criteria in patients. Therefore, its strongest advantage, the best indications for its use, and its performance in comparison with other transection methods remain to be clarified. In this report, we present several representative cases to help answer these questions., Methods: We started using the ADPJ in December 2017, only in cases where the tumor was very close to major vessels or attached to them, along a considerable length, to preserve vessels and prevent postoperative liver failure. All the cases underwent highly demanding procedures. We avoided using this device in cases such as liver cirrhosis, where the hepatic parenchyma was very hard., Results: Six cases fulfilled our limited indications for using ADPJ. The median age and number of tumors were 55 years (10 to 69 y) and 2.5 years (1 to 4 y), respectively. The mean tumor size was 7.8 cm (2.8 to 21 cm), the minimum distance between the tumor and major vessels to be preserved was 0 mm (0 to 4 mm), and the contact length of the tumor and major vessels was 26 mm (19 to 40 mm). Regarding the surgical outcome, the median operation time and blood loss were 559 minutes (508 to 919 min) and 620 mL (230 to 860 mL), respectively. We achieved a negative surgical margin (R0 resection) in all cases., Conclusions: Using ADPJ, we could perform R0 hepatectomy in all cases, which preoperatively were considered to have a high chance of being margin positive. We consider the best indication for using ADPJ is when the tumor and vessels to be preserved are attached or very close over a long distance.

Background: The indications for the surgical treatment of gastric cancer liver metastases (GCLMs) remain controversial. In addition, the outcome of surgery for the treatment of liver metastases of alpha-fetoprotein-producing gastric cancer (AFP-GC) has not yet been reported. We assessed the clinicopathologic features, including AFP-GC, and the surgical results of these patients., Methods: This retrospective study analyzed 20 patients who underwent hepatectomy for GCLM at Odawara Municipal Hospital between April 2006 and January 2016., Results: The actuarial 1-, 3-, and 5-year overall survival (OS) rates after primary hepatectomy were 80.0%, 55.5%, and 31.7%, respectively, with a median OS of 42 months. Four patients survived for more than 5 years after their final hepatectomy procedures. A multivariate analysis showed multiple metastases in the liver, the elevated level of carbohydrate antigen 19-9 (CA19-9), and an age of less than 70 years to be independently associated with a poor prognosis in terms of OS. No significant differences were noted between the AFP-GC and AFP-negative GC groups., Conclusion: Surgical treatment is therefore considered to be a feasible option for GCLM. The findings of the present study showed the number of metastatic liver tumors, the level of CA19-9, and the patient age to be prognostic indicators for the surgical treatment of GCLM.

Objective: Chemotherapy is generally recommended as the first-line standard treatment in patients with liver metastasis from gastric cancer. However, the clinical impact of surgical treatment remains unclear in responders after chemotherapy. The present study aimed to investigate the tumor response and prognosis after chemotherapy and to assess the clinical indication of conversion surgery in responders., Methods: The study retrospectively reviewed the clinical data of 44 patients with liver metastasis from gastric cancer who were treated with chemotherapy between February 2002 and January 2019. These patients were classified into progressive disease (PD) and non-PD groups according to tumor response., Results: Among the 44 patients, 7 and 26 had peritoneal dissemination and ≥5 had metastatic liver nodules. Additionally, 15 and 29 patients had PD and non-PD, respectively. Surgical treatment was significantly correlated with tumor response (p < 0.0321). Prognostic differences between the PD and non-PD groups were significant (p < 0.0001). Moreover, gastrectomy and hepatectomy were significantly correlated with the number of liver metastases (≥5 vs. <5, respectively) in the non-PD group (p = 0.0025 and p = 0.0169, respectively). The 3-year survival rates among patients with non-PD undergoing both gastrectomy and hepatectomy (n = 6), gastrectomy alone (n = 7), and nonsurgical treatments (n = 16) were 100, 66.7, and 0%, respectively (p = 0.0026). Multivariate analysis identified peritoneal dissemination as an independent prognostic factor (p = 0.0225)., Conclusion: Our preliminary results suggest that conversion surgery for gastric cancer with liver metastasis might be clinically indicated in chemotherapy responders with <5 metastatic liver nodules and without peritoneal dissemination., (© 2020 S. Karger AG, Basel.)

A 78-year-old woman underwent left total mastectomy for breast cancer at 65 years of age.Thirteen years after the primary surgery, CT showed a single 46mm tumor located in liver segment 4.The tumor was difficult to distinguish between cholangiocellular carcinoma and liver metastasis of the breast cancer.We did not perform biopsy, considering dissemination, and performed left hemihepatectomy and left caudate lobectomy.Pathological findings revealed liver metastasis of breast cancer.Hepatic resection is a useful option in cases of single liver metastasis from breast cancer that are difficult to distinguish from cholangiocellular carcinoma.

Background: The aim of this study was to establish a new scoring system for hepatocellular carcinoma (HCC) that can be used to predict the postoperative prognosis of HCC patients., Methods: A total of 359 HCC patients who underwent hepatectomy were included in this study. All eligible patients were randomly allocated to derivation cohort or validation cohort samples. We assigned one point each for preoperative factors identified in the derivation cohort, and the sum of the scores was used to classify the patients into high-risk and low-risk groups. The scoring system established using the derivation cohort was fitted to the validation cohort., Results: The prognosis of the high-risk group was significantly poorer than that of the low-risk group in both the derivation and validation samples (p = 0.04, p < 0.01, respectively). In the high-risk group, major hepatectomy resulted in a significantly better prognosis than minor hepatectomy in both samples (p = 0.04, p = 0.03, respectively). On the other hand, the extent of hepatectomy did not influence the prognosis of the low-risk group in either sample (p = 0.14, p = 0.34, respectively)., Conclusion: Our new scoring system can predict the treatment outcome of patients undergoing curative hepatectomy for HCC and could help determine the optimal extent of resection., (Copyright © 2019. Published by Elsevier Ltd.)

Long non-coding RNAs (lncRNAs) are aberrantly expressed in many disease conditions, including cancer. Accumulating evidence indicates that some lncRNAs may play critical roles in cancer progression and metastasis. Here, we identify a set of lncRNAs that are upregulated in metastatic subpopulations isolated from colon cancer HCT116 cells in vivo and show that one of these lncRNAs, which we name CALIC, is required for the metastatic activity of colon cancer cells. We show that CALIC associates with the RNA-binding protein hnRNP-L and imparts specificity to hnRNP-L-mediated gene expression. Furthermore, we demonstrate that the CALIC/hnRNP-L complex upregulates the tyrosine kinase receptor AXL and that knockdown of CALIC or AXL using shRNA in colon cancer cells attenuates their ability to form metastases in mice. These results suggest that the CALIC/hnRNP-L complex enhances the metastatic potential of colon cancer cells., (© 2019 The Authors.)

Background/aim: High mobility group box-1 (HMGB1) induces the release of proinflammatory cytokines and chemokines as a late-acting mediator of inflammation. Hepatocellular carcinoma (HCC) is a typical inflammation-related cancer. However, little is known about the relationship between HCC and HMGB1 and its receptor RAGE (receptor for advanced glycation end products). This study analyzes the clinicopathological relevance of HMGB1 expression level and the effect of HMGB1 expression on the characteristics of HCC., Materials and Methods: Samples from 75 HCC patients including 13 with positive hepatitis B surface antigen and 36 with hepatitis C antibody were studied. The expression of HMGB1 in paired cancer and non-cancerous tissues from patients with HCC was assessed using reverse-transcription polymerase chain reaction (RT-PCR) and western blotting. Quantitative RT-PCR data were analyzed in association with the clinicopathological factors of patients with HCC., Results: The expression of HMGB1 mRNA in HCC was high in well-differentiated tumors, but declined as tumors dedifferentiated to moderately and poorly differentiated HCC. The levels of HMGB1 mRNA showed a negative correlation with the presence of portal invasion (p=0.005) and the rise of serum PIVKA-II (p=0.034). There was no clear correlation between HMGB1 expression and proliferation activity of HCC using Ki-67 staining., Conclusion: In HCC, HMGB1 expression level correlated inversely with tumor differentiation. The RAGE-HMGB1 interaction may play a greater role in the early stages of HCC tumorigenesis than during cancer development., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

