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We report a case of survival for nearly 8 years after treatment of unresectable multiple liver metastases from colon cancer, using microwave ablation and the nontoxic antitumor agent, the antineoplastons. A 72-year-old man diagnosed with adenocarcinoma of the ascending colon and 14 bilateral liver metastases underwent a right hemicolectomy combined with microwave ablation of six metastatic liver tumors. We also decided to give antineoplastons to inhibit metastatic tumor growth and recurrence. Antineoplaston A10 was given intravenously, followed by oral antineoplaston AS2-1. Computed tomography scans done 1 and 4 years after the initial diagnosis showed recurrent tumors in S(4) and S(7), respectively. The patient underwent a second and a third microwave ablation of the recurrent tumors, and has survived for nearly 8 years without suffering any serious adverse effects. He is currently free from cancer. This case report demonstrates the potential effectiveness of the nontoxic antitumor agent, the antineoplastons, for controlling liver metastases from colon cancer.

症例は60歳,女性.平成13年10月他院で左乳癌に対して胸筋温存乳房切除術が施行された.同時に多発肝転移を認めたため,術後化学療法を勧められたが,本人が手術を強く希望し,当九州医療センター肝臓病センター外科を受診.肝両葉の計16個の肝転移に対して平成13年11月外側区域切除,尾状葉切除,マイクロ波凝固壊死療法(以下, MCN)を行った.術後,トラスツズマブとパクリタキセルを投与し,肝転移術後13カ月の現在,再発の徴候は認めていない.乳癌肝転移は肝切除の適応にならないという意見がこれまで支配的であり,全身化学療法などが施行されるのが一般的であったが,今回われわれは多発肝転移に対して肝切除術とMCNを組み合わせたvolume reduction surgeryを先行し,術後に全身化学療法を行うことで良好な結果を得た1例を経験したので報告した.

最近われわれは十二指腸原発gastrointestinal stromal tumor (GIST)の2例を経験したので報告する.症例1: 75歳,女性.右側腹部圧迫感で紹介入院.十二指腸造影および上部内視鏡検査にて十二指腸下行部～水平部の移行部に,粘膜面の変化を伴わない分葉状の隆起性病変を認めた. CT, MRI,血管造影検査所見を考慮し非上皮性腫瘍(GIST疑い)の診断で手術施行した.術中所見では肝転移,腹膜播種,リンパ節転移は認めなかった.大きさは11×11×8 cmであった.症例2: 58歳,男性.人間ドックの際上部消化管造影にて異常を指摘され当科紹介となる.精査にて十二指腸水平部に辺縁平滑な3 cm大の管腔内に突出する隆起性病変を認めた.非上皮性腫瘍(GIST疑い)の診断で手術施行した.手術は2例とも十二指腸局所切除術を行った.術後病理組織診断は十二指腸原発GIST (uncommitted type)で,症例1は悪性,症例2は良性と診断した.

This paper presents a case of hemangioma of the small intestine, which is relatively rare, in a 63-year-old woman complaining of anemia. She had been treated for anemia since 1993 when no other abnormalities were revealed on examinations of the stomach and large intestine. In 1996, anemia took a turn for the worse again and an oral fluoroscopy of the small intestine revealed abnormality in the ileum. So the patient was referred to the hospital. After admission, a sounding to the small intestine disclosed a nodular protrusion in the ileum. CT scan visualized a segmented tumor with calcification having marginal irregularity in the small intestine. With a diagnosis of small bowel tumor, the patient was operatec on. At operation, a soft tumor, with the size of about 3cm, about 170cm oral to the terminal ileum was palpated, and distended vessels on serosa were confirmed. Macroscopically, hemangioma was suspected and a partial excision of the ileum was carried out. Histopathological diagnosis was hemangioma of the small intestine. In the treatment of patients with anemia without any abnormalities in the esophagus, stomach, duodenum and large intestine, we must conduct close examination of the small intestine by entertaining the possibility of the disease.

Deep abdominal lymph node enlargement has been detected by ultrasound examination in patients with hepatitis C virus (HCV) infection. To clarify the potential for extrahepatic existence and/or replication of HCV in such abdominal lymph node, positive- and negative-strand HCV RNA were investigated in abdominal lymph node mononuclear cells (MNC) as well as in the serum of patients with HCV. The study population consisted of eight hepatocellular carcinoma (HCC) patients positive for antibody to HCV (anti-HCV). Lymph nodes of hepatoduodenal ligament were resected at surgery for HCC. Both HCV RNA strands were examined using highly strand-specific r Tth reverse transcription-polymerase chain reaction (r Tth RT-PCR) followed by Southern blotting analysis. Positive-strand HCV RNA was detected in three (37.5%) abdominal lymph node MNC and in seven (87.5%) serum samples. Negative-strand HCV RNA was not detected in abdominal lymph node MNC, while it was observed in two (25%) serum samples. Histologically, the lymph nodes taken from subjects showed reactive follicular hyperplasia with or without the presence of HCV RNA. These observations suggest that HCV is located in the abdominal lymph nodes, but does not replicate within them. Negative-strand HCV RNA detected in serum samples may have been due to contamination with circulating HCV RNA from hepatocytes.

To clarify whether pre-operative transcatheter arterial embolization (TAE) improves survival after hepatectomy, a prospective randomized comparative study was done. Of a total of 115 registered patients having solitary hepatocellular carcinoma (HCC) 2 to 5 cm in diameter, 18 (15.7%) were excluded after randomization. As a result, 97 patients were chosen as subjects and divided into two groups: hepatectomy with (group A: n=50) and without (group B: n=47) pre-operative TAE. The period of observation of the patients who survived the surgery was between 4.0 and 6.6 years. The randomization appeared to have provided well-balanced groups of patients and the clinico-pathological characteristics of the two groups were quite similar. The necrotic part of the cancerous lesions, as confirmed by operative specimens, amounted to 74.8+/-33.4% (mean +/-SD) in group A and 6.8+/-7.2% in group B (P

Hilar bile duct resection, by which only the bile duct is resected, was carried out in 31 patients with bile duct carcinoma at the hepatic hilus. However, curative resection was possible in only 4 patients (12.9%). The postoperative 1-, 3-, and 5-year survival rates were 58.1%, 19.4%, and 7.7%, respectively. These results indicate that treatment of this hilar bile duct carcinoma by hilar bile duct resection is of limited value. We believe that this operative procedure should be used only for papillary or nodular carcinoma at the hepatic confluence at relatively early stages of Bismuth's type I or II.

This report is based on an analysis of the recurrent patterns and post-treatment clinical outcome of 78 patients following hepatectomy for hepatocellular carcinoma (HCC). Patients with a single recurrent tumor (group A;n=41) often had multicentric carcinogenesis (41.7%) and were treated locally; i.e., by re-resection or by percutaneous ethanol injection therapy (PEIT). Many of them (42.9%) followed the “curative pattern,” with good prognosis (70.3% 5-year survival rate). Although 6 of the patients with two or three recurrent tumors (group B;n=19) had multicentric carcinogenesis that could be treated locally, 13 of the 19 followed the “non-curative pattern,” with a poor prognosis after recurrence (14.8% 3-year survival rate after recurrence). The primary tumors of the patients with multiple or infiltrating type (group C;n=18) were advanced and these patients had metastatic recurrence, thereby following the “early death pattern” (58.8%) with a poor prognosis (30% 5-year survival rate). For group C patients, hepatectomy was regarded as part of a multidisciplinary treatment regimen that included aggressive postoperative chemotherapy as a necessary component.

