Search

Hepatocellular carcinoma (HCC) frequently develops in patients with chronic viral hepatitis and cirrhosis. In these chronic liver disorders, an increased production of reactive oxygen species (ROS) causing oxidative DNA damage has been reported. In this study, we immunohistologically (LSAB method) demonstrated the presence of 8-hydroxy-2'-deoxyguanosine (8-OHdG) that was generated when oxidative DNA damage was caused by active oxygen species in noncancerous region obtained at hepatectomy for HCC, and investigated the relationship between 8-OHdG and remnant liver recurrence. We found that the 8-OHdG labeling index (LI) for noncancerous region at the time of hepatectomy was significantly higher in recurrent (31.1+/-10.2%) than in nonrecurrent (20.6+/-8.0%) patients (P0.01). The high 8-OHdG LI (/=30%) group showed a significantly higher recurrence rate, compared with the low LI (30%) group (P0.01). The cancer-free survival curves also showed that the high 8-OHdG LI (/=30%) group had a significantly poorer prognosis because of remnant liver recurrence than the low 8-OHdG LI (30%) group (P0.05). The 8-OHdG LI showed a significant correlation with the histopathologic evaluation of noncancerous region based on the New Inuyama Classification: a higher pathologic Staging and a higher pathologic Grading were associated with a higher 8-OhdG LI. Analysis by Grading and Staging showed that the high 8-OHdG LI group (/=30%) of Grade A2, Stage F3, or Stage F4 had a significantly higher recurrence rate compared with the low 8-OHdG LI group (30%) of Grade A2, Stage F3, or Stage F4, respectively. In addition, using multivariate analysis, we compared the influence on recurrence of the histological features that, at the time of hepatectomy, showed significant differences in the rate of remnant liver recurrence, that is, the number of tumors and the presence or absence of portal involvement, and three variables of the Grading, Staging, and 8-OHdG LI of noncancerous regions. The results suggested that 8-OHdG LI (P=0.02) and portal involvement (P=0.04), in this order, were useful as independent prognostic factors for recurrence. From this, we consider that, if patients with high 8-OHdG LI (/=30%) in noncancerous region at the time of hepatectomy are regarded as being at high risk for remnant liver recurrence (heterochronous multicentric carcinogenesis) and are given careful follow-up treatment with preventive therapy for remnant liver recurrence, the prognosis will be improved.

目的: 肝癌切除後の再発例を対象に再発後の予後因子を多変量解析を用いて検討した. 対象: 肝癌治癒切除後, 術後再発を認めた143例を対象とした. 検討項目は初回手術時因子として18項目, 再発時因子として6項目の計24項目を選択した. 結果: 再発後生存率の比較では初回切除時因子のうち性別(男性), 術前transcatheter arterial chemoembolization (TACE)(無), 肝硬変例, 被膜浸潤(有), 門脈浸潤(有)で, また再発時因子では無再発期間(

We investigated numerical chromosomal abnormalities, using the fluorescence in situ hybridization (FISH) method, in gastric mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBL). We also compared the histopathological findings, including the presence or absence of Helicobacter pylori infection, with the analytical results. Methods: Sixteen patients who underwent operation for malignant gastric lymphoma in our department were divided into three groups: patients with low-grade gastric MALT lymphoma (l-MALT; n = 5), those with high-grade gastric MALT lymphoma (h-MALT; n = 8), and those with DLBL (n = 3). Numerical abnormalities of chromosomes 8, 9, 12, and 17 were investigated by the FISH method, and the presence or absence of H. pylori infection was microscopically examined. Results: Numerical abnormality was observed in chromosome 12 in 11 patients (68.8%), in chromosome 8 in 10 (62.5%), and in chromosome 17 in 5 (31.3%), showing a high frequency. H. pylori infection was detected in 80% and 50% of patients with l-MALT and h-MALT, respectively, but no H. pylori infection was observed in patients with DLBL. Conclusions: A new biological characteristic of gastric MALT lymphoma was obtained, i.e., a high frequency of numerical abnormalities of chromosomes 12, 8, and 17. There was no correlation between the numerical chromosomal abnormalities and the clinicopathological findings.