A 24-year-old woman was admitted to the hospital for abdominal pain. Abdominal contrast-enhanced computed tomography( CT)revealed a cystic mass measuring 11×8 cm in the left lobe of the liver with extravasation. Vascular embolization was performed, but extravasation remained on CT images. She was then transferred to our hospital. We performed an emergency extended left hepatectomy. Histopathological examination revealed solid proliferation of spindle-shaped cells. Immunohistochemical staining showed that the tumor cells were positive for vimentin and negative for AE1/AE3. Thus, a diagnosis of undifferentiated sarcoma was confirmed. Multiple recurrent tumors were recognized on CT images of the lung and right atrium taken 1 year and 10 months post-surgery. Partial resection of the tumor was performed for the right atrial mass, the left lingular segment, the left inferior lobe, and the right middle lobe. Pathological diagnosis confirmed metastasis of undifferentiated sarcoma from the liver. Chemotherapy consisting of vincristine, actinomycin D, and cyclophosphamide(VAC) was not effective, and the patient died 31 months after the primary surgery. Undifferentiated sarcoma of the liver is a rare malignant mesenchymal tumor, whose occurrence is extremely rare in adults. Although surgical treatment is the first choice, outcomes remain poor. Multimodality treatment should be used to improve the outcome.

The patient was a woman in her 50's. She went to the hospitalfor epigastric discomfort. Numerous hypovascular tumors spreading almost to the entire liver were detected via abdominal CT. We diagnosed the tumors as unresectable intrahepatic cholangiocarcinoma(ICC). Chemotherapy with gemcitabine(GEM)and S-1 was given. The tumors shrunk markedly, and stable disease status was maintained for 2 years and 4 months. Thereafter, the regimen was changed to GEM plus cisplatin (CDDP)because of progressive disease, which was then uncontrolled. Although proton beam therapy and radiofrequency ablation were subsequently performed, multiple lesions appeared in the liver, and metastasis was also observed shortly in the left lung. Right hepatic trisegmentectomy and thoracoscopic left lung partial resection were performed in 2 stages. Histopathological findings showed morphological hepatocellular carcinoma(HCC)as well as positive immunostaining with CEA, CK7, and CK19. The final diagnosis was combined hepatocellular-cholangiocarcinoma. The patient is without recurrence for 9 months following operation, and long-term survivalfor 4 years and 6 months has been obtained.

A 52-year-old man was initially diagnosed with an unresectable acinar cell carcinoma of the pancreas with liver metastasis and involvement of the superior mesenteric artery. After 5 courses of systemic chemotherapy(gemcitabine and S-1), the size of the pancreatic tumor had decreased from 31mm to 19mm and the liver metastasis had disappeared. We initiated chemoradiotherapy( CRT: S-1+56 Gy)for further local treatment. After CRT the size of the pancreatic tumor decreased to 13mm and his serum CA 19-9 level decreased from 677.2 U/mL to 38.1 U/mL. After 2months of S-1 administration, we performed subtotal stomach-preserving pancreaticoduodenectomy with D2 lymph node dissection. Histopathological examination revealed that most of the pancreatic cancer was replaced by fibrosis and only a few atypical epithelial cells existed. No cancer cells were found at the surgical margin. The patient remains alive without any signs of recurrence 59 months after the systemic chemotherapy and 51 months after the surgical resection.