A 62-year-old woman being treated for chronic hepatitis C and high blood pressure was shown by computed tomography to have tumors in the lateral and medial segments of her liver, and in her right breast. The tumor in the lateral segment of the liver was excised, the tumor in the medial segment of the liver was treated with microwave coagulation therapy, and the breast tumor was treated with simple mastectomy and sentinel lymph-node biopsy. Based on pathological features, the liver tumors were classified as moderately differentiated liver cell carcinoma, and the breast tumor as estrogen receptor-negative, progesterone receptor-negative, and human epidermal growth factor receptor-2-positive ductal carcinoma. Hepatic arterial infusion chemotherapy using fluorouracil and cisplatin with trastuzumab as an adjuvant was administered to treat both cancers simultaneously. Twelve months after the operation, neither of the cancers had relapsed. This case suggests that when the breast cancer is human epidermal growth factor receptor-2-positive, trastuzumab should be administered as adjuvant therapy.

Nutritional states of Japanese patients with liver cirrhosis have recently shown great diversity, some show protein energy malnutrition and others excessive nutrition and obesity. For there to be adequate guidance regarding dietary treatment, it is important that a patient's current nutritional state be clarified.We assessed nutritive intake in Japanese cirrhotic patients and determined their nutritional problems. Subjects were non-hospitalized patients with hepatitis C virus (HCV)-related cirrhosis in the compensated stage (n=47), chronic hepatitis C (n=46) or healthy volunteers (n=32). A brief self-administered diet history questionnaire was conducted with assistance from a registered dietitian.We categorized patients with cirrhosis according to daily intake of energy and protein; 10.6% had an energy and protein intake within a normal range, 72.4% showed excessive intake, and 17.0% showed insufficient intake of energy or protein. In cirrhotic patients with diabetic complications, the intake levels of energy, proteins, fat and carbohydrates were significantly higher than in patients without diabetes. Moreover, cirrhotic patients had significantly higher intake levels of energy, protein and fat than did chronic hepatitis C patients and healthy individuals. In patients with HCV-related liver cirrhosis, insufficient intake of energy and protein was shown in some, while many, especially those with diabetes, showed excessive intake.For nutritive management of cirrhotic patients, the intake of various nutrients should be appropriately assessed and effective nutritional education systems established.

A 31-year-old woman was seen at the hospital because of a left palpated breast mass in September 1989, which had been noticed about 5 months before, but she did not consult with any hospitals. On physical examination a 40×30mm tumor was palpated in the left upper lateral portion of the left breast and a 21×10mm lymph node was also palpated in the left axillary. Ultrasonography of the breast visualized an irregular shaped tumor in the same portion with calcification internally. Biopsy cytology indicated carcinoma of the breast. Radical mastectomy was carried out on September 21, followed by postoperative radiation and drug regimen with carmoful and tamoxifen. The patient still alive, as of 3 years and 5 months after the operation. Histological findings of the excised tumor suggested ring cell carcinoma of the breast. This disease is so rare that only 20 cases have been seen in the Japanese literature. This paper present such a rare case with a review of the literature.

最近,腹部超音波診断法(ECHO)で,単発あるいは多発の肝内小結節性病変を指摘され,肝生検施行すると凝固壊死を伴う肉芽組織が採取され,質的診断が困難な症例を著者らの施設では,しばしば経験するようになった.このような凝固壊死を呈する肉芽性結節14例について検討した.対象とした14例は臨床的に2例を除きウイルスマーカーは陰性,腫瘍マーカーは全例が陰性であり,ECHOでは14例中10例(71.4%)が結節内に2本の線状エコー(bead sign)を有し,病理学的には凝固壊死と肉芽組織で構成され,凝固壊死部をさらに詳しく検討すると,著明な好酸球浸潤や14例中7例(50%)にCharcot-Leyden結晶が認められることから,寄生虫感染(特にイヌ・ネコ蛔虫症や肝蛭症)との密接な関連が示唆される病変である.

Antineoplaston AS2-1 exhibits cytostatic growth inhibition of human hepatocellular carcinoma cells in vitro and showed minimum adverse effects in a phase I clinical trial. Liver cancer is difficult to control because of multicentricity and underlying liver disease. We reviewed two clinical cases of liver cancer (hepatocellular carcinoma and multiple liver metastases from colon cancer) in whom we believe antineoplaston A2-1 was useful as a maintenance therapy after transcatheter arterial embolization (TAE) and microwave coagulation necrosis (MCN). The two patients have continued to be in good condition for more than two years without limitation of their normal activities. Antineoplaston AS2-1 may be effective and useful as a maintenance agent after TAE and MCN in patients with liver cancer.

