Extrahepatic Lesions Research Articles

Diffuse Liver Hemangiomatosis: An Atypical Liver Transplantation Indication in Adult

Introduction: Patients with diffuse liver hemangiomatosis (DLH) showed symptoms of abdominal pain and a palpable abdominal mass. The natural history and its etiology are uncertain, although in the literature have been cited the role of steroids and metoclopramide. DLH usually occurs in neonates characterized by hemangiomas of the skin and involvement of at least two visceral organs. DLH without extrahepatic lesions is extremely rare in adults. The prognosis is still unclear because it occurs so rarely and has variable clinical courses in affected patients. When patients became symptomatic, liver transplantation is a good choice of treatment if surgical resection can not be performed. Material and methods: We present 2 patients who underwent orthotopic liver transplantation (OLT) for diffuse liver hemangiomatosis. The first one is a 50 years old woman, who showed a 2-year history of progressive abdomen distention and abