A validation study of combined resection and ablation therapy for multiple hepatocellular carcinoma.

AIM: To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report. MATERIALS AND METHODS: A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed. RESULTS: There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761). CONCLUSIONS: The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.

Hepatitis B surface antigen reduction by switching from long-term nucleoside/nucleotide analogue administration to pegylated interferon.

Hepatitis B surface antigen (HBsAg) reduction during nucleoside/nucleotide analogue (NA) therapy is slow and an alternative strategy for patients receiving ongoing NA to facilitate HBsAg reduction is required. We investigated whether switching to pegylated interferon (PEG-IFN) after long-term NA administration enhances HBsAg reduction. Forty-nine patients who switched from long-term NA to 48 weeks of PEG-IFN alfa-2a were studied. The mean duration of previous NA was 48 months (sequential group). A total of 147 patients who continued NA and matched for baseline characteristics were analysed for comparison (NA continuation group). The treatment response was defined as HBsAg reduction ≥1.0 logIU/mL at the end of PEG-IFN. HBsAg reduction at week 48 was 0.81±1.1 logIU/mL in the sequential group, which was significantly higher than that in the NA continuation group (0.11±0.3 logIU/mL, P < .001). The treatment response was achieved in 29% and 2% of the sequential group and NA continuation group (P < .001), and the odds ratio of sequential therapy for the treatment response was 19 compared with the NA continuation (P < .001). In patients tested positive for hepatitis B e antigen (HBeAg), HBeAg seroconversion was higher in the sequential group (44% vs 8%, P < .001). In HBeAg-negative patients, only patients in the sequential group achieved HBsAg loss. No patient needed to resume NA administration because of HBV DNA increase accompanied by alanine aminotransferase flares. In summary, sequential therapy with PEG-IFN after long-term NA enhances the reduction of HBsAg and may represent a treatment option to promote HBsAg loss.

Mechanism and therapeutic potential of DNA-based immunization against the envelope proteins of hepatitis B virus in normal and transgenic mice.

Two plasmid DNA vectors, pCAGGS(S) encoding the genes of the major envelope protein of hepatitis B virus (HBV), and pCAGGS(S + preS2) encoding the genes of the middle envelope protein were used to study the mechanism and therapeutic potential of DNA-based immunization. Injection of these plasmids into the regenerating bilateral tibialis anterior muscle (TA) of normal C57BL/6 mice induced hepatitis B surface antigen (HBsAg)-specific humoral and cellular immune responses. Seventy-two hours after injection of pCAGGS(S), infiltrating cells including antigen-presenting dendritic cells (DC) were localized around the injection site and HBsAg was expressed by both muscle cells and infiltrating cells. Spleen DC from the mice were exposed to HBsAg for up to 32 weeks after a single injection of pCAGGS(S), because these DC induced the proliferation of HBsAg-specific memory lymphocytes in culture without exogenous HBsAg. A single injection of pCAGGS(S) or pCAGGS(S + preS2) resulted in the clearance of HBsAg in 28 out of 30 HBV-transgenic (Tg) mice. In contrast, more than 7 monthly injections of an HBsAg-based vaccine were required for the clearance of HBsAg in 6 out of 29 HBV-Tg mice. Infiltrating DC at the DNA vaccine injection site may have a role in initiating HBsAg-specific immune response, whereas the persistence of HBsAg exposed spleen DC may contribute to long-lasting immunity. This study also suggested that DNA-based vaccines may be a potent tool for treating chronic HBV carriers.

[Two cases of testicular infarction: the usefulness of enhanced MRI for preoperative diagnosis].

The differential diagnosis in acute scrotum, particularly torsion of spermatic cord and epididymitis, is sometimes difficult. An erroneous diagnosis may result in unnecessary and improper treatment. We report two cases of testicular infarction including torsion of spermatic cord, preoperatively diagnosed by enhanced magnetic resonance imaging (MRI). Case 1: A 16-year-old boy presented with a 3-day history of left scrotal swelling and left lower abdominal pain. He had fever and leukocytosis. Antibiotics for 2 days failed to relieve the symptoms. Enhanced MRI showed absence of blood flow in the left testis. Scrotal exploration revealed hemorrhage and necrosis in the left testis. Left orchiectomy and right orchiopexy were performed. Case 2: A 12-year-old boy visited with scrotal swelling and fever 30 hours after an acute onset of left scrotal pain. Enhanced MRI showed absence of blood flow in the left testis. Exploration revealed left necrotic testis with torsion of spermatic cord. Left orchiectomy and right orchiopexy were performed. Our two cases suggested that enhanced MRI, by which the intratesticular blood flow can be evaluated, may be useful for the diagnosis of testicular infarction.