Non-hepatitis B virus/non-hepatitis C virus-related hepatocellular carcinoma (NBNC-HCC) is often detected at an advanced stage, and the pathology associated with the staging of NBNC-HCC remains unclear. Data mining is a set of statistical techniques which uncovers interactions and meaningful patterns of factors from a large data collection. The aims of this study were to reveal complex interactions of the risk factors and clinical feature profiling associated with the staging of NBNC-HCC using data mining techniques. A database was created from 663 patients with NBNC-HCC at 20 institutions. The Milan criteria were used as staging of HCC. Complex associations of variables and clinical feature profiling with the Milan criteria were analyzed by graphical modeling and decision tree algorithm methods, respectively. Graphical modeling identified six factors independently associated with the Milan criteria: diagnostic year of HCC; diagnosis of liver cirrhosis; serum aspartate aminotransferase (AST); alanine aminotransferase (ALT); α-fetoprotein (AFP); and des-γ-carboxy prothrombin (DCP) levels. The decision trees were created with five variables to classify six groups of patients. Sixty-nine percent of the patients were within the Milan criteria, when patients showed an AFP level of 200 ng/mL or less, diagnosis of liver cirrhosis and an AST level of less than 93 IU/mL. On the other hand, 18% of the patients were within the Milan criteria, when patients showed an AFP level of more than 200 ng/mL and ALT level of 20 IU/mL or more. Data mining disclosed complex interactions of the risk factors and clinical feature profiling associated with the staging of NBNC-HCC.

Pulmonary metastasis is the most common type of extrahepatic recurrence of hepatocellular carcinoma (HCC). The outcome of pulmonary metastasectomy of HCC has not yet been thoroughly investigated. The outcomes of surgical treatment of pulmonary metastases from HCC were reviewed in order to analyze the postoperative survival and the relevant prognostic factors.This study retrospectively reviewed 20 patients who underwent pulmonary metastasectomy from an HCC between 1990 and 2007 at two institutions. The surgical outcome was evaluated by both the overall survival and cancer-specific survival after pulmonary resection. The association between various clinico-pathological factors and the survival outcome was analyzed.The overall survival rate after the initial pulmonary metastasectomy was 46.9% at 5 years, and the cancer-specific 5-year survival rate was 63.2%. One patient died of surgery-related events 19 days after the pulmonary resection. The preoperative AFP (alpha-fetoprotein) level was found to be a significant prognostic factor for both overall and cancer-specific survival for patients undergoing pulmonary metastasectomy. Both the overall and cancer-specific survival rates were significantly worse for the patients with AFP ≥ 500 ng/ml in comparison to those with AFP 500 ng/ml (p 0.05). No other factors were associated with the survival after pulmonary metastasectomy.The serum level of AFP might be a valuable predictor for the outcome of pulmonary metastasectomy required for metastasis of HCC.

Postoperative metachronous multicentric carcinogenesis of hepatocellular carcinoma (HCC) was studied by comparison of the histologic grade of resected and recurrent tumors in 31 cases which underwent ultrasound-guided fine-needle biopsies for the initial recurrent tumors with diameter of less than 20 mm. The criteria that the cases in which recurrent tumors show well-differentiated HCC without regard to the differentiation of resected tumors should be multicentric carcinogenesis, and that the cases in which recurrent tumors show moderate or poorly differentiated HCC with the same or lower degree of differentiation compared with the differentiation of resected tumor was consistent with metastasis, were applied. In 16 (51.6%) out of the 31 cases, multicentric carcinogenesis was thought to occur (multicentric group). In 14 cases, recurrence was thought to be metastasis (metastatic group). The multicentric group tended to have smaller diameters in resected tumors and a high incidence of the association of liver cirrhosis and adenomatous hyperplasia. In gross classification of resected tumors, six cases of all single nodular with perinodular tumor growth type and infiltrative type had metastatic recurrences, and multicentric carcinogenesis was often seen in cases of single nodular type, multinodular type and confluent multinodular type. In the multicentric group, recurrence occurred at every postoperative period as long as 65 months including four cases of early recurrence within 6 months and six cases of late recurrence later than 24 months. On the contrary, in 12 cases in the metastatic group the recurrent interval ranged from 6 to 19 months.

