Hepatectomy using an ultrasonically activated scalpel for hepatocellular carcinoma.

BACKGROUND: The first retrospective studies were performed to compare the efficacy of the ultrasonic cavitational aspirator (aspirator group) and the ultrasonically activated scalpel (scalpel group) for hepatic resection in patients with hepatocellular carcinoma. PATIENTS AND METHODS: The aspirator group consisted of 8 patients (6 with liver cirrhosis and 2 with chronic hepatitis in the nontumorous liver), and the scalpel group of 7 patients (6 with liver cirrhosis and 1 with chronic hepatitis). All patients underwent limited hepatic resection, and the intermittent Pringle maneuver was applied during hepatic transection. RESULTS: There were no significant differences in preoperative hepatic function, type of hepatectomy, tumor size and maximum cross-sectional area of the resected specimen between the 2 groups. The amount of intraoperative blood loss was significantly less in the scalpel group than in the aspirator group (684 versus 1,859 ml, p < 0.05). The operation time was significanly shorter in the scalpel group than in the aspirator group (176 versus 262 min, p < 0.05). There were no significant differences in postoperative liver function and morbidity between the 2 groups. CONCLUSIONS: The ultrasonically activated scalpel is effective in reducing blood loss and in shortening the time of operation, and can be employed during limited resection of the liver with cirrhosis or chronic hepatitis.

Mitotic index is the best predictive factor for survival of patients with resected hepatocellular carcinoma.

BACKGROUND: In patients with hepatocellular carcinoma (HCC), tumor recurrence is not infrequent after resection. It is presumed that characteristics of the tumor such as cellular malignancy might influence the prognosis of the patients in association with tumor stage and radicality of the procedure. METHODS: Univariate and multivariate analyses were used to retrospectively determine the clinicopathologic factors potentially related to survival in 40 patients who underwent hepatectomy for HCC. RESULTS: In univariate analysis, tumor stage I or II, mitotic index of 4 or less/10 random high-power fields, solitary tumor, and curative resection were significantly correlated with better survival. In multivariate analysis, the mitotic index and surgical curability were independently significant variables influencing survival of patients, and the mitotic index was the best predictive factor. A highly significant correlation was found between the mitotic index and Ki-67 labeling index. Compared to tumors with a mitotic index of 4 or less, those with a mitotic index of 5 or more had a higher association with multiple tumors and advanced tumor stage, which preclude curative resection. CONCLUSION: Analysis of the mitotic index is quite simple, and the mitotic index could be a useful factor for predicting the long-term survival of patients with HCC following hepatic resection.

Prediction of recurrence and extratumor spread of hepatocellular carcinoma following resection.

BACKGROUND AND OBJECTIVES: The prognosis of patients with hepatocellular carcinoma (HCC) undergoing hepatectomy depends mostly on tumor recurrence. Portal vein invasion (Vp) and intrahepatic metastasis (IM) might strongly reflect the invasiveness of HCC, but the number of patients in the present series in whom either of these factors were detected was small. In this study, we defined Vp and IM as the extratumor spread, and we focused on the relationship between recurrence in patients after hepatectomy and the extratumor spread and the mitotic activities of cancer cells, in the hope that careful monitoring of recurrence might be possible by simply analyzing histology of the resected specimens. METHODS: Univariate and multivariate analyses were used to determine the factors potentially related to recurrence in 50 patients who underwent hepatectomy for HCC. RESULTS: The cumulative recurrence rate at 5 years was 81.0%. In univariate analysis, absence of the extratumor spread, mitotic index of four or less, and curative resection were significantly correlated with low incidence of recurrence. In multivariate analysis, the extratumor spread was the only significant variable influencing recurrence. The mitotic index in HCCs with the extratumor spread was significantly higher than the mitotic index in HCCs without the extratumor spread. CONCLUSIONS: As a predictive factor for recurrence after resection of HCC, the extratumor spread that reflects the malignant potential of cancer cells was found to be more accurate than is any single invasiveness parameter such as Vp or IM.

Total number and size distribution of hepatic metastases of carcinoma.

OBJECTIVE: To quantify the susceptibility of carcinoma to hepatic metastases by studying autopsy livers with carcinoma metastases, the primary sites of which were mostly the digestive organs. STUDY DESIGN: We developed a stereologic method of estimating the total number, N, and the size distribution of metastatic tumors in the liver based on a geometric model of spherical nodules with varying radii, r. This method proved to be sufficiently reliable by disector analysis simultaneously performed in some cases; it gave an approximate result. This method was applied to the 31 autopsy cases. Correlation and regression analyses were performed among N, the mean radius of nodules, rmean, and conventional pathologic features of the primary tumor. RESULTS: The estimates of N ranged from 10 to 3.2 x 10(5). A close negative correlation was confirmed between N and rmean. Neither significant correlation nor regression was observed among N and the other pathologic factors of the primary tumors. CONCLUSION: N turned out to serve as a useful index for evaluating the metastatic potential of a carcinoma. However, investigation has yet to be made to determine biologic factors in the primary tumor closely associated with N.

