Current Status of Conversion Hepatectomy After Sorafenib and Lenvatinib Treatment for Unresectable Hepatocellular Carcinoma.

BACKGROUND/AIM: Sorafenib and lenvatinib have long been used as a first-line treatment for advanced hepatocellular carcinoma (HCC). Along with the development of systemic chemotherapy for HCC, the concept of conversion hepatectomy has recently become widespread. The present study aimed to assess the clinical outcomes of sorafenib and lenvatinib for HCC regarding the possibility of conversion hepatectomy in clinical practice. PATIENTS AND METHODS: A total of 295 patients with advanced HCC receiving sorafenib and lenvatinib, accounting for 306 treatments (sorafenib, n=157; lenvatinib, n=149, 11 patients received lenvatinib after sorafenib treatment) at five different institutions were enrolled. Patients were assessed for their clinical characteristics and therapeutic response using both Response Evaluation Criteria in Solid Tumors criteria (RECIST) and modified RECIST (mRECIST) criteria. Additionally, an indication of surgery after tyrosine kinase inhibitor administration was determined based on the tumor status of patients. RESULTS: The median survival times of patients treated with sorafenib and lenvatinib were 12.8 and 16.4 months, respectively, without significant difference (p=0.1645). The objective response rates (ORR) of sorafenib based on mRECIST and RECIST were 10.1% and 5.9%, respectively, and those of lenvatinib were 38.1% and 19.0%, respectively. Among the 306 treatments, two cases (sorafenib and lenvatinib, one each) underwent hepatectomy after systemic chemotherapy. CONCLUSION: Few cases with unresectable HCC were amenable to conversion hepatectomy after sorafenib and lenvatinib treatments due to the limited ORR by RECIST. Cautious approach must be taken when administering neoadjuvant chemotherapy aimed at conversion hepatectomy.

The Influences of Changes in Physical Activity Levels With Easing Restriction of Access to the University Campus on Empathy and Social Supports in College Students During the COVID-19 Pandemic.

College students in Japan are restricted from accessing the campus associated with promoting online classes during the COVID-19 pandemic; it would lead to less physical activity and poor relationships with others. Here, we measured 887 college students' amounts of physical activity, sitting time, self-reported cognitive and affective empathy, and perceived social support before and after easing campus entrance restrictions. The amounts of total activity, vigorous-intensity, and moderate-intensity activity in college students, both male and female, increased after easing restrictions of accessing the campus compared during restrictions. The amounts of walking activity were unchanged. Self-reported cognitive empathy scores significantly increased in female students after mitigating restrictions, but not in males. Furthermore, the total of physical activity's change amounts was positively correlated with changes in the scores of affective empathy and perceived family support. In addition, changes in the scores of affective empathy were positively correlated with perceived social help from family, friends, and close people. The current findings imply that increasing physical activity levels after easing restriction of access to the campus would lead to a better quality of life in young adults during the COVID-19 pandemic.

A case of peripancreatic plexiform schwannoma.

BACKGROUND: Plexiform schwannoma is one of the least common variants of schwannoma, accounting for only 5% of all schwannoma cases. It generally occurs in the skin and subcutaneous tissues and is uncommon in deep soft tissue or viscera. We present an extremely rare case of plexiform schwannoma arising from the peripancreatic plexus. CASE PRESENTATION: A 29-year-old man presented with hyperglycemia detected during a medical checkup. He was diagnosed with type 1 diabetes based on the clinical findings and laboratory tests. During the diagnostic process for diabetes, a 2.5 cm mass was incidentally detected in the pancreas by abdominal ultrasound. Contrast-enhanced computed tomography revealed a mass that was gradually enhanced at the body and tail of the pancreas. Magnetic resonance imaging revealed low signal intensity of the mass on T1-weighted images and high signal intensity on T2-weighted and diffusion-weighted images. Magnetic resonance cholangiopancreatography showed no abnormal findings in the main pancreatic duct. Endoscopic ultrasonography (EUS) showed a lobulated, low-echoic mass with a clear boundary. EUS-guided fine needle biopsy was performed, and spindle-shaped cells that were diffusely immunopositive for S-100 and negative for c-kit and desmin were detected, resulting in a diagnosis of a neurogenic tumor arising from the pancreas or the peripancreatic nerve plexus. The patient underwent laparoscopic spleen-preserving distal pancreatectomy. Although the tumor was connected to the splenic plexus, the splenic artery could be divided along its adventitial plane. Macroscopic findings of the excised tumor consisted of multiple yellowish-white nodules, and its histopathological features were consistent with plexiform schwannoma. There was no pancreatic tissue on the dorsal surface of the tumor, which suggested that the tumor arose from the peripancreatic nerve plexus. CONCLUSIONS: The findings documented herein can aid in the differential diagnosis of peripancreatic schwannoma and in planning appropriate treatment.

