Spontaneous complete necrosis of hepatocellular carcinoma: A case report and review of the literature.

The present study reports the case of a 68-year-old male patient who presented to Tokyo Rosai Hospital for the treatment of alcoholic liver disease. A high density was observed in liver segment S2, while a tumor, 30 mm in size, exhibiting a low density was observed in the delayed phase upon contrast-enhanced computed tomography (CT), which was performed prior to admission. The tumor appeared slightly poorly defined upon abdominal ultrasound and was observed as a 30 mm low-echoic nodule that was internally heterogeneous. A 5-mm thick contrast enhancement effect was observed in the tumor border in the vascular phase on Sonazoid contrast-enhanced ultrasonography, while a defect in the entire tumor was observed in the post-vascular phase. Dysphagia had commenced three months prior to presentation and a weight loss of ~3 kg was observed. Therefore, the patient was admitted to Tokyo Rosai Hospital due to the presence of a hepatic tumor, and to undergo a close inspection of the cause of the tumor. Upon close inspection, it was determined that the weight loss and aphagia were caused by progressive bulbar paralysis. A contrast-enhanced CT was performed on post-admission day 29 as a follow-up regarding the hepatic tumor. As a result, although no change in the tumor size was observed, the contrast enhancement in the tumor borderline had disappeared. Necrosis of the tumor was considered. However, as viable persistence of the malignant tumor could not be excluded, a hepatic left lobe excision was performed. The patient was diagnosed with hepatocellular carcinoma (HCC) based on the morphology of the cellular necrosis. In addition, occlusion due to thrombus was observed within the blood vessels passing inside the fibrous capsule. It was hypothesized that the formation of a thick fibrous capsule and occlusion due to thrombus in the feeding vessel were possibly involved as the cause of complete spontaneous necrosis. Written informed consent was obtained from the patient.

Mucinous cystadenocarcinoma of the appendix in which contrast-enhanced ultrasonography was useful for assessing blood flow in a focal nodular lesion in the tumor cavity: A case report.

A 63-year-old woman was admitted to hospital with pain in the right lower quadrant. Abdominal computed tomography (CT) revealed a 60-mm cystic mass at a site corresponding to the appendix. The mass wall on the appendicular ostium was thickened and enhanced by contrast, while calcification was observed in the mass wall on the appendicular tip. No projection was observed in the mass cavity. On abdominal ultrasonography (US), the mass wall on the appendicular ostium was thickened and projections were observed at two sites in the mass cavity. On contrast-enhanced US (CEUS), only one of these projections was enhanced. Based on the thickened and contrast-enhanced wall of the mass on the appendicular ostium on CT and US, as well as the contrast enhancement of a projection on US, the mass was diagnosed as mucinous cystadenocarcinoma of the appendix. Ileocecal resection was subsequently performed on day 10. A detailed examination of the surgical specimen revealed carcinoma cells in the mass wall on the appendicular ostium. The contrast-enhanced projection was identified as granulation tissue that had grown to come into contact with the tumor, while the non-contrast-enhanced projection was identified as solidified mucus. US enabled successful visualization of projections in the mass cavity that were not visible on abdominal CT. CEUS also proved useful for assessing blood flow in these projections.

A case of branch duct type intraductal papillary neoplasm of the bile duct treated by open surgery after 11 years of follow-up.

The intraductal papillary neoplasm of the bile duct (IPNB) is a novel disease concept that was recently classified as a biliary cystic tumor by the revised World Health Organization classification. This is the case report of a 70-year-old female patient who experienced repeated episodes of obstructive jaundice and cholangitis since 2000, attributed to a mucus-producing hepatic tumor. Surgery was advised due to the repeated episodes; however, the patient refused. In May, 2011, the patient developed jaundice and fever and was treated with antibiotics. Since there was no improvement, the patient was admitted to the Tokyo Rosai Hospital. Abdominal computed tomography (CT) revealed a 50-mm cystic mass with an internal septum in the left hepatic lobe. Although the tumor size had remained almost unchanged compared to the initial CT scan performed in 2000, intra- and extra-hepatic bile duct dilation was more prominent on the second CT scan. Following admission, endoscopic retrograde cholangiopancreatography was performed and revealed an expanded papilla of Vater due to a mucous plug. A balloon catheter was inserted into the bile duct to remove the mucous plug, resulting in the drainage of copious amounts of mucus and infected bile. The patient finally consented to surgery and left hepatic lobectomy was performed. Consequently, the diagnosis of low-grade IPNB was made. Branch duct type IPNB, which is characterized by imaging appearance of a cystic mass and slow progression, is attracting increasing attention. In the present case, a cystic mass was identified in the left hepatic lobe, with no significant change in size after 11 years of follow-up, leading to the diagnosis of branch duct type IPNB. Considering the fact that IPNB is usually treated surgically at the time of diagnosis, the present case, due to the long-term follow-up, provides valuable insight into the natural history of the tumor.