Therapeutic significance of palliative operations for gastric cancer for survival and quality of life.

BACKGROUND AND OBJECTIVES: There have been few reports on the objective assessment of quality of life (QOL) in patients with gastric cancer following palliative operations. The benefit of a palliative operation for survival and QOL of patients with gastric cancer is not clear. METHODS: Survival and hospital-free survival (HFS), which is considered to be one objective indicator of QOL, were studied in 95 patients undergoing palliative operations for gastric cancer. Univariate and multivariate analyses were used to determine the clinicopathologic factors potentially related to survival of patients. RESULTS: In univariate analysis, palliative gastrectomy and absence of peritoneal dissemination were significantly correlated with better survival. The significance of palliative gastrectomy for survival was, therefore, evaluated for various degrees of peritoneal dissemination: P0 no dissemination; P1, metastasis to the adjacent peritoneum; P2, a few scattered metastases to the distant peritoneum; and P3, numerous metastases. Survival and achievement of HFS for 3 months or longer were higher following palliative gastrectomy than gastrojejunostomy. Among gastrectomies, however, total gastrectomy performed in patients with P2 or P3 showed a poorer outcome for survival and HFS than total gastrectomy performed with P0 or P1 and distal gastrectomy. CONCLUSIONS: As a palliative measure, gastrojejunostomy and total gastrectomy performed with P2 or P3 peritoneal dissemination had no beneficial effect on the prolongation of survival or improvement of QOL of patients with gastric cancer.

Palliative operation for cancer of the head of the pancreas: significance of pancreaticoduodenectomy and intraoperative radiation therapy for survival and quality of life.

The benefits of a palliative operation and intraoperative radiation therapy (IORT) for survival and quality of life (QOL) of patients with cancer of the head of the pancreas are not clear. Survival and hospital-free survival (HFS), which are considered to be objective indicators of QOL, were studied in 13 patients who underwent palliative pancreaticoduodenectomy (PD) and 32 patients who underwent surgical bypass. Although there was no significant difference in the survival of patients who underwent PD or bypass (median survivals of 9 months and 7 months, respectively), HFS for 3 months or longer was achieved in 84.6% of the patients who underwent PD, which was significantly higher than that of the 53.1% in patients who underwent surgical bypass (p < 0.05). Among TNM stage III patients, a significant difference in survival was observed between surgical bypass associated with IORT and bypass alone (p < 0.05); the median survival time of the IORT group was 10 months, whereas that of the control group was 5 months. In addition, HFS of 3 months or longer was achieved in 83.3% of patients who underwent bypass with IORT but in only 25.0% of the patients who underwent surgery alone (p < 0.01). The addition of IORT to palliative PD neither prolonged survival nor improved HFS. These results show the beneficial effect of palliative PD on QOL, and the efficacy of IORT for survival and QOL was proved in cases with stage III pancreatic cancer who underwent surgical bypass. For patients subjected to palliative PD, however, IORT is not thought to be beneficial for either survival or QOL.

[Transfer of carmofur (HCFU) to the serum, bile, pancreatic juice and pancreatic tumor tissue in the cases of peri-pancreatic head cancer].

The concentrations of carmofur, 1-hexyl-carbamoyl-5-fluorouracil (HCFU), in the serum, bile, pancreatic juice and pancreatic tumor tissue were studied in 18 cases of peri-pancreatic head cancer with drainages of the pancreatic and biliary ducts after pancreatico-duodenectomy. As a result, high concentrations of HCFU and 5-FU were detected in the serum, bile and pancreatic juice after a per-oral administration of HCFU, 200 mg: HCFU was high in the order of serum > bile and pancreatic juice, and 5-FU in the order of bile, serum and pancreatic juice. Two hours after administration, 5-FU concentration in the bile and serum attained to the maximum levels of 0.45 and 0.19 micrograms/ml, respectively, which demonstrated a lasting transfer of 5-FU to the bile at high concentration. HCFU and 5-FU levels in the tumor tissue were 0.079 and 0.024 micrograms/g, respectively. In conclusion, antitumor effect against the malignant tumors of the pancreatobiliary system can be expected by peroral administration of carmofur.