Purpose. Our aim was to investigate the thymidine phosphorylase (TdRPase) expression and Ki-67 labeling index (LI) of primary tumors of colorectal cancer and hepatic metastases immunochemically and to evaluate the relationship of these parameters to various clinicopathologic factors and hepatic metastasis. Methods. We performed immunochemical studies in 74 patients with colorectal cancer, using anti-TdRPase antibody and MIB-1 antibody. Results. TdRPase expression and a Ki-67 LI ≧30% in primary lesions were significantly more common in patients with lymphatic invasion (ly), venous invasion (v), lymph node involvement (n), and hepatic metastasis. A Ki-67 LI ≧ 30% of the primary tumor was associated with a significantly higher frequency of metachronous liver metastasis. In the same patients, the mean Ki-67 LI was 24.3 ± 17.9 for primary lesions and 5.0 ± 4.2 for hepatic metastases, this difference being significant. Conclusions. These results indicate that TdRPase expression and the Ki-67 LI are related to various clinicopathologic factors, suggesting their usefulness as indices of tumor malignancy. We suggest that the Ki-67 LI of primary colorectal cancer could be an important predictor of the future development of metachronous liver metastasis.

This study deals with the indication and significance of surgical therapy for recurred hepatocellular carcinoma in terms of comparison of prognoses by modes of recurrence and long-term therapeutic results after re-hepatectomy. Subjects were 79 recurred cases after hepatectomy. For comparison, the survival rates after recurrence were calculated by the following five items; time from operation to recurrence, the existence of extrahepatic growth, mode of recurrence in the remnant liver, recurred site in the remnant liver, and therapy after recurrence. As a result, significantly better prognoses were noted in recurrences after 2 years of time lapse following hepatectomy, no extrahepatic growth, solitary cases, and re-resected cases. No significant difference was observed between the sites of recurrence in the remnant liver, namely isolateral and counterlateral lobes. In 11 re-resected cases which involved only three cases suspected of heterochronous multicentric carcinoma, a mean survival time after re-resection of solitary recurrence in the remnant liver was as good as 5.2 years. And five patients of them have not experienced re-recurrence for 5 years after the re-resection. It is thought that re-resection can be considered aggressively in patients with two factors, namely, recurrence after 2 years following hepatectomy and solitary recurrence in the hepatic remnant. And the re-resection which provides favorable prognosis appears to be significant for such cases.

We successfully saved a patient with rupture of a hepatic artery aneurysm. A 20-year-old man was brought into hospital by ambulance because of abrupt development of abdominal pain and shock. An abdominal ultrasonogram demonstrated a small mass and intraperitoneal fluid accumulation. Pancture of this space, disclosed pooling of intraperitoneal bleeding. Surgical treatment was performed on emergency, and the rupture of a hepatic artery aneurysm was diagnosed. As it was diffucult to resect the aneurysm, we had sutured that wall and both the gastrodeodenal and common hapatic arteries were ligated proximal to it. The postoperative course was uneventful. Hepatic artery aneurysm is a relatively rare entity. But if the ptient is seen in emergency situations after rupture, the clinical course can be clitical. In the treatment of patients with intraabdominal bleeding of unknown origin, we have to decide the treatment as soon as possible keeping the possibility of the disease in mind.