Caval invasion by liver tumor is limited.

BACKGROUND: Successful hepatic resection with combined inferior vena cava (IVC) resection has been reported. The necessity of a combined IVC resection for hepatic malignancies that have attached to the IVC has not been fully evaluated. STUDY DESIGN: In this retrospective study, 162 lesions for which preoperative CT findings suggested attachment to the IVC were evaluated. Patient survival rates were examined according to type of tumor and the operative procedure. For adenocarcinoma lesions, several CT findings, including extent of the IVC circumference attached to the tumor compared with the whole IVC circumference (E(IVC)), were evaluated in conjunction with IVC resection. RESULTS: Among 162 lesions, 18 adenocarcinoma lesions were resected in combination with an IVC resection. Histologic IVC invasion was confirmed in eight patients. None of the 67 hepatocellular carcinoma lesions required concomitant IVC resection. Overall 5-year survival rate of the patients who underwent concomitant liver and IVC resections was 33.1%. Among the adenocarcinoma lesions, the positive predictive factors for IVC resection were an E(IVC) value > 25% and a peaked deformity of the IVC wall, according to a multivariate analysis. CONCLUSIONS: Most hepatic malignancies attached to the IVC wall can be completely removed without IVC resection. E(IVC) and deformity of the IVC on CT can be useful indicators for a concomitant liver and IVC resection. Careful separation of the liver and IVC is a key point for minimizing the size of the resected IVC and to avoid unnecessary IVC resection.

Staging of hepatocellular carcinoma: assessment of the Japanese TNM and AJCC/UICC TNM systems in a cohort of 13,772 patients in Japan.

OBJECTIVE: The aims of this study were to present evidence to develop and validate the Japanese Tumor-Node-Metastasis (TNM) staging system for primary liver cancer and to compare its discriminatory ability and predictive power with those of Vauthey's simplified staging, which was adopted as the TNM staging system of the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC). SUMMARY BACKGROUND DATA: Among many staging systems for hepatocellular carcinoma, the Japanese TNM staging system and the AJCC/UICC staging system were developed based on a survival analysis of surgical patients. These 2 staging systems have not been compared in large series. METHODS: The Liver Cancer Study Group of Japan (LCSGJ) prospectively collected clinicopathologic data of 63,736 patients with primary liver cancer from 1995 to 2001. Among them, 13,772 patients received curative hepatic resection. Based on univariate and multivariate survival analyses, the Japanese TNM staging system was developed. The accuracy of the Japanese TNM staging system for predicting patient survival was compared with that of the AJCC/UICC staging system using the cross-validation method. RESULTS: The independent prognostic factors (relative risk; 95% confidence interval) were vascular or bile duct invasion (1.36;1.29-1.43), liver cirrhosis (1.26;1.20-1.32), diameter (< or =2 cm or >2 cm) (1.21;1.14-1.28), alpha-fetoprotein (1.20;1.15-1.25), single/multiple (1.18;1.12-1.23), liver damage (1.15;1.10-1.20), hepatic involvement (1.14;1.09-1.19), histologic differentiation (1.14;1.08-1.20), gross classification (1.13;1.08-1.18), and esophageal varices (1.07;1.02-1.13). Based on these results, 3 criteria (vascular or bile duct invasion, diameter, and single/multiple) were selected. Patients with none of these 3 factors were considered T1, and those with 1, 2, and 3 factors were T2, T3, and T4, respectively. The number of patients and 5-year survival rates for T1, T2, T3, and T4 were 2078, 70%; 6853, 58%; 3021, 41%; and 582, 24% (P < 0.0001), respectively, while those for the AJCC-T were 8457, 61% in T1, 2888, 46% in T2, and 1189, 30% in T3 (P < 0.0001). While both the LCSGJ-T and the AJCC-T had good discriminating ability, the former was significantly superior (P = 0.0007). CONCLUSIONS: Our findings support the development of LCSG stage. While both staging systems allow for the clear stratification of patients into prognostic groups, the LCSGJ staging may be more appropriate for stratifying patients with early-stage HCC.