The patient was a 58-year-old male with small cell lung cancer [T2N1M1 (HEP) ED case] who was treated systemic chemotherapy with 2 courses of CDDP+CPT-11 and 3 courses of CBDCA+PTX. After 5 courses of chemotherapy, the total response was stable disease (SD). Because the primary lesion had achieved a minor response, however, liver metastasis evidenced no change. Because of his good performance status, he was immediately treated by hepatic arterial infusion chemotherapy ( HAI) using CPT-11 to control the liver metastasis. After the HAI of weekly CPT-11 during eleven months until progression of primary lung lesion, no change in size of the liver metastasis was recognized with decreasing ProGRP (18,400 --5,800). HAI is considered very useful for disease control without progression and for good quality of life.

Excepting operation-related deaths, including deaths within 30 days after operation and hospital deaths, and absolute non-curative resection cases, 171 resected cases of Hepatocellular carcinoma (HCC) were classified into 3 groups in terms of Kobayashi's risk score, namely, group A (score 7.5 or above; 29 cases), group B (7.4-6.0; 94) and group C (5.9 or below; 48). Results were: 1) The number of cases with a score of 6.0 or above was 123 out of 171 cases (71.9%). 2) In comparison with the other 2 groups, both postoperative survival rate and non-recurrent rate were significantly poor in group A (p

肝後下区域(S6)の腹側表面に,癌腫の一部が露出し存在した22×21mmの小肝細胞癌に対して,新たに開発した手術機器を用いて,本邦で初めて,腹腔鏡下マイクロ波凝固壊死療法を行ったところ,本法は,小肝細胞癌に対する新しい治療法として,有用と考えられたので報告した.症例は63歳,男性.肝機能,および凝固系検査の術後推移をみると,術後1日目に,GOTは423K.U, GPTは241K.U, T. Bil.は2.1mg/100mlと上昇した.また,術後,凍結血漿をまったく使用しなかったため,HPTは42%, PTは48.3%に低下した.しかし,すべての検査値は,術後7日目には術前値に復した.胃管は,術翌日には抜去し,2日目より食事を開始した.術後3週目に撮影したCTでは,治療部は癌腫を含め,著しくlow density areaに陥り,まったくenhanceされず,治療効果も充分であると判断された.また,術後合併症はまったく認められなかった.

The growth rates of recurrent hepatocellular carcinoma (HCC) after orthotopic liver transplantation (OLTX) were estimated by calculating the tumor doubling time (TDT) in 20 patients. The mean TDT, calculated by multiple measurement of tumor size, was 44.3 +/- 11.3 days (mean +/- standard error) in 12 patients with pulmonary metastasis (range, 10 to 161 days) and 37.6 +/- 8.9 days (range, 7 to 65 days) in 5 patients with liver allograft recurrence. The TDT as estimated by serum alpha-fetoprotein (AFP) levels in 6 patients was 37.3 +/- 10.0 days (range, 12 to 84 days). The mean TDT obtained from 5 control subjects with HCC who were treated with liver resection (without immunosuppression) was 273.8 +/- 79.1 days (range, 82 to 560 days). The disease-free period and survival time after OLTX both correlated well with the TDT (r = 0.546 and r = 0.701, respectively). The patients with fibrolamellar HCC had a greater TDT and a longer survival time than those with nonfibrolamellar HCC. Despite a wide range of TDT in patients who received transplants, their recurrent HCC tumors grew significantly faster than those of patients with the same disease who did not receive transplants. The factors involved in this accelerated growth rate may include the use of immunosuppressive drugs and the consequent suppression of host immunity against the growth of micrometastasis.