A patient with Fournier's gangrene associated with advanced rectal cancer who could not be saved because of rapidly deteriorated course is reported. A 75-year-old man complaining of tarry stool revealed apple core sign in the rectum Rb on a barium enema study, and was admitted to the hospital with a diagnosis of rectal cancer. At a digital examination of the rectum, a whole-circumference tumor was palpated. No perianal abnormalities were noted, but swellings in the same region and scrotum were confirmed and incision drainage was performed. Two days later a swelling with crackling sensation covering from the perineum to right lateral abdominal region continuously appeared. Emergency operation was performed where an incision drainage and a removal of necrosed tissues were performed. The patient was associated with postoperative disseminated intravascular coagulation (DIC) and consequent adult respiratory distress syndrome (ARDS), and was managed by artificial respiration. But the patient's condition deteriorated and died on the 6th postoperative day. There have been only one domestic case and two foreign cases in which Fournier's gangrene was associated with rectal cancer before operation as far as we could review. In all cases, rectal cancers perforated the rectal wall and this direct invasion of cancer caused perianal abscess.

A relatively rare case of malignant lymphoma of the mesenterium is reported with a review of the literature. A 54-year-old man was admitted to the hospital because of an abdominal tumor. An increase in LDH was noted. An elastic hard and well movable tumor 20cm in diameter around the navel was palpated. On imagings, the tumor was associated with sandwich sign by an abdomina CT scan, was visualized as a hypovascular tumor on an angiography of the superior mesenteric artery. Upon laparotomy, a tumor 15cm in size in the mesentery of the small intestine and lymph node swelling along the superior mesenteric artery starting from the pancreatic inferior margin were seen. The main tumor alone was excised as possible as we could. Histopathological diagnosis was malignant lymphoma (diffuse, large cell. B cell type) . It was inferred that transformation from follicular type to diffuse type might occur, because lymph node surface marker CD 10 was positive. It indicated a poor prognosis for the patient and postoperative chemotherapy was added. It is said that malignant lymphoma of the mesentery presents difficulty in preoperative diagnosis and has a poor prognosis. Radical operation can be performed only in limited patients. We think that it is better to switch to chemotherapy as soon as possible rather than to pursur surgical therapy.

This report presents 46 Japanese patients with idiopathic portal hypertension (IPH) in whom non-shunt operation was performed for the management of esophageal varices. Non-shunt operation included transthoracic esophageal transection (Sugiura's procedure) in 37 patients, transabdominal esophageal transection (TAET) in 3 patients, and Hassab's procedure in 6 patients. Rates of postoperative variceal eradication were: 78.4% by Sugiura's procedure; 100% by TAET; and 50% by Hassab's procedure. The cumulative rates for recurrent varices and recurrent bleeding were 3.9%, and 5.1%, respectively, at 5 years, and 8.9% and 9.8% at both 10 and 15 years. Only 3 patients required additional endoscopic injection sclerotherapy to treat recurrent varices. Although 3 patients developed upper gastrointestinal bleeding, the source of hemorrhage was esophageal varices in 1, and portal hypertensive gastropathy in 2; none of the patients died from bleeding. Actuarial survival for all patients was 87.5% at 5 years, 77.9% at 10 years, and 58.8% at 15 years. There were no deaths within the first 30 days after surgery. These results show that non-shunt operation is useful in preventing bleeding from esophageal varices in patients with IPH.

A 51-year-old woman was admitted to another hospital because of repeated hematemesis which started on September 21, 1994, and was diagnosed as having Felty's syndrome. The patient had been suffering from rheumatoid arthritis for about 10 years and had been pointed out a splenomegaly and esophageal varices 3 years before. The patient was admitted to the hospital for close examination and treatment on January 4, 1995. Physical examination on admission revealed pigmentation in the skin of bilateral legs. Decreases in white blood cells and plateletes counts, positive response to antinuclear antibody, and an increased level of rheumatoid factor were noted. Abdominal CT visualized remarkable splenomegaly. On catheter examination via the hepatic vein, there were some findings suggestive of idiopathic portal hypertension (IPH). For the esophageal varices, endoscopic sclerotherapy was conducted the three times, and thereafter a Hassab operation and hepatic biopsy were performed on March 8. Histopathologic findings of the liver were compatible with IPH. Upper gastrointestinal endoscopic study conducted on the first month after the operation confirmed disappearance of the esophageal varices, and the white blood cells and platelets counts were normalized.

Our experience with a case of spontaneously ruptured hepatic cyst is presented. A 51-year-old man who had been pointed out having a giant hepatic cyst at the department of internal medicine in our hospital 2 years before admission was seen at the hospital because of severe abdominal pain which occurred during sleeping without no particular cause. The patient complained of severe pain entire the abdomen, and peritoneal signs such as muscular defense and rebound tenderness were present. Though no difinitive diagnosis was made, an emergency laparotomy was performed. Upon laparotomy, muddy ascites was noted and a perforated portion was found in the hepatic cyst. Intraoperative fluoroscopy of the bile duct visualized no clear communication between the hepatic cyst and biliary duct. So an extirpation of the hepatic cyst was conducted. Postoperative course was uneventful.

Background: Cholangiocellular carcinoma (CCC) is known to be associated with poor prognosis even when surgical treatment is applied, and few studies of its biological behavior have been conducted because of the relatively low incidence (about 2.7% of primary liver cancer cases in Japan according to the Liver Cancer Study Group of Japan, 1994). Methods: We analyzed 41 specimens from 17 resected CCC tumors to assess the biological behavior using immunohistochemical staining for the tumor suppressor protein, p53; the cell proliferation marker, Ki-67; and two tumor antigens, CEA and CA19-9. Results: In the central and marginal regions, 15 of 17 tumors demonstrated immunoreactivity for p53, and all 17 immunoreactivity for Ki-67. All tumors were immunostained for CEA and CA19-9. A significant difference between the central and marginal regions was found in p53 and Ki-67 staining intensity but not in CEA and CA19-9 staining intensity. There was a significant relationship with survival for the p53 and Ki-67 labeling index (LI) in the marginal region, and a significant correlation was also found between the marginal p53 and Ki-67 LI. The survival of patients with the stromal type of CEA staining pattern was significantly shorter than those with other types. Conclusions: We conclude that immunohistochemical investigations using p53, Ki-67 and CEA offer prognostic value in CCC. Furthermore, consideration of the regional heterogeneity is of great importance in the evaluation of the biological behavior of CCC, and more aggressive features are found in the marginal region.

先天性と思われる門脈瘤に合併した血栓によって肝外門脈閉塞をきたし, Hassab手術を行うに至った症例を経験した. 症例は28歳, 男性. 生来健康であったが, 平成5年10月18日急激な心窩部痛のため近医受診. 急性腹症の診断で緊急手術施行. 術中門脈造影にて門脈本幹の球状の腫大とその内部に血栓を認めたため, 門脈切開, 血栓除去術を行った. 術直後脾腫, 食道静脈瘤は認めなかったが, 平成6年2月に肝門部に著明な側副血行路を, 3月には食道静脈瘤, 4月には著明な脾腫が証明され, その後胃静脈瘤の増悪を認めたため, 手術目的で6月2日当科入院. 7月12日Hassab手術を施行. 術中肝臓は肉眼的にはほぼ正常であった. 術後経過は順調で静脈瘤は消失した.

One hundred and nineteen patients with hepatocellular carcinoma (HCC) who had had an angiography several weeks (4-9 weeks) after hepatectomy were investigated. In 15 cases (13%) tumor stains were observed in the hepatic remnant. The positivity of tumor stain was signifficantly high in cases of portal invasion, intrahepatic metastasis and infiltration to the tumor capsule as pathological factors had been found in the primary tumor. There was an increasing tendency to positive tumor stain as the clinical stage become higher, and a significant difference was noted between patient groups of Stage I and II and Stage IV. In addition, the frequency of positive tumor stain was high in patients whose preoperative AFP level were more than 21 ng/ml. The present study suggested the development of intrahepatic micrometastasis which were could not have detected with pre- or intra-operative image analyses. Therefore, the post operative angiography is an inevitable method to confirm the curability. Further, it enables us to make a prophylactic treatment of the remnant which is of useful for a postoperative adjuvant chemotherapy.