Adenocarcinoma developing in an ileal conduit.

We report a case of adenocarcinoma that developed in an ileal conduit 18 years after cystectomy for transitional cell carcinoma of the bladder. The only presenting sign was gross hematuria. Retrograde ileal loopography and endoscopy of the ileal loop were useful in the diagnosis. To our knowledge adenocarcinoma arising in an ileal conduit after a radical procedure for transitional cell carcinoma of the bladder has not been reported previously. The literature regarding malignancies that arise in portions of intestinal segments used as conduits is reviewed and carcinogenesis is discussed.

[Clinical study of sonography and percutaneous nephrostomy in pyonephrosis].

Sonography and percutaneous nephrostomy (PNS) were performed on 16 patients with pyonephrosis and the following results were obtained. Sonography revealed a dilated collecting system in all cases within which, however, neither debris nor gas was observed in any case, the pelvocaliceal system appeared hypoechoic in 2 cases and anechoic in 14 cases. From the clinical symptoms and the dilated collecting system demonstrated by sonography, pyonephrosis was diagnosed in 14 cases. The purulent fluid aspirated from the collecting system confirmed the diagnosis in all cases. The clinical condition was stabilized by PNS and antibacterial therapy in all cases. However, in 5 of the patients with pyrexia for more than 6 days before PNS, sepsis developed in 3 cases and pyrexia continued for more than 3 days after the treatment in 4 cases. The affected 11 kidneys showing recovery of renal function following PNS were all salvaged by elective surgery. These findings suggest that prompt diagnosis by needle aspiration is necessary, even in the absence of any sonographically characteristic findings, whenever pyonephrosis is suspected. Our experience suggests that PNS is a useful therapeutic procedure for pyonephrosis.

[Transurethral incision and fulguration of the bladder diverticulum: radicality and clinical efficacy].

We performed transurethral incision and fulguration of the bladder diverticulum (TUIFBD) for 8 diverticula in 6 patients. In combination with TUIFBD, one patient received transurethral resection of the prostate and another one transurethral lithotripsy of bladder stones. TUIFBD has been easily performed without any operative complications. All 8 diverticula had shrunken from one to two months after the operation but only one diverticulum had disappeared. Symptoms related to the bladder diverticulum had disappeared postoperatively in all cases. In conclusion, TUIFBD can be easily and safely performed in combination with other transurethral surgical procedures. TUIFBD may be insufficient for radicality, but is clinically effective.

[Multiorgan failure following intravesical bacillus Calmette-Guerin administration: a case report].

We describe a case of multiorgan failure after intravesical bacillus Carmette-Guern (BCG) immunotherapy for bladder cancer. A 58-year-old man with superficial transitional cell carcinoma of the bladder was initially treated by transurethral resection and intravenous chemotherapy, and then administered 11 sessions of BCG intravesically. He was administered BCG intravesically after cystoscopic examination. The next day he complained of nausea and malaise. He became hypotensive. The symptom progressed with multiorgan failure, disseminated intravascular coagulation and respiratory failure. The patient gradually improved with administration of antibiotics and corticosteroid, and hemodialysis, without antituberculous antibiotics. Intravesical instillation of BCG should not be carried out immediately after cystoscopic examination.

[Herniation of the bladder observed 3 days after herniorrhaphy: a case report].

A 72-year-old man complained of right hemiscrotal swelling and pollakisuria which had appeared 3 days after herniorrhaphy. On physical examination, a large mass in the right scrotum did not transmit light nor shrink upon pressure application. The concentrations of blood urea nitrogen and creatinine in the fluid obtained by puncture from the scrotal mass were high. Cystography demonstrated influx of contrast media into the scrotal mass from the bladder. From these findings, diagnosis was made as herniation of the bladder. An operation was performed through inguinoscrotal incision. The herniated bladder, to which peritoneum was laterally adherent, was incarcerated. The hernia ring, which was located medially to the suture line of previous herniorraphy, had strangulated the herniated bladder. The bladder wall was edematous and the mucosa was dark red. These findings suggested that the blood circulation in the herniated bladder had been disturbed for a relatively long time. Resection of the herniated bladder with the adherent peritoneum was performed in addition to hernia repair. Incomplete herniorrhaphy may be one of the causes of herniation of the bladder in our case.