超音波検査にて高エコー像を呈する肝細胞癌の病理組織像について検討した.対象とした3cm以下の肝細胞癌切除例88例中,高エコー像を呈したのは34例(38.6%)であり,腫瘍径別では1cm以下では9例中1例,1.1～2.0cmでは38例中17例,2.1～3.0cmでは41例中16例と1.1～2.0cmで最も高頻度であった.高エコーの組織像としては,癌細胞の脂肪化20例,偽腺管構造6例,Peliosis hepatis様に拡張した血洞より成る6例,淡明細胞化および線維化が各1例にみられ,脂肪化によるものが最も高頻度であった.なお,脂肪化により高エコー像を呈した症例では,脂肪化は癌組織の1/3以上に認められるもので,また,高エコーを呈する偽腺管型肝細胞癌は偽腺管の嚢胞状拡張を伴うものに限られていた.

肝細胞癌に対し, 従来の肝流入血遮断法に併用して, パルーンカテーテルによる選択的肝静脈遮断を行って肝中央2区域切除を施行した. カテーテルは術中経肝的に超音波ガイド下に経皮経肝的門脈造影の際のカテーテル挿入手技に準じて, 右および中肝静脈それぞれに挿入した. 切除線右側の右肝静脈に沿った切除の際は, 肝門部でのグリソン氏輪右枝遮断に併用してバルーンによる右肝静脈根部の遮断を, 切除線左側の中および左肝静脈近傍に沿った切除の際は, Pringle法による流入血全遮断に併用して中肝静脈根部の遮断を行うことにより, 良好な無血術野が得られた. 肝授動も肝鎌状間膜の切離のみで切除しえた. 術中出血量は1,100mlで, 術後の肝機能推移も良好であり, 本法は系統的切除あるいは腫瘍が主幹肝静脈に接して存在する場合などで, 肝切除の際, 肝静脈からの出血が予想される例には有用な方法と思われた.

The number of elderly gastric cancer patients undergoing surgery is rapidly increasing because of the current aging society. To determine an effective surgical treatment method, the clinicopathological characteristics of such patients should therefore be clarified.Between 1979 and 2005, 2010 patients with gastric cancer underwent curative surgery in our institute. Clinicopathological characteristics of 109 patients in the elderly group (or = 80-years-old) were compared with those of 1901 patients in the young group (80-years-old).In the elderly group, cancers of the lower third of the stomach and differentiated types, and less-invasive surgery were common. The 5-year survival rate specific to gastric cancer was not significantly different between groups, but the overall 5-year survival rate including causes other than gastric cancer was significantly different (p0.01) at 82% in the elderly group and 67% in the young group.In the medical care of elderly gastric cancer patients, it is necessary to accurately determine the specific clinicopathological characteristics, and subsequently, an effective surgical treatment method.

Middle ligation (ML) of the inferior mesenteric artery (IMA) maintains adequate blood supply to an anastomosis and has no risk of autonomic nerve injury. If apical node dissection of the IMA improves the prognosis, ML and prophylactic dissection of the apical node without division of the IMA above the colic artery may also result in an additional prognostic improvement in patients with sigmoid colon or rectal cancer.Four hundred and one patients with either Dukes' B or Dukes' C colorectal cancer were clinicopathologically examined. In order to evaluate the influence of the prophylactic dissection of the apical node on the prognosis, the two groups of ML with and without apical node dissection were compared.The 5-year survival rates in the groups of ML and ML with apical node dissection were 90% and 91%, respectively, in 218 Dukes' B patients. The 5-year survival rates in the groups of ML and ML with apical node dissection were 73% and 71%, respectively, in 183 Dukes' C patients. There were no significant differences between the two groups in both Dukes' B and Dukes' C patients.When ML is adopted for patients with sigmoid colon or rectal cancer, additional dissection of the apical node is not needed.

Colorectal cancer patients without lymph node metastasis usually show a favorable prognosis with low recurrence rates; however, there is an increased risk of the development of a second primary cancer. Understanding the features of a second primary cancer is important to establish an effective postoperative follow-up program for colorectal cancer without lymph node metastasis.The clinicopathological data on 801 patients with Dukes' A and Dukes' B colorectal cancer were examined in respect to second primary cancer.In patients with Dukes' A cancer, the incidences of recurrence and second primary cancer were similar. When tumor invasion was limited within subserosa in Dukes' B patients, the incidence of a second primary cancer was almost two-thirds that of recurrence. More than half of the second primary cancers again developed from the colorectum, followed by stomach and lung.When colorectal cancer patients without lymph node metastasis show tumor invasion limited within the subserosa, postoperative follow-up should monitor a balance of recurrence with a second primary cancer.

Either hepatic resection, microwave coagulonecrotic therapy (MCN), or a combination of liver resection and MCN was performed in 166 patients with liver metastases from colorectal cancer. In 53 patients who underwent liver resection, the 1-, 3-, and 5-year actual survival rates were 85.0%, 51.2%, and 42.2%, respectively. In 77 who underwent MCN, the 1-, 3-, and 5-year actual survival rates were 82.8%, 46.7%, and 36.0%, respectively. In 34 who underwent both liver resection and MCN, the 1-, 3-, and 5-year actual survival rates were 84.2%, 41.6%, and 21.1%, respectively. The survival rates among the three groups did not differ significantly. Of 166 patients with liver metastases, 44 showed multiple liver metastases (H3). Of 44 patients with multiple liver metastases, 27 underwent MCN (mean tumor diameter 27.2 mm, mean number of tumors 11.2), and the 1-, 3-, and 5-year actual survival rates were 73.1%, 31.3%, and 25.1%, respectively. Of 44 patients with multiple liver metastases, 17 underwent both liver resection and MCN (mean tumor diameter 41.9mm, mean number of tumors 8.1), and the 1-, 3-, and 5-year actual survival rates were 66.3% and 14.7%, respectively. To perform MCN more effectively in the treatment of liver metastases, surgical margins around tumors should be from 10 mm to 15 mm, and both the feeding artery and drainage vein should be coagulated before MCN.

The rarity of the occurrence of metastatic malignancy in injured liver has been noted by many observers. However, since the clinicopathological features of primary carcinoma and the etiology of liver disease of these patients vary greatly, this phenomenon may not be universal.We evaluated the relationship between either hepatitis B virus (HBV) or hepatitis C virus (HCV) infection and the incidence of colorectal liver metastasis in 438 patients undergoing surgical treatment for advanced colorectal carcinoma.The liver function of the patients in the infection group (n = 37) was significantly worse than that of those in the noninfection group (n = 401). The incidences of tumor recurrence in the lung or peritoneum were comparable between the two groups. However, the percentage of patients with liver metastases in the infection group (3 of 37, 8.1%) was significantly lower (P0.05) than that of those in the noninfection group (85 of 401, 21.2%). The patients in the infection group tended to survive longer than the patients in the noninfection group.We herein report an initial finding that colorectal carcinoma rarely metastasizes to livers infected with HBV or HCV.

We investigated T cell immunity against hepatocellular carcinoma (HCC), and showed that both peripheral blood mononuclear cells and tumor-infiltrating lymphocytes incubated with interleukin-2 alone displayed HLA-nonrestricted but hepatic cancer-specific cytotoxicity in a majority of patients with HCC. Namely, they lysed both HCC and cholangiocellular carcinomas in an HLA-nonrestricted manner, but they did not lyse any tumors with the other histological types tested, normal hepatocytes, or the cells transfected with hepatitis C virus or MUC1 gene. These CTL lines and clones were phenotypically CD3+CD4+CD8-. These unique CTL could play important roles in T cell immunity against HCC.