A case of inflammatory pseudotumor of the liver which was difficult to differentiate from malignant tumor is reported with a discussion on this case along with 58 cases of liver pseudotumor in the literature in terms of clinical pictures and preoperative diagnosis. A 71-year-old man was admitted to the hospital because of hepatic dysfunction and fever. Upon entering the hosptal, his temperature was 37.8°C, and a blood test showed a marked inflammatory reaction. In addition, a tumor with a diameter of 57mm in the posterior segment of the liver was seen with an ultrasound and a tumor stain with an angiography. The hepatic vein was displaced by the expansive tumor without invasion. A malignant tumor was suspected and right lobectomy of the liver and cholecystectmy were performed. The resected tumor was solid with its section colored yellowish-white, and was diagnosed pathologically as inflammatory pseudotumor of the liver. In a review of the literature, it is suggested that we should entertain the disease as a probable diagnosis for liver tumors with inflammatory reaction.

Non-esterified (non-sulfated and non-glucuronidated) bile acid profile in the serum and bile was assessed using mass fragmentation spectrometry in relation to the decrement rate of the serum total bilirubin after relief of the biliary obstruction by external biliary drainage in fourteen patients. Biliary excretion of the total bile acid was decreased and the serum ratio of cholic to cenodeoxycholic acid was low in the patients with refractory jaundice. An unusual bile acid, 3 beta,7 alpha-dihydroxy-5 beta-cholan-24-oic acid, was detected in the sera of all patients early after biliary drainage. Disappearance of this bile acid from the serum was delayed in refractory jaundice. These findings suggested that extremely prolonged jaundice after biliary drainage resulted from profound liver cell damage secondary to biliary obstruction.

Our goal was to compare the benefits and complications of using an ultrasonically activated scalpel (UAS) and conventional blunt dissection in hepatic resection.We evaluated the effectiveness of dividing the liver by UAS (n=18) (the UAS group) compared with conventional blunt dissection (n=34) (the BD group) in patients undergoing hepatic resection. In the UAS group, UAS was used to dissect the superficial parenchyma and a crushing and clamping technique was used to divide the deep parenchyma.No serious complications attributable to the use of UAS were encountered, and there were no significant differences in morbidity or mortality between the two groups. The duration of surgery was significantly longer in the UAS group (281 +/- 81 min) than in the BD group (223 +/- 76 min) (P0.05), and in the UAS group as a whole there were no advantages in using the new scalpel. However, when we compared only those patients who underwent minor hepatectomy, the intraoperative blood loss was significantly less in the UAS group (657 +/- 588mL) than in the BD group (1447 +/- 984mL) (P=0.03). The duration of drainage from the hepatic stump in these patients was also significantly shorter in the UAS group (P=0.02).The UAS is a useful new device for transection of the liver during hepatic resection. It may reduce the amount of blood loss during liver surgery, particularly in minor hepatectomy.

The effects of preoperative transcatheter arterial chemoembolization (TACE) were retrospectively evaluated in patients with resectable hepatocellular carcinoma (HCC). A total of 227 patients who underwent hepatectomy for HCC were studied (146 underwent preoperative TACE and 81 did not). We compared operative outcome, mortality, and disease-free survival between TACE and non-TACE groups. We also compared the pattern of recurrence and postrecurrence survival between subgroups according to staging. Of the 227 patients, 105 with tumor stage I-II were assigned to group A (group A/TACE, n = 69; group A/non-TACE, n = 36), and the remaining 122 with tumor stage III-IV were assigned to group B (group B/TACE, n =77; group B/non-TACE, n =45). Complete necrosis was found to be more frequent in the TACE group (p < 0.01). Operating time, blood loss, and mortality did not differ between those who did and did not undergo preoperative TACE. TACE did not significantly improve disease-free survival within either the entire TACE group or group A/TACE. In contrast, in group B/TACE the disease-free survival rates were significantly higher than in group B/non-TACE. Furthermore, both extrahepatic metastasis and diffuse intrahepatic metastasis were significantly more frequent in group B/non-TACE than in group B/TACE. The preoperative TACE also improved the postrecurrence survival in group B. We speculate that preoperative TACE reduced tumor recurrence and that it might confer a survival advantage after surgery, particularly in patients with advanced HCC. In addition, it is expected that this procedure may improve the pattern of tumor recurrence when it does occur.

