[Efficacy of combined local therapy especially with hepatic arterial infusion for liver metastasis from gastric cancer].

Herein, we report four cases of a single liver metastasis after gastric cancer resection. Initially, we chose to perform hepatic arterial infusion( HAI) with high-dose 5-fluorouracil( 5-FU)( 6,000 mg/week) or weekly 500-750 mg of 5-FU. Three patients showed a partial response (PR) and one patient showed no change (NC). Therefore, we performed hepatectomy or radiofrequency ablation( RFA) 300-350 days after HAI. All four patients received postoperative HAI. Two patients survived without recurrence for 12 and 21 months. One patient developed prostate cancer but survived for 22 months as an outpatient. Finally, one patient experienced recurrence in the residual liver, but at a site not supplied by the hepatic artery. This patient survived for 36 months as an outpatient. In conclusion, HAI, liver resection, and RFA are effective in the management of single liver metastasis from gastric cancer.

[A case of primary duodenal cancer near the papilla of Vater which had initial symptoms of obstructive jaundice].

A 63-year-old man visited our hospital complaining of brown urine. A physical examination showed jaundice of the skin and conjunctiva bulbar. Blood tests showed elevated serum levels of bilirubin and hepatobiliary enzymes. A type 2-like mass lesion was found near the papilla of Vater during the endoscopic retrograde cholangiopancreatography and was histologically proven to be a well-differentiated adenocarcinoma. A diagnosis of obstructive jaundice due to primary duodenal cancer arising near the papilla of Vater was made. After the jaundice was decreased by endoscopic biliary stenting, a pancreatoduodenectomy was performed. A histopathological examination of the resected specimen concerning the location and manner of invasion of cancer cells revealed that the cancer arose from the duodenal mucosa near the papilla of Vater.

[Four cases of successful multidisciplinary treatment for hepatocellular carcinoma with portal venous thrombus].

CASE 1: TAI and radiation therapy were performed for a lateral segment and tumor thrombus extended into the left portal branch. Then, we diagnosed a tumor thrombus that extended into the right portal branch and TAI and operation were performed. The patient died about 9 months after the diagnosis of tumor thrombus. CASE 2: An operation was performed for hepatoma involving the right lobe and the tumor thrombus extended into the right portal branch. TAI and TAE were performed for residual tumor. The patient died about 12 months after diagnosis of tumor thrombus. CASE 3: An operation was performed for hepatoma involving an anterior segment and tumor thrombus extended into the right portal branch. Then, TAI, TAE and PMCT were performed for residual tumor. The patient is alive for 33 months with recurrence after the diagnosis of tumor thrombus. CASE 4: An operation was performed for hepatoma involving a posterior segment and tumor thrombus extended into the right portal branch. For recurrent TAI and TAE, radiation therapy was performed. The patient is alive for 20 months without recurrence after the diagnosis of tumor thrombus.

[A case report of hepatocellular carcinoma (Vp4)--an attempt to reduce residual tumor thrombus using combination therapy (hepatic arterial infusion, hepatic arterial embolization and radiation)].

A 57-year-old man was found to have elevated levels of HCC markers during an observation of chronic hepatitis C. Diffused hepatoma was involved in the posterior lobe, and tumor thrombus extended into the main portal vein (Vp4). Posterior segmentectomy and tumor thrombectomy were performed. But, CT scan 45 days after the operation showed an enhancement at the residual tumor thrombus in the posterior branch. The patient received a hepatic arterial infusion of 5-FU, followed by hepatic arterial embolization. Then, we chose radiation therapy to the tumor thrombus. The most recent CT showed no enhancement at the reduced tumor thrombus. There have been almost no reports of treatment for residual portal thrombus. Careful observations are necessary in such patients.

[A case of unresectable cholangiocellular carcinoma treated with surgery followed by combination chemotherapy].