Between January 1965 and September 1995, 330 patients underwent pancreatoduodenectomy in our institution. In 249 cases, we performed the Child method of reconstruction after pancreatoduodenectomy. Of these patients, 299 underwent pancreatoduodenectomy because of malignant disease and 19 died in the hospital after the operation; the mortality rate was 5.8%. We must be aware of certain complications after pancreatoduodenectomy, especially anastomotic leakage of the pancreatiocojejunostomy. It 16 cases of pancreatic fistula, 7 patients died of this complication. Five-year survival rates of patients with carcinoma of the pancreas, bile duct, and papilla of Vater were 17.3%, 19.7%, and 56.2%, respectively. In cases of carcinoma of the papilla of Vater with no lymph node involvement, the 5-year survival rate was 64.9%; for cases with lymph node involvement, it was 40.0%. Many more strategies must be developed to obtain a better outcome in cases of carcinoma of the pancreas and bile duct. The most important need is to prevent metastasis of carcinoma to the liver in these patients.

A 56-year-old male consulted us because of a palpable mass and pain of the left flank 8 and a half years after resection of hepatocellular carcinoma of the left lobe about 3 cm in diameter. Ultrasound examination of the abdomen demonstrated a tumor about 10 cm in diameter showing a mosaic of hyperechoic and hypoechoic areas on the upper pole of the left kidney. By angiography, the tumor was found to be supplied mainly by the inferior adrenal artery. PIVKA-II was increased. Adrenal metastasis of hepatocellular carcinoma was suspected, and adrenalectomy was carried out. No intrahepatic metastasis was noted. The tumor was histopathologically identified as a pseudo-glandular type of moderately differentiated hepatocellular carcinoma with a trabecular pattern similar to the primary lesion. In this patient, a resectable giant metastasis was observed only in the left adrenal gland and no intrahepatic metastasis was demonstrated 8 and a half years after resection of hepatocellular carcinoma. The patient has survived 10 years after the first operation. This case is considered to be important for evaluation of the treatment for distant metastasis of hepatocellular carcinoma.

To minimize intraoperative bleeding and allow more accurate resection, we have devised a new technique for hepatectomy. In addition to occlusion of the afferent vessels, we occlude the hepatic vein at the hepatocaval junction using a balloon catheter inserted transhepatically under intraoperative ultrasonic guidance. We have performed eight hepatectomies using this method. A sequence of 15 minutes of vascular occlusion followed by 5 minutes reperfusion was repeated throughout the operation, and the total ischemic time ranged from 45 to 90 minutes. This method greatly decreased intraoperative bleeding without causing significant elevation of the postoperative transaminase or lactic dehydrogenase levels when compared with occlusion of only the afferent vessels or nonischemic resection using a microwave tissue coagulator in patients undergoing equivalent resections. Also, the postoperative prothrombin time recovered to a significantly higher level, and there were no fatal postoperative complications using this method. Our method is useful for systematic hepatic resection along the hepatic vein or for resection of tumor sited at the confluence of the hepatic vein.

Cholangiocellular carcinoma (CCC), the malignant tumor arising from epithelial cells of the intrahepatic bile duct, has been classified as a primary liver cancer, although CCC has occurred less frequently than hepatocellular carcinoma (HCC) in Japan [1]. Most CCCs are advanced because a system for early diagnosis has not been established [2], and even though CCC is resectable, the prognosis is generally unfavorable [3–5]. We therefore studied clinically the 36 patients with CCC encountered at our hospital, and reported the current status of surgical treatment in Japan.

Background/Aim: We describe a novel use of the cholangioscope to help in the intraoperative localization of small colonic malignancies on the right side of the colon. Methods: A small incision was made at the base of the appendix and a cholangioscope was inserted into the ascending colon through the incised hole of the appendix. Results: The site of the lesion was precisely determined by palpating the distal end of the cholangioscope while observing the area right under it. Conclusion: Our procedure therefore appears to be worthy of consideration in patients with small colonic lesions on the right side of the colon in whom preoperative endoscopic marking techniques might otherwise be required.