Thirty-six patients with extrahepatic portal vein obstruction (EHO) were studied. Twenty-one patients, whose age at onset was under 20 years old, were thought to be primary EHO. Ten of 15 patients over 21 years old, had a history of abdominal diseases, and were thus considered to be secondary EHO; only 5 were primary EHO. EHO was classified into three categories, based on selective celiac-superior mesenteric arteriography, and intraoperative trans-splenic and superior mesenteric venography: the hilar obstruction of portal vein, the portal trunk obstruction, and the portal trunk-splenic vein obstruction. Both primary and secondary EHO cases were found to have extended their obstructed region over time by progressing from hepatic hilum to portal trunk obstruction followed by splenic vein obstruction. On the other hand, based on retrograde portography, EHO was classified into the absence of intrahepatic portal obstruction (portal trunk type) and the intrahepatic obstruction (portal branch type) and the portal branch type tended to predominate. Changes of intra- and extra-hepatic portal obstruction were examined by comparing various angiographies of the 14 patients available for between 1 and 26 years of long-term follow-up. While EHO tended to progress with time, no patient showed progress of a intrahepatic portal vein obstruction. From these results, EHO patients are expected to show continuous progression of EHOs during long-term follow-ups, and to have high recurrence rates of gastrointestinal varices after various treatments due to the persistent portal hypertension. However, effective hepatic flow is likely to be maintained because collateral circulation to the liver develops, and intrahepatic portal vein obstruction does not progress, resulting in a good prognosis for EHO.

The purpose of this study was to evaluate whether transendoscopic microvascular Doppler sonography (EMDS) is useful to analyze Hassab's operation and esophageal transection (non-shunting operation) which are effective for patients with esophagogastric varices. Twenty patients with esophagogastric varices were examined. Before the operation, we examined the conditions of the esophagogastric varices and measured the velocity of the varices with EMDS. The blood flow velocity in the largest varices (F3) was significantly higher than that in the straight varices (F1). After the operation, the esophageal and gastric variceal blood flow velocities were markedly decreased in 15 patients. In five of the patients who received Hassab's operation, the esophageal variceal form and blood flow velocity still remained. After endoscopic injection sclerotherapy, the velocity and form were completely resolved. The non-shunting operation is effective therapy in the esophageal and gastric varices. It is concluded that EMDS is a non-invasive method and it appears to be very useful for the evaluation of the non-shunting operation.

We report a 69-year-old man with double cancers in the common bile duct. One cancer was located between the superior and middle parts of the bile duct, while the other cancer was in the inferior part of the bile duct. Pylorus-preserving pancreatoduodenectomy was performed. There was no communication between the two cancers in either the mucosal layer or the subepithelial layer. On pathological examination, the upper cancer was diagnosed as poorly differentiated adenocarcinoma, while the lower one was found to be moderately differentiated adenocarcinoma. We analyzed loss of heterozygosity (LOH), using microsatellite markers on five chromosomal arms, in both the upper and the lower cancers. Both cancers showed common regions of LOH at 5q, 6q, 9p, 17p, and 18q, whereas the upper cancer showed one additional region of LOH at 8p, thus suggesting progression, due to the acquisition of the additional LOH, in the upper cancer. No LOH was observed in the region between the two cancers. The presence of one additional LOH in the upper cancer suggests that the upper cancer was a metastasis of the lower one.