Surgical spacer placement for proton radiotherapy in locally advanced pancreatic body and tail cancers: initial clinical results.

BACKGROUND: Particle radiotherapy has increasingly gained acceptance for locally advanced pancreatic cancers owing to superior tumor conformity and dosimetry compared to conventional photon radiotherapy. However, the close proximity of the pancreas to the stomach and duodenum leads to radiation-induced gastrointestinal toxicities, which hinder the delivery of curative doses to the tumor. To overcome this problem, a surgical spacer was placed between the tumor and gastrointestinal tract, and subsequent proton radiotherapy was performed in this study. METHODS: Data from 9 patients who underwent surgical spacer placement and subsequent proton radiotherapy were analyzed. The safety and feasibility of the spacer placement surgery were evaluated; the impact of the spacer on dosimetry was also assessed using dose volume histogram (DVH) analyses, before and after surgical spacer placement. RESULTS: Surgical spacer placement and subsequent proton radiotherapy were successfully completed in all cases. Surgical spacer placement significantly improved the dose intensity covering 95%, mean, and minimum doses for the gross tumor volume, and the clinical and planning target volume based on the DVH, while respecting the dose constraints of the gastrointestinal tract. Based on the Common Terminology Criteria for Adverse Events, two patients (22.2%) developed gastrointestinal ulcer (Grade 2) at 1 and 35 months, and one patient (11.1%) developed gastric perforation (Grade 4) at 4 months after proton radiotherapy. CONCLUSIONS: Surgical spacer placement in the locally advanced pancreatic body and tail cancers is relatively safe and technically feasible. Comparing radiation plans, surgical spacer placement seems to improve the dose distribution in the locally advanced pancreatic body and tail cancers, which are close to the gastrointestinal tract.

Impact of Albumin-Bilirubin Score on Short- and Long-Term Survival After Living-Donor Liver Transplantation: A Retrospective Study.

BACKGROUND: The albumin-bilirubin (ALBI) grade, stratified from the ALBI score, may have prognostic value in patients with hepatocellular carcinoma. We aim to evaluate the prognostic abilities of the ALBI score/grade among living-donor liver transplantation patients. METHODS: We retrospectively collected data of 81 patients who underwent living-donor liver transplant at Kobe University Hospital between June 2000 and October 2018. The efficacy of the ALBI score/grade as a prognostic factor was assessed and compared with that of the well-established Model for End-Stage Liver Disease (MELD) score. MAIN FINDINGS: Multivariate analysis indicated that recipient age (P = .003), donor age (P = .003), ALBI score ≥ -1.28 (P = .002), and ALBI grade III (P = .004) were independently associated with post-transplant survival. A high MELD score was not associated with post-transplant survival in univariate or multivariate analyses. Although there was no significant difference in the overall survival rate relative to recipient and donor age, ALBI score/grade was significantly associated with the 1- and 5-year survival rates (P = .023, P = .005). ALBI scores specifically detected fatal complications of post-transplant graft dysfunction (P = .031) and infection (P = .020). CONCLUSION: ALBI score/grade predicted patient survival more precisely than the MELD score did, suggesting that it is a more useful prognostic factor compared to the MELD score in living-donor liver transplantation cases.

[A Case of Multiple Lung Metastases after Liver Resection for Multiple Hepatocellular Carcinomas with Remarkable Effects of Regorafenib].

The patient was a 63-year-old man with hepatitis C. He discontinued combination therapy containing interferon and ribavirin because of the development of skin symptoms. A screening examination showed multiple early-stage hepatocellular carcinomas. He refused treatment and was followed up as an outpatient. During follow-up, his PIVKA-Ⅱ level remarkably elevated to 59,994mAU/mL. Computed tomography(CT)showed an enlarged tumor with portal invasion(vp2)in segment 8 and intrahepaticmetastasis. We performed right and partial hepatectomy. Three months later, CT showed multiple lung metastases. We initiated the daily administration of 800 mg of sorafenib. However, 6 months after hepatectomy, the lung metastases increased in size and number. We considered the therapeutic effect as progressive disease(PD)according to the RECIST criteria. We then initiated administering 120 mg of regorafenib daily as second-line therapy. In a course of the treatment containing sorafenib and regorafenib, the dose was reduced due to hand-foot skin reactions. 8.5 months after hepatectomy, the lung metastases significantly decreased in size. One year after hepatectomy, almost complete response(CR) was obtained, and no intrahepatic recurrence was found.