Simplified staging system for predicting the prognosis of patients with resectable liver metastasis: development and validation.

HYPOTHESIS: Although several staging systems for colorectal liver metastasis have been proposed, simple and generally accepted staging systems are not available for this disease. We hypothesized that more detailed analysis of primary colorectal cancer may make it possible to develop a simple staging system and that its stratification ability may be demonstrated by validation against data from unrelated patients. DESIGN: Retrospective analysis of prospectively documented data, development of a stage, and validation against an unrelated cohort. SETTING: Four tertiary referral centers. PATIENTS: Twenty-two clinicopathologic factors were examined in 369 consecutive patients who underwent curative resection for liver metastasis from colorectal cancer (original cohort). Using the independent prognostic factors, a simplified staging system was developed and was validated by data from 229 unrelated patients (validation cohort). MAIN OUTCOME MEASURES: Kaplan-Meier survival curve analyses between different prognostic groups in the cohorts. RESULTS: Multivariate analysis revealed several independent prognostic variables, including hepatic lymph node metastasis (relative risk 4.39), 4 or more colorectal lymph node metastases (RR 1.50), carcinoembryonic antigen level of 50 ng/mL or higher (RR 1.29), and multiple hepatic metastases (RR 1.27). Patients with hepatic lymph node metastasis were assigned to stage 4, and the remaining patients were divided according to number of factors: none, stage 1; 1, stage 2; 2 or 3, stage 3. In the original cohort, median survival in stages 1, 2, 3, and 4 was 7.2, 3.5, 2.0, and 1.3 years, respectively. In the validation cohort, these values were 9.6, 4.1, 2.8, and 1.6 years, respectively. CONCLUSIONS: The proposed simplified staging system was easy to use, was highly predictive of patient outcome, and permitted categorization of patients into treatment groups. Although we validated this staging system, further validation and improvements are needed.

Inflammatory pseudotumor of the spleen: clinical impact in surgical treatment.

An inflammatory pseudotumor of the spleen is a rare benign tumor and designated as mass-like lesions with histologic features of nonspecific inflammation and mesenchymal repair although its etiopathogenesis still remains unknown. Here we describe the case of an inflammatory pseudotumor of the spleen in a 57-year-old woman, whose lesion was accidentally found and thought to be lymphoma at first. Generally splenic tumors are difficult to diagnose exactly before surgery, then the patient underwent splenectomy, followed by histopathological diagnosis of inflammatory pseudotumor of the spleen. The optimal management of the asymptomastic patient with such disease is still controversial. The clinical and pathological features of previously reported cases are also reviewed in this paper.

Treatment of hepatocellular carcinoma accompanied by portal vein tumor thrombus.

The prognosis of patients with hepatocellular carcinoma (HCC) accompanied by portal vein tumor thrombus (PVTT) is generally poor if left untreated: a median survival time of 2.7-4.0 mo has been reported. Furthermore, while transcatheter arterial chemoembolization (TACE) has been shown to be safe in selected patients, the median survival time with this treatment is still only 3.8-9.5 mo. Systemic single-agent chemotherapy for HCC with PVTT has failed to improve the prognosis, and the response rates have been less than 20%. While regional chemotherapy with low-dose cisplatin and 5-fluorouracil or interferon and 5-fluorouracil via hepatic arterial infusion has increased the response rate, the median survival time has not exceeded 12 (range 4.5-11.8) mo. Combined treatment consisting of radiation for PVTT and TACE for liver tumor has achieved a high response rate, but the median survival rates have still been only 3.8-10.7 mo. With hepatic resection as monotherapy, the 5-year survival rate and median survival time were reportedly 4%-28.5% and 6-14 mo. The most promising results were reported for combined treatments consisting of hepatectomy and TACE, chemotherapy, or internal radiation. The reported 5-year survival rates and median survival times were 42% and 31 mo for TACE followed by hepatectomy; 36.3% and 22.1 mo for hepatectomy followed by hepatic arterial infusion chemotherapy; and 56% for chemotherapy or internal radiation followed by hepatectomy.