Sorafenib has been a standard therapy for advanced hepatocellular carcinoma (HCC) with portal vein thrombosis. Hepatic arterial infusion chemotherapy (HAIC) is still preferably performed in Japan because of its relatively good tumor-shrinking effect. We report a case of advanced multiple HCC with portal thrombus that responded to combination chemotherapy with sorafenib and repeat hepatic arterial infusion with a fine-powder formulation of cisplatin (IA-call®). A 57-year-old man presented for the treatment of HCC with alcoholic cirrhosis. Multiple HCC were found to be rapidly progressing with portal thrombosis. HAIC with IA-call® was performed, but the tumors progressed. TAE was performed 3 times thereafter and the main tumor shrunk to some extent. A month after the last TAE, the HCC was found to progress again, and oral sorafenib was administered. A reservoir and catheter were placed and HAIC with low-dose 5-fluorouracil and cisplatin was performed for 3 cycles following 1 HAIC cycle with epirubicin and mitomycin C, which was not effective. For 10 months after initial therapy, HAIC using IA-call® has been performed once for 6 weeks. After performing HAIC with IA-call® 5 times, the serum levels of HCC tumor markers AFP and PIVKA-Ⅱdecreased, and the tumors continued to shrink and were not stained on enhanced CT scan. The patient has been alive for 23 months after the initial therapy and has maintained stable disease.

Background: The estimation of recurrence risk remains a critical issue in relation to gastrointestinal stromal tumors (GISTs) treated with adjuvant therapy. The accuracy of the commonly used risk stratifications is not always adequate., Methods: For this study, data were prospectively collected from 68 patients with GISTs who underwent R0 surgery between 2004 and 2009. The results from this analysis cohort were evaluated using the data obtained from an additional 40 patients in the validation cohort. Cyclin-dependent kinase 1 (CDK1)- and CDK2-specific activities were measured using a non-RI kinase assay system., Results: The specific activities of CDK1 and CDK2, but not their expression, significantly correlated with recurrence. The specific activities of both CDK1 and CDK2 were independently correlated with mitosis and significantly correlated with recurrence-free survival (RFS). In the multivariate analysis, CDK2-specific activity (P = 0.0006), tumor size (P = 0.0347), and KIT deletion mutations (P = 0.0006) were significantly correlated with RFS in the analysis cohort. In the validation cohort, CDK2-specific activity (P = 0.0368) was identified as an independent prognostic factor for tumor recurrences with tumor location (P = 0.0442)., Conclusion: The results suggest that the specific activities of CDK1 and CDK2 may reflect the proliferative activity of GISTs and that CDK2-specific activity is a good prognostic factor predicting recurrence after macroscopic complete resection of GISTs.

Purpose: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC), and consequently laparoscopic hepatic resection is widely performed. However, most anatomical resections, except left lateral sectionectomy, remain difficult technically, and laparoscopy-assisted procedures have been introduced as an alternative approach because of the safety and curative success of the operation. We reported previously pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites. Herein, we describe pure anatomical laparoscopic segmentectomy using the puncture method with indocyanine green (ICG) injection under laparoscopic US., Patients and Methods: Pure laparoscopic segmentectomy was planned for 2 patients with HCC of the liver. Identification of the segment was performed by ICG injection for optical imaging using near-infrared fluorescence under laparoscopic US guidance., Results: The procedures were completed successfully, and the postoperative courses were uneventful., Conclusions: Pure laparoscopic segmentectomy for HCC with a conventional puncture technique by ICG injection under laparoscopic US is considered to be a useful procedure featuring both low invasiveness and curative success.