The patient was a 44-year-old man, who was investigated for lateral abdominal pain and liver dysfunction, and subsequently referred to our department with a diagnosis of unresectable intrahepatic cholangiocellular carcinoma (CCC). Radiological examinations revealed the huge mass in the right lobe of the liver with intrahepatic metastasis in the left lobe. The main tumor was surgically removed, but the metastases were not removed. A month after the operation, a subcutaneous implant reservoir was indwelled for repeated transcatheter hepatic arterial chemo infusion therapy (5-fluorouracil 500 mg/day continuous infusion, day 1-5, and CDDP 10 mg/day, day 1) from the right femoral artery. After 15 courses of home anti-cancer chemotherapy, abdominal CT revealed that the size of intrahepatic metastasis in the left lobe of the liver had not shown growth, whereas other metastitic sites popped up in the caudate lobe, which were free of chemical agent flow. There was no major complication related to the chemotherapy throughout the post-treatment course. Although he maintained a good level of QOL, he refused further chemotherapy due to depression. He died of liver failure 7 months after the operation. In conclusion, volume reduction surgery followed by transcatheter hepatic arterial chemo infusion might be promising as an effective therapy for non resectable CCC.

[A case report--Efficacy of combination therapy to unresectable advanced gall bladder carcinoma--palliative operation, hepatic arterial infusion therapy, and radiation therapy].

A patient of advanced gall bladder carcinoma with liver metastases and direct invasions to the duodenum and liver underwent a palliative operation, 3 hepatic arterial infusion (HAI) therapies, and radiation therapy at the obstructive common biliary duct. (Palliative operation was a partial resection of duodenum and transverse colon, HAI therapy with 5-FU (1 g/day) was given as a continuous infusion for 6 days, radiation therapy was given 2 Gy/day for 20 times) After the combination therapy, the main tumor of gall bladder and hepatic metastases were decreased and tumor markers were normalized. (CEA 15.1 ng/ml, CA19-9 93 U/ml to CEA 4.4 ng/ml, CA19-9 29 U/ml) Then, an expandable metallic stent (EMS) could be inserted to the stenotic common biliary duct after radiation therapy. Although para-aotic lymph nodes were existent, systemic chemotherapy (UFT 300 mg/day p.o., MMC 2 mg/week div) has been performed as an outpatient with a good quality of life.

[A case of Vp3 hepatocellular carcinoma with a good QOL after multidisciplinary treatments].

A 74-year-old male was examined with abdominal CT scan because of general fatigue. Abdominal CT scan indicated enhanced tumors, 9x8 cm in size in subsegment 6/7 and 5 mm in size in subsegment 3. Tumor thrombus was observed in the right portal branch to the main portal vein. We diagnosed the patient with Vp3 hepatocellular carcinoma. A right hepatectomy with extraction of portal venous thrombus was performed. Unresectable tumor was treated with one shot arterial infusion (epi-ADM 40 mg) and TAE 3 times at an interval of three months. The side effect was only a fever and the QOL was good under the treatment. But a tumor in S1 had developed, and the patient died at about 12 months after the operation.

[Non-surgical treatment of hepatocellular carcinoma with tumor thrombus in the right atrium].

A 65-year-old Japanese man who had been suffering from severe and progressive dyspnea for more than 2 months underwent an extended right hepatectomy for hepatocellular carcinoma (HCC) in August 2001. Radiological examination, performed in August 2003, revealed the mass in the left lobe of the liver extended into the left hepatic vein, the inferior vena cava and the right atrium. Those clinical manifestations were supposedly attributed to HCC tumor thrombus in the right atrium. The decision to carry out the palliative operation for the tumor thrombus was not made because of poor prognosis in light of hemodynamic compromise indicating a reasonable liver function. A sequential course of treatments for the tumor thrombus was performed including transcatheter chemotherapy, transarterial chemoembolization and radiation therapy. Although a radiological response rate was 27% in diameter of the tumor thrombus, the clinical manifestations, such as dyspnea or edema, completely disappeared during the treatment. No surgical standard or interventional regimen for HCC tumor thrombus in the right atrium has been established. However, we here demonstrated the possibility for the treatment of the tumor thrombus with intensive combination therapies.