Selection criteria for simultaneous resection in patients with synchronous liver metastasis.

HYPOTHESIS: While simultaneous resection has been shown to be safe and effective in patients with synchronous metastasis, neoadjuvant chemotherapy followed by hepatectomy has gradually gained acceptance for both initially nonresectable metastasis and resectable metastasis. The boundary between these treatments is becoming unclear. We hypothesized that factors associated with colorectal cancer may play an important role in the prognosis of patients with synchronous metastasis and may be useful for identifying patients who can be expected to have adequate results following simultaneous resection. DESIGN: Outcome study. SETTING: Tertiary referral center. PATIENTS: From January 1980 to December 2002, 187 patients underwent curative resection for synchronous liver metastasis from colorectal cancer. One hundred forty-two patients received simultaneous resection, 18 underwent staged resection, and 27 underwent delayed hepatic resection. Twenty-one clinicopathological factors were analyzed, and long-term prognosis was assessed. MAIN OUTCOME MEASURES: Prognostic factors and patient survival. RESULTS: There was no in-hospital death. In a multivariate analysis, the factors that significantly affected the prognosis of synchronous metastasis were 4 or more lymph node metastases around the primary cancer (P<.001) and multiple liver metastases (P = .003). In patients with 3 or fewer lymph node metastases around the primary cancer, the 5-year survival rates of those with 1, 2 to 3, and 4 or more liver metastases were 63%, 33%, and 40%, respectively, but these rates were 15%, 22%, and 0%, respectively, in patients with 4 or more lymph node metastases around the primary cancer. CONCLUSIONS: The results support the application of simultaneous resection in patients with 0 to 3 colorectal lymph node metastases. However, in patients with 4 or more colorectal lymph node metastases, biological selection by neoadjuvant chemotherapy may be more suitable.

Pancreaticoduodenectomy after esophageal and gastric surgery preserving right gastroepiploic vessels.

Secondary pancreaticoduodenectomy was performed in 2 patients, 1 who had undergone proximal gastrectomy for a gastric carcinoma and 1 who had undergone subtotal esophagectomy with stomach tube reconstruction for an inferior thoracic esophageal carcinoma. To prevent ischemia and congestion of the remnant stomach, the inflow and outflow pathways to the stomach, such as the right gastroepiploic artery and vein, were preserved. In this article, we describe the preservation procedures and discuss the problems of the secondary abdominal surgical procedure.

Prognostic impact of anatomic resection for hepatocellular carcinoma.

OBJECTIVES: To evaluate the prognostic impact of anatomic versus nonanatomic resection on the patients' survival after resection of a single hepatocellular carcinoma (HCC). SUMMARY OF BACKGROUND DATA: Anatomic resection is a reasonable treatment option for HCC; however, its clinical significance remains to be confirmed. METHODS: Curative hepatic resection was performed for a single HCC in 210 patients; the patients were classified into the anatomic resection (n = 156) and nonanatomic resection (n = 54) groups. In 84 patients assigned to the anatomic resection group, segmentectomy or subsegmentectomy was performed. We evaluated the outcome of anatomic resection, including segmentectomy and subsegmentectomy, in comparison with that of nonanatomic resection, by the multivariate analysis taking into consideration 14 other clinical factors. RESULTS: Both the 5-year overall survival and disease-free survival rates in the anatomic resection group were significantly better than those in the nonanatomic resection group (66% versus 35%, P = 0.01, and 34% versus 16%, P = 0.006, respectively). In the segmentectomy and subsegmentectomy group, the 5-year overall and disease-free survival rates were 67% and 28%, respectively, both of which were also higher than the corresponding rates in the nonanatomic resection group (P = 0.007 and P = 0.001, respectively). The results of multivariate analysis revealed that anatomic resection was a significantly favorable factor for overall and disease-free survivals: the hazard ratios were 0.57 (95% confidence interval, 0.32-0.99, P= 0.04), and 0.65 (0.43-0.96, P = 0.03). CONCLUSION: Anatomic resection for a single HCC yields more favorable results rather than nonanatomic resection.

Histochemical expression of sialoglycoconjugates in carcinoma of the papilla of Vater.

BACKGROUND/AIMS: Cell surface glycosylation changes during oncogenesis and is thought to correlate with the malignant potential of cancers. To investigate the role of sialylation in carcinoma of the papilla of Vater, histochemical analyses were performed using sialic acid-binding lectins, Maackia amurensis leukoagglutinin and Sambucus nigra agglutinin. METHODOLOGY: Thirty-six papillary carcinoma tissues and 8 normal papillary tissues were subjected to lectin-histochemical staining. The relationship between lectin staining characteristics and clinicopathological parameters was statistically analyzed. RESULTS: Epithelial cells of glands in normal tissues were stained with Sambucus nigra agglutinin but not with Maackia amurensis leukoagglutinin. Of 36 papillary carcinoma tissues, 20 showed Maackia amurensis leukoagglutinin-positive staining in cancer cells, whereas all 36 were Sambucus nigra agglutinin-positive in cancer cells. According to Maackia amurensis leukoagglutinin-staining characteristics, the 36 cases were divided into two groups: positive (n=20) and negative (n=16). Statistical analysis indicated that positive staining in cancer cells was frequent in cases of lymph node metastasis (p=0.001) and in cases classified > or = T2 by TNM classification (p=0.036). CONCLUSIONS: Aberrant expression of sialoglycoconjugates recognized by Maackia amurensis leukoagglutinin might participate in lymph node metastasis and in an advanced stage of invasion in carcinoma of the papilla of Vater.

p16INK4A hypermethylation is associated with hepatitis virus infection, age, and gender in hepatocellular carcinoma.

PURPOSE: The tumor suppressor gene p16INK4A is mainly inactivated by an epigenetic change involving promoter hypermethylation in hepatocarcinogenesis. The possible clinical impact of p16INK4A methylation and the potential risk factors for this epigenetic alteration have not been thoroughly investigated. EXPERIMENTAL DESIGN: We studied the methylation status and mRNA and protein expression of p16INK4A in 50 hepatocellular carcinomas and corresponding nonneoplastic liver lesions using methylation-specific PCR, reverse transcription-PCR, and immunohistochemical techniques. RESULTS: p16INK4A hypermethylation was observed in 58% (29 of 50) of the hepatocellular carcinomas and 16% (6 of 38) of the corresponding chronic hepatitis and cirrhosis tissue samples. p16INK4A methylation was significantly associated with mRNA and protein expression (P <0.001 and P=0.003, respectively). All of the p16INK4A-methylated tumors were positive for hepatitis B virus or hepatitis C virus markers, but none of the virus-negative tumors exhibited p16INK4A methylation (P=0.006). The frequency of p16INK4A hypermethylation tended to be higher in hepatitis C virus-related tumors (23 of 32, 72%) than in hepatitis B virus-related tumors (6 of 13, 46%; P=0.1). Aberrant methylation of p16INK4A was also related significantly to increasing age, female gender, and normal levels of serum PIVKA-II (P=0.02, 0.04, and 0.04, respectively). No statistically significant difference in survival was observed between patients with p16INK4A hypermethylation and those without. CONCLUSIONS: Our observations suggest that p16INK4A hypermethylation may contribute to hepatocarcinogenesis from an early stage and that multiple risk factors, such as viral infections, age, and gender, may be associated with p16INK4A hypermethylation in hepatocarcinogenesis.

Intraoperative three-dimensional visualization of liver vasculature by ultrasonography.

BACKGROUND/AIMS: To understand the three-dimensional relationship between the liver vasculature and tumor by intraoperative sonography, some training is inevitable. Three-dimensional ultrasound has been evaluated in various fields, but not yet in intraoperative sonography. METHODOLOGY: Extracorporeal 3-D ultrasonography was performed in 32 patients. Of these, 20 underwent intraoperative 3-D ultrasonography. Using these images, we evaluated whether or not the portal vein, hepatic vein and its branches were discernible. RESULTS: Satisfactory images were obtained in all 32 patients by extracorporeal methods and in 15 by intraoperative 3-D ultrasonography. The number of visualized veins, including the right portal vein, its anterior branch, posterior branch, anterior superior branch, anterior inferior branch and right hepatic vein, was 32, 32, 23, 28, 22, and 30 by extracorporeal 3-D ultrasonography, and 15, 14, 10, 8, 5, and 12 by intraoperative 3-D ultrasonography. The relationships between the intrahepatic artery, portal vein, and hepatic vein were more clearly visualized by intraoperative 3-D sonography. CONCLUSIONS: Intraoperative 3-D ultrasonography clearly showed small branches of the liver vasculature and their 3-D relation, which may be helpful for liver surgery. However, this method requires further improvement.

Surgical approach to liver metastasis with hepatic hilar invasion.

We present a surgical procedure for liver metastases with hepatic hilar invasion, which was originally developed for hilar bile duct cancer. A 64-year-old man with 8 metastatic nodules from colon cancer and hepatic hilar invasion received this technique, and lived for more than 5 years without any restriction in his life. The authors recommend this procedure for those patients in order to preserve their quality of life.

Single and multiple resections of multiple hepatic metastases of colorectal origin.

BACKGROUND: Indications for hepatectomy in patients with 4 or more hepatic colorectal metastases remain controversial. METHODS: A retrospective cohort study was performed with data from 131 patients who underwent a total of 198 hepatectomies. Patients were grouped according to the number of metastases at the initial hepatectomy (analysis 1) or by the total number of metastases removed by multiple hepatectomies (analysis 2). RESULTS: In analysis 1, the risk ratios for death of patients with 4 to 9 and 10 nodules to those with 1 to 3 nodules were 2.12 (95% CI, 0.99-4.23) and 7.32 (95% CI, 2.82-16.9), respectively. In analysis 2, the risk ratios for death were 1.32 (95% CI, 0.66-2.59) and 3.07 (95% CI, 1.41-6.36), respectively. These values in 106 patients with negative surgical margins were 1.52 (95% CI, 0.51-3.73) and 5.40 (95% CI, 1.25-16.5), and 1.06 (95% CI, 0.45-2.32) and 1.70 (95% CI, 0.49-4.61), respectively. In analysis 2, the 5-year survival rates of patients with 1 to 3, 4 to 9, and 10 or more nodules were 51%, 46%, and 25%, respectively. CONCLUSION: Hepatic resection for patients with 4 to 9 nodules clearly is warranted. On the other hand, for patients with 10 or more tumor nodules, surgery cannot be ensured absolutely to be contraindicated in high volume centers at which the surgical mortality rate is nearly zero.

Hepatic resection with reconstruction of the inferior vena cava or hepatic venous confluence for metastatic liver tumor from colorectal cancer.

BACKGROUND: Resection of colorectal liver metastases infiltrating the inferior vena cava (IVC) or hepatic venous confluence (HVC) is technically feasible, but the procedure frequently involves invasive techniques, and its long-term outcome has not yet been fully described. STUDY DESIGN: From October 1994 through June 2001, 87 patients underwent first curative hepatic resections for colorectal metastases. Nine patients (the IVC/HVC group) received hepatectomy combined with IVC or HVC reconstruction. Clinicopathologic characteristics, surgical results, and patient survival were investigated and compared with those of the remaining 78 patients (the comparison group). RESULTS: Three IVCs and eight hepatic veins were successfully resected and reconstructed by primary closure (n = 3), direct anastomosis (n = 1), or by the use of autologous vein grafts (n = 7). A comparison between the two groups revealed that the primary colorectal tumor stage was similar, but the IVC/HVC group had more (median 4 versus 2, p < 0.05) and larger (median 5.0 versus 3.2 cm, p < 0.05) lesions. The IVC/HVC group required longer operating times (median 600 versus 320 minutes, p < 0.001) and suffered greater blood loss (median 1,034 versus 434 g, p < 0.01) and more extensive liver parenchyma resection (median 585 versus 155 g, p < 0.001). Patients in the IVC/HVC group had a shorter survival time (median survival time 25.8 versus 44.0 months, p < 0.01). CONCLUSIONS: Hepatic resection combined with the IVC or HVC reconstruction for colorectal liver metastases can be performed with acceptable morbidity, and possibly with no mortality. Although no definite conclusion on long-term survival can be drawn from our study, given the limited number of patients, their overall survival was unsatisfactory. Further studies are needed to clarify the contribution of combined resection and reconstruction of IVC/HVC to long-term survival, because surgical resection currently provides the only hope of cure.