Case 1 involved a 63-year-old woman who had multiple hepatocellular carcinomas (HCC) associated with hepatitis C virus infection. She was treated with hepatic arterial infusion chemotherapy (HAIC) and transcatheter arterial chemoembolization (TACE), followed by oral administration of sorafenib (200 mg/day). However, a lesion on the left lateral segment of the liver enlarged rapidly. Laparoscopic left lateral sectionectomy was performed. Histopathological examination revealed combined hepatocellular and cholangiocellular carcinoma. Case 2 involved a 54-year-old man who had multiple recurrent HCCs associated with hepatitis C virus infection after undergoing hepatectomy twice. Oral administration of sorafenib (200 mg/day) was initiated. The intrahepatic lesions decreased in size, but metastasis in an enlarged lymph node behind the portal vein was suspected. Laparoscopic partial hepatectomy and lymph node dissection were performed. HCC metastasis in the lymph node and partial necrosis in the intrahepatic lesions were identified histopathologically. Case 3 involved a 56- year-old man who had multiple recurrent HCCs associated with hepatitis C virus infection. TACE was performed thrice, and oral administration of sorafenib( 400-600 mg/day) was initiated. The lesion in the right lateral segment of the liver decreased in size but lesions in the left lateral segment were enlarged. Therefore, laparoscopic left hemihepatectomy was performed.

Purpose: It is important to minimize surgical invasiveness in the therapy of patients with hepatocellular carcinoma (HCC) and, consequently, laparoscopic hepatic resection is widely performed. However, most anatomic resections, except left lateral sectionectomy, are still difficult technically and, as an alternative approach, laparoscopy-assisted procedures also have been introduced because of the safety and curative success of the operation. Herein, we describe pure laparoscopic subsegmentectomy of the liver using puncture of the portal branch under percutaneous ultrasound (US) with artificial ascites., Methods: Pure laparoscopic subsegmentectomy of segment 6 (S6) was planned for a patient with HCC of S6 of the liver. The identification of the segment was performed by dye injection under percutaneous US guidance with artificial ascites., Results: The procedure was completed successfully in a minimally invasive manner with an operative time of 260 minutes and with intraoperative blood loss of 10 mL. The difference between the size of the resected specimen and that estimated by 3-dimensional computed tomography was very small. The postoperative course was uneventful and the patient was discharged 10 days after surgery., Conclusions: Pure laparoscopic subsegmentectomy for HCC with a conventional puncture technique under percutaneous US with artificial ascites is considered to be a useful procedure featuring both low invasiveness and curative success.

Background: Surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is associated with superior oncological outcome in comparison with percutaneous RFA. The present study aimed to retrospectively evaluate the relative perioperative safety and postoperative outcome of the laparoscopic or thoracoscopic approach versus the open approach to RFA for small HCC., Methods: A retrospective analysis was performed in 55 consecutive patients who underwent open (n = 32) or laparoscopic/thoracoscopic (LTS) RFA (n = 23) for primary unresectable HCC between January 2005 and December 2010. Baseline characteristics, survival/recurrence rates, and complications after treatment were compared between the two groups., Results: There was a trend showing that LTS RFA was performed for tumors located in the anterior segment (e.g., segments III, V, VIII). The LTS RFA group had a significantly lower intraoperative blood loss, shorter operative time, and shorter postoperative hospital stay, compared with the open RFA group. No major postoperative complications occurred in patients who underwent LTS RFA. No significant differences in overall survival, recurrence-free survival and local recurrence rates were observed between the two groups., Conclusions: In consideration of operative invasiveness and postoperative recovery, LTS RFA is superior to the open approach in patients with small HCC. Moreover, the surgical outcome did not differ between the two approaches. Laparoscopic/thorascopic RFA can be considered to be a useful procedure for ablation therapy.

A spontaneous regression of hepatocellular carcinoma is an extremely rare phenomenon. A 69-year-old Japanese man with hepatitis C virus-related chronic hepatitis presented with a liver tumor. We diagnosed the tumor to be hepatocellular carcinoma in the course of spontaneous regression, by imaging studies and changes in the tumor markers. Because the possible presence of viable cancer cells could not be ruled out, we recommended surgery. He refused all treatments at first, but finally agreed to undergo surgery about 10 months after presentation. A hepatectomy was performed. Histologically, no viable tumor cells were found. In our case, the vascularity of the tumor according to the imaging findings was followed up during the clinical course. The patient is now doing well and without any evidence of recurrence at 37 months after surgery.