[A case of hepatocellular carcinoma( Vp3)-planned radiotherapy after extended right hepatectomy].

The patient was a 57-year-old man who was diagnosed as having hepatocellular carcinoma (HCC). The tumor, 13 cm in diameter, occupied almost the entire right lobe and directly permeated the gallbladder. In addition, invasion of the portal vein umbilical region was seen from an inside area progress department. Because of the small remnant liver volume due to 3 procedures for right area excision and because liver failure was a concern after the operation, we decided to perform extended right hepatectomy for which we retained one S4 Glisson's capsule. Radiotherapy was planned for portal vein tumor thrombus after the operation. We started radiotherapy( 2.0 Gy×25) on postoperative day 14, and the patient was discharged without complications on postoperative day 55. We initiated the internal administration of tegafur-uraci(l UFT 400 mg/day) on postoperative day 44 and continued the treatment for half a year; however, metastasis was frequently noted in the lungs on computed tomography (CT) at 9 months after the operation. We administered low-dose 5-fluorouracil plus cisplatin( FP, intravenous) therapy combined with sorafenib( 800 mg/day), and the patient is being followed up. No recurrence has been noted in the liver at 16 months after the operation.

[A case of hepatocellular carcinoma (Vp4)-combination therapy prolonged survival in a patient with advanced hepatocellular carcinoma with a tumor thrombus in the portal vein trunk].

A 44-year-old man with advanced hepatocellular carcinoma (HCC) was admitted to our institution. Abdominal computed tomography( CT) revealed diffuse HCC in the right lobe, with a tumor thrombus in the main trunk and contralateral branch of the portal vein. Right lobectomy and tumor thrombectomy were performed. Three months later, oral tegafur-uraci( l UFT) administration( 300 mg/day) was initiated. Twelve months after surgery, intrahepatic recurrence was detected on CT scans. Therefore, the patient was treated with transcatheter arterial infusion( TAI) and percutaneous ethanol injection therapy (PEIT). Since then, no evidence of HCC recurrence has been noted for 46 months after the initial treatment.

[A case of bilobar multiple hepatocellular carcinoma in which complete remission was achieved by preoperative percutaneous isolated hepatic perfusion and subsequent hepatectomy].

We report a case of bilobar multiple hepatocellular carcinoma (HCC) successfully treated by preoperative percutaneous isolated hepatic perfusion(PIHP) and subsequent hepatectomy. A 77-year-old man with elevated serum PIVKA-II level and hepatomas was referred to our hospital. Abdominal dynamic computed tomography and gadoxetate disodium-enhanced magnetic resonance imaging demonstrated advanced HCCs: 11 tumors with a maximum tumor size of 4.8 cm diameter in the right lobe, and 1 tumor of 3.6 cm diameter in the left lobe. Curative resection was impossible due to insufficient liver function and due to the locations of the tumors. Therefore, we performed preoperative PIHP in order to control the multiple HCCs in the right lobe. This resulted in normalization of serum PIVKA-II level and complete necrosis of all tumors in the right lobe, as observed on dynamic computed tomography after 4 weeks of PIHP. Then, at 7 weeks after PIHP, we performed extended left lobectomy for residual tumor in the left lobe. Finally, complete remission was thought to have been achieved. The patient is alive 6 months after PIHP, without recurrence.

[Lung cancer incidentally detected at the treatment of pneumothorax ; report of two cases].

We report 2 cases of lung cancer incidentally detected following pneumothorax. Case 1:A 40-year-old man complaining of dyspnea was admitted with right pneumothorax. Chest computed tomography (CT) after chest drainage showed a cavitary nodule with pleural indentations in the right lower lobe. It was indicated at surgery that pneumothorax was caused by perforation of the tumor into the pleural cavity. Right lower lobectomy was performed because the pathological diagnosis of the nodule was a large cell carcinoma. The final histopathological diagnosis was stage II A (pT2aN1M0). The patient died of recurrence 14 months after surgery. Case 2:A 47-year-old man who admitted with right pneumothorax was found to have a nodule with pleural indentations closely a bulla at the apex of the right lung by chest CT after chest drainage. Pneumothorax was indicated to be caused by rupture of the bulla at surgery. Right upper lobectomy was performed because the pathological diagnosis of the nodule was a squamous carcinoma. The final histopathological diagnosis was stage I A (pT1bN0M0). The patient is alive at 2 years after the operation without recurrence. Lung cancer detected following pneumothorax which was caused by perforation of the tumor is generally considered to have poor prognosis. Whereas, prognosis of lung cancer incidentally detected following pneumothorax depends on its staging.