Complete remission of disease for 5 years following initial and repeat resection of the liver for the removal of 22 metastases of colorectal origin.

Although liver resection is accepted as the only available treatment that regularly produces long-term survival with possible cure in patients with colorectal carcinoma metastatic to the liver, controversy appears to exist regarding the surgical indication for patients with more than four nodules. Similarly, it may be arguable to perform a repeated hepatic resection for a patient who developed multiple recurrent liver metastases with a short disease-free period after the initial liver resection. During the last 7 years, we have adopted constantly the aggressive surgical approach to patients with colorectal carcinoma metastatic to the liver if the number of tumor nodules identified preoperatively were less than ten and irrespective of the length of disease-free period after the previous resection. Here we report on a patient who underwent hepatic resection twice at an interval of 3 months and in whom a total of 22 metastatic nodules (6 in the initial hepatic resection and 22 in the repeated resection) were removed. The patient is now alive and remains disease-free, 5 years after the first liver resection.

[Surgical treatment of colorectal liver metastasis].

The aim of this study was to evaluate retrospectively the long-term results of our approach, which consists of surgically treating every case in which radical resection of all metastatic disease was technically feasible. The indications for surgical resection for liver metastases from colorectal cancer remain controversial. Several clinical risk factors have been reported to influence survival. Between 1980 and 2001, 304 patients underwent curative hepatic resection for metastatic colorectal cancer at our institution. Survival rates and disease-free survival as a function of clinical and pathological determinants were examined retrospectively. The overall 3-, 5, 10-, and 20-year survival rates were 51%, 36%, 26%, and 25%, respectively. The stage of the primary tumor, lymph node metastasis, multiple nodules, a high preoperative CEA level and a short interval between treatment of the primary and metastatic tumors were significantly associated with a poor prognosis. Patients with 4 or more metastases had almost the same survival rate as those with 2 or 3 nodules. Extrahepatic metastases or invasion at hepatectomy did not worsen the survival rate if curatively resected. These results confirm that surgical resection is useful for treating liver metastases from colorectal cancer. While multiple metastases significantly impair patient prognosis, the life expectancy of patients with 4 or more nodules makes their resection mandatory.

Selection criteria for repeat hepatectomy in patients with recurrent hepatocellular carcinoma.

OBJECTIVE: The purpose of this study was to evaluate prognostic factors in patients with recurrence after curative resection of hepatocellular carcinoma (HCC) and to identify selection criteria for repeat resection. SUMMARY BACKGROUND DATA: Recent studies have demonstrated that repeat hepatectomy is effective for treating intrahepatic recurrent HCC in selected patients. However, the prognostic factors in these patients have not been fully evaluated. METHODS: From October 1994 to December 2000, 334 patients underwent primary resection for HCC, and 67 received a 2nd hepatectomy for recurrent HCC. The survival results in these 67 patients were analyzed, and prognostic factors were determined using 38 clinicopathological variables. The prognosis and operative risk in 11 and 6 patients who received a 3rd and 4th resection were also evaluated. RESULTS: The overall 1-, 3-, and 5-year survival rates of the 334 patients after primary hepatectomy were 94%, 75%, and 56%, while those of the 67 patients after a 2nd resection were 93%, 70%, and 56%, respectively. There was no difference in survival (P = 0.64). All of the patients who underwent a 3rd or 4th are currently alive at a median follow-up of 2.5 and 1.4 years, respectively. The operative time and blood loss in the 2nd resection in patients who underwent a major primary resection were not different from those in patients who underwent minor hepatectomy at the 1st resection, and there were also no differences in these variables among the 2nd, 3rd, and 4th resections. In a multivariate analysis, absence of portal invasion at the 2nd resection (P = 0.01), single HCC at primary hepatectomy (P = 0.01), and a disease-free interval of 1 year or more after primary hepatectomy (P = 0.02) were independent prognostic factors after the 2nd resection. Twenty-nine patients with all 3 of these factors showed 3- and 5-year survival rates of 100% and 86%, respectively, after the 2nd resection. CONCLUSIONS: Repeat hepatic resection is the treatment of choice for patients who have previously undergone resection of a single HCC at the primary resection and in whom recurrence developed after a disease-free interval of 1 year or more and the recurrent tumor had no portal invasion.