A 62-year-old female patient was hospitalized for general fatigue and appetite loss. Type 3 gastric cancer (moderate differentiated adenocarcinoma) with liver metastasis (S8) and direct invasion to the retro-peritoneal space and duodenal third portion was detected by endoscopic and radiographic examination. This case was judged to be unresectable from these findings. TS-1 plus divided administration of CDDP was performed. TS-1 (100 mg/day) was administrated from day 1 to 21 followed by 14 days rest as one course. CDDP (20 mg/m2) was infused for 2 hours on day 1, 8, and 15. One course was done in the hospital, and the following 2 courses as ambulatory treatment. Grade 2 neutropenia was observed as an adverse reaction. At the completion of 3 courses, partial response in the primary tumor, complete response in the duodenal third portion and no change in the liver metastasis were assessed by examination. Because of this remarkable down-staging, distal gastrectomy and radiofrequency ablation (RFA) for liver metastasis were performed. There was no evidence of direct invasion to the other organs from the primary tumor in intraoperative findings. Pathological examination revealed the disappearance of carcinoma cell in the resected stomach and the surrounding lymphnodes. In conclusion, this chemotherapy regimen has an excellent antitumor effect with low toxicities. Therefore, this regimen was comparatively safe for outpatients and was an effective neo-adjuvant chemotherapy.

Perchloric acid-soluble protein (PSP) is a members of a new hypothetical family (YER057c/YJGF family) of small proteins with presently unknown function. The high degree of evolutionary conservation of these proteins reflect an involvement in basic cellular regulation. The expression of PSP was examined in rat hepatoma cell dRLh 84-beared rats. The tumor weight increased to 4.24 g at 3 weeks after the transplantation of hepatoma cells and hepatoma which has less differentiated characteristics were observed in rat liver. The expression of PSP in rat hepatoma was down regulated as compared with intact tissue. Thus the expression of PSP seems to be associated with the differentiation process in these transformed cells. On the other hand, some positive cells against the PSP-antibody were observed in the central region of tumor tissue by immunohistochemistry. These cells were shown to be the lymphocytes and the macrophages. The involvement of PSP to cellular growth and differentiation is discussed.

We report a case of advanced gastric cancer producing Alpha Fetoprotein (AFP) with multiple liver metastases in which TS-1 is effective. Prognosis of gastric cancer producing AFP is well known to poor. A 74-year-old female was admitted complaining of anemia. She was diagnosed as having advanced gastric cancer with multiple liver metastases producing AFP by endoscopy, computed tomography and angiography. Her serum AFP level was 17,666 ng/ml and her serum CEA level was 5-2 ng/ml. After transarterial embolization (TAE), her family rejected her operation because it would not be curative. So, she was treated with TS-1, 40 mg, administered orally every day, followed by 14 days rest, as the first course. The next was TS-1, 80 mg orally administered for 6 courses. Her serum AFP level was down from 17,666 ng/ml to 94 ng/ml after 6 courses of TS-1. CT revealed that liver metastases did not change and endoscopy showed the primary lesion has diminished. Our report is the first to demonstrate that TS-1 is effective for patients with advanced gastric cancer producing AFP with multiple liver metastases.

The rate of clearance (K value) of 99mTc tin colloid in the liver differentiates normal subjects from liver cirrhosis patients; so 99mTc tin colloid is as useful as 198Au colloid as a marker of liver function. There are several reports concerning volume estimation using liver scintigraphy. Our original method was devised to measure the effective liver volume by scintigraphy. By combining the K value with effective liver volume, a predictive index was obtained in order to predict the residual liver function before hepatic resection. The index in 24 patients with liver diseases was investigated before hepatic resection. Three of them died due to hepatic failure after hepatic resection. The indices were between 0.40 and 0.45 in two of these three patients and 0.338 in one. Among the patients without hepatic failure, the indices showed more than 0.45 in 19 patients and between 0.40 and 0.45 in two. These results indicate that the limitation of hepatic resection is between 0.40 and 0.45 of the predictive index.