Development of subclassification of intermediate-stage hepatocellular carcinoma (HCC) by treatment suitability is in demand. We aimed to identify predictors that define treatment refractoriness ...against locoregional(transarterial chemoembolization(TACE) or thermal ablation) and surgical therapy. This multicenter retrospective study enrolled 1167 HCC patients between 2015 and 2021. Of those, 209 patients were initially diagnosed with intermediate-stage HCC. Treatment refractoriness was defined as clinical settings that meets the following untreatable progressive conditions by TACE (1) 25% increase of intrahepatic tumor, (2) transient deterioration to Child-Pugh class C, (3) macrovascular invasion or extrahepatic spread, within one year. We then analyzed factors contributing to treatment refractoriness. The Child-Pugh score/class, number of tumors, infiltrative radiological type, and recurrence were significant factors. Focusing on recurrence as a predictor, median time to untreatable progression (TTUP) was 17.2 months in the recurrence subgroup whereas 35.5 months in the initial occurrence subgroup (HR, 2.06; 95% CI, 1.44-2.96; P = 0.001). Median TTUP decreased in cases with more later times of recurrence (3-5 recurrences, 17.3 months; ≥ 6 recurrences, 7.7 months). Recurrence, even more at later times, leads to increased treatment refractoriness. Early introduction of multidisciplinary treatment should be considered against HCC patients after multiple recurrent episodes.
Colorectal cancer (CRC) can occasionally coexist with diverticulitis, thereby complicating diagnosis and treatment. In cases of refractory diverticulitis, it is important to consider the possibility ...of malignancy and determine appropriate treatment strategies. An 85-year-old male presented with lower left abdominal pain; he was admitted for further examination and the treatment of suspected sigmoid diverticulitis. On examination, a firm mass was palpated in the lower left quadrant. Imaging revealed sigmoid diverticulitis, partial abscess formation, and the involvement of the small bowel and abdominal wall. Although malignancy was suspected, a definitive diagnosis was not made. Because of the refractory nature of the disease, early surgical intervention, sigmoid colectomy, partial small bowel resection, abdominal wall resection, and lymph node dissection, was performed in accordance with the malignancy protocol. Pathologic diagnosis revealed adenocarcinoma within the diverticulitis with negative resection margins, indicating curative surgery. The low preoperative diagnostic rate of CRC associated with diverticulitis highlights the need for vigilance. Refractory diverticulitis may indicate the presence of concealed malignancy requiring surgical intervention. In the management of refractory diverticulitis, it is important to consider the potential coexistence of cancer. Even if extensive investigations are performed and a definitive diagnosis remains elusive, surgery must be considered.
Although surgery is the definitive curative treatment for biliary tract cancer (BTC), outcomes after surgery alone have not been satisfactory. Adjuvant therapy with S-1 may improve survival in ...patients with BTC. This study examined the safety and efficacy of 1 year adjuvant S-1 therapy for BTC in a multi-institutional trial.
The inclusion criteria were as follows: histologically proven BTC, Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1, R0 or R1 surgery performed, cancer classified as Stage IB to III. Within 10 weeks post-surgery, a 42-day cycle of treatment with S-1 (80 mg/m
/day orally twice daily on days 1-28 of each cycle) was initiated and continued up to 1 year post surgery. The primary endpoint was adjuvant therapy completion rate. The secondary endpoints were toxicities, disease-free survival (DFS), and overall survival (OS).
Forty-six patients met the inclusion criteria of whom 19 had extrahepatic cholangiocarcinoma, 10 had gallbladder carcinoma, 9 had ampullary carcinoma, and 8 had intrahepatic cholangiocarcinoma. Overall, 25 patients completed adjuvant chemotherapy, with a 54.3% completion rate while the completion rate without recurrence during the 1 year administration was 62.5%. Seven patients (15%) experienced adverse events (grade 3/4). The median number of courses administered was 7.5. Thirteen patients needed dose reduction or temporary therapy withdrawal. OS and DFS rates at 1/2 years were 91.2/80.0% and 84.3/77.2%, respectively. Among patients who were administered more than 3 courses of S-1, only one patient discontinued because of adverse events.
One-year administration of adjuvant S-1 therapy for resected BTC was feasible and may be a promising treatment for those with resected BTC. Now, a randomized trial to determine the optimal duration of S-1 is ongoing.
UMIN-CTR, UMIN000009029. Registered 5 October 2012-Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000009347.
A 63-year-old man was under observation after the resection of a stomach cancer. Abdominal computed tomography showed a low-density region, 8 mm in diameter, at segment 7 of the liver. Qualitative ...diagnosis was difficult, and the patient's clinical course was monitored. Six months later, the size of the low-density region increased to 25 mm. Malignant tumor was suspected, and partial resection of the liver (S7) was performed. Hepatic angiosarcoma was diagnosed on the basis of postoperative pathological examination. Because the surgical margin of the tumor was positive, right lobectomy of the liver was performed after 3 weeks. Two months later, recurrence was detected in the remnant liver ; diffuse small metastatic lesions appeared 5 months after the operation. Continuous arterial infusion of recombinant interleukin-2 was administered, and a partial response was obtained temporarily. However, the tumor recurred immediately, and the best supportive care was given. Although the tumor gradually increased in size, the patient's general condition was good for a long period. Around 1 year 9 months after the operation, the tumor began to grow rapidly, and liver dysfunction occurred. Two years 8 months after the onset, the patient died of hepatic failure.
A 74-year-old woman with carcinoma of the pancreatic head underwent pylorus-preserving pancreatoduodenectomy in October 2009. The diagnosis based on histological findings was invasive ductal ...carcinoma (IDC), T1N0M0, stage I. She underwent adjuvant chemotherapy with gemcitabine and was followed up. Abdominal computed tomography performed 1 year 5 months after the operation revealed a mass in the remnant pancreas. Pancreatic cancer was suspected after careful examination. At the time of operation, 2 tumors measuring around 1 cm were observed in the remnant pancreas. Subtotal remnant pancreatectomy was performed, and about 3 cm of the pancreas body was preserved. Because the pancreas was preserved, the patient showed fairly good glycemic control. On the basis of histological findings, we diagnosed both tumors as IDC. One of them was T1N0M0 stage I and the other was T3N0M0 stage III. Because continuity of the lesions, including the first tumor, was not observed, multicentric occurrence was suspected. Pancreatic intraepithelial neoplasia was evident in the noncancerous pancreatic parenchyma, and this finding could be related to the development of multicentric IDC.
A 67-year-old man transferred to our hospital with abdominal pain was diagnosed as having colon ileus caused by sigmoid colon cancer. After reducing the colon pressure with an ileus tube, he received ...a laparoscopic-assisted sigmoidectomy. On and after the eighth day after the surgery, unusual bleeding (melena, hemoperitoneum, muscle hemorrhage, and subcutaneous hemorrhage) was noted. Coagulation tests revealed exclusively prolonged APTT, normal PT, a decrease in the factor VIII, and a high titer of factor VIII inhibitor. Acquired hemophilia A was thus diagnosed. We started the therapy with factor VIII concentrates and predonizoron. On the next day, he was transferred to another hospital for hematological treatments. Thereafter administration of steroids alone and cyclosporine alone were unsuccessful and the combined therapy with cyclophosphamide and steroids achieved a partial remission. The patient was saved. Acquired hemophilia A is a rare and fatal condition of coagulopathy. When we surgens encounter a sudden onset of severe hemorrhagic tendency of unknown origin, we should consider a possibility of acquired hemophilia A.
Hepatic sarcomatous carcinomas are rare and are associated with poor prognosis. We report herein on a case of hepatic sarcomatous carcinoma with a long recurrence-free survival following intensive ...combined therapy. A 69-year-old Japanese woman with right chest pain visited a local hospital where elevation of CRP and elevation of liver and biliary enzymes were found. She was referred to our hospital and abdominal CT showed a hypoattenuating 60 mm lesion in the left lateral segment and the peripheral areas of the mass were enhanced in the arterial phase, yielding a diagnosis of intrahepatic cholangiocarcinoma. A laparoscopic left hepatic lobectomy was performed. Histopathological examination revealed the resected specimen consisted of spindle-shaped cells and had no component of glandular structure or hepatocytes. The patient was given a diagnosis of hepatic sarcomatous carcinoma. Although adjuvant chemotherapy with S-1 was performed, a recurrent 56 mm tumor was detected in the anterior segment of the right hepatic lobe 4 months after the operation. Gemcitabine+cisplatin therapy was introduced for 6 months and the tumor gradually decreased in size. Subsequently the patient underwent a ventral anterior segmentectomy and Spiegel lobectomy. The patient has survived for 55 months from the first hepatectomy and 45 months from the rehepatectomy with no recurrence and with no adjuvant chemotherapy.
A 74-year-old woman underwent a distal pancreatectomy for stage IIA cancer of the pancreatic body (JPS 7th) in February 2013. She received S-1 as adjuvant chemotherapy for 6 months. In February 2015, ...computed tomography scan showed a left inguinal mass, and FDG-PET imaging showed abnormal uptake in the left inguinal mass. Metastasis of pancreatic cancer to the left inguinal region was suspected and no other metastases were detected. In March 2015, the left inguinal mass was resected. An inguinal hernia was not detected during the operation. Histological examination of the resected mass revealed well-differentiated adenocarcinoma compatible with a metastasis from the pancreatic cancer. The patient survived for 54 months after distal pancreatectomy and 29 months after resection of the metastasis until August 2017, when she died of pneumonia. Metastasis of pancreatic cancer to the inguinal canal in women is very rare, especially in the absence of an inguinal hernia.
The precise intraoperative localization of insulinoma is essential for successful surgical management.
To assess the usefulness of measuring insulin levels by preoperative percutaneous transhepatic ...portal catheterization (PTPC) and intraoperative ultrasonography (US).
PTPC and other preoperative procedures (enhanced computed tomography CT, arteriography, and US) were performed in eight patients with insulinoma based on our experience during the past 18 years. Intraoperative US was performed in six of the eight patients.
PTPC was undertaken in all eight patients, and increased levels of insulin at the sites corresponding to tumors were observed in all patients. Intraoperative US was performed in six patients, which made it possible to detect insulinomas as hypoechoic masses in all of these patients. All tumors were found to exist as single entities.
PTPC showed the highest diagnostic accuracy in detecting the number of and accurately localizing the tumors before surgery. Meanwhile, all findings from intraoperative US were identical to those of the resection samples, suggesting that this method is a highly reliable examination technique. We conclude that a combination of PTPC and intraoperative US may be essential for the successful surgical management of insulinomas.
PDF