[Papillary adenocarcinoma of the prostate with good response to antiandrogen therapy and delayed radiotherapy: a case report].

A 76-year-old man complained of initial hematuria and dysuria. Right lobe of the prostate was elastic soft, enlarged and hypoechoic. The serum levels of PA and gamma-Sm were abnormally high. Prostatic biopsy showed papillary adenocarcinoma which was stained by prostatic specific antigen (PA). The cancer was clinically diagnosed as stage C. Antiandrogen therapy was performed. After three months, the prostatic tumor markers decreased to the normal range and the tumor reduced in size without any findings of metastasis on CT scan. Because prostatic biopsy showed viable cancer cells, radiotherapy was added. After six months, the tumor reduced in size without any signs of metastasis on CT scan and prostatic biopsy revealed no viable cancer cells or elevation of the tumor markers. The positive staining for PA and the good response to antiandrogen therapy in our case support the view that papillary adenocarcinoma of the prostate is only a morphologic variant of ordinary prostatic carcinoma (acinous adenocarcinoma).

[Mucinous adenocarcinoma of the prostate with good response to hormonal therapy: a case report].

A 79-year-old man complained of pollakisuria and sense of retention. The prostate was stony hard and heterogeneously enhanced on computed tomographic (CT) scan. The serum levels of prostatic specific antigen, prostatic acid phosphatase and gamma-Seminoprotein were abnormally high. Prostatic biopsy showed mucinous adenocarcinoma which was stained by prostatic specific antigen. Bone scintigraphy revealed multiple metastases. Hormonal therapy was performed. Each prostatic tumor marker decreased to the normal range within 2 months. After 3 months, the prostate was almost normalized on digital examination and CT scan. There were no new metastases, prostatic biopsy revealed that most cancer cells had degenerated to nonviable cells and bone metastases had decreased.

[Transitional cell carcinoma of pelvis in a giant hydronephrotic kidney].

A 73-year-old man complained of macroscopic hematuria. Preoperative diagnosis was left giant hydronephrosis due to UPJ stenosis. Resected kidney unsuspectedly contained multiple papillary tumors. Ureterectomy and partial cystectomy was additionally performed. Histological examination showed transitional cell carcinoma. Urinary stasis in the dilated pelvis may have been one of the causes of carcinomatous changes in the epithelium in our case.

[Clinical evaluation of piperacillin in the urological field].

The sensitivity of 249 etiological bacterial strains causing inflammation isolated from patients with infections of the urogenital tract who were under treatment on an in-patient basis in our Department was examined by the Disc (3 concentration) assay method. Piperacillin (PIPC) was employed for prophylactic treatment in 18 patients against postoperative infections and for therapeutic treatment in 3 patients against complicated infections of urogenital tracts. The results of these studies are reported along with some discussion on the utility of PIPC in the urological field. The frequency of detection of bacteria isolated from the patients on their admission into our hospital was in the decreasing order of Streptococcus Sp., Proteus Sp. and E. coli Pseudomonas aeruginosa and Klebsiella Sp. also were noted in some of the patients. Pseudomonas aeruginosa, nonfermentative Gram's-negative bacilli (NF- GNB ), and Streptococcus Sp. were detected in many of the patients who had had an operation or who had been in hospital for a long time. The sensitivity of E. coli, Proteus Sp., Streptococcus Sp. and Pseudomonas aeruginosa was invariably more than 80%, while that of NF- GNB was more than 50%. PIPC was used for prophylactic treatment of patients against infections at the postoperative stage in the urogenital field. Out of 18 cases, it proved to be markedly effective in 14 cases and moderately effective in 4 cases. There was no poorly effective case. PIPC was employed for treatment in 5 cases complicated infections of urogenital tracts. There was no markedly effective case, and 2 moderately effective and 3 poorly effective cases resulted according to the UTI efficacy evaluation standards However, its bacteriological efficacy could be identified in all the treated cases. Therefore, PIPC is a valuable prophylactic antibiotic agent against infections after an operation in the urological field. It may also prove valuable in the therapeutic treatment of complicated infections in the urogenital tracts. PIPC has a relatively large margin of safety in terms of side effects as in the case of conventional penicillin group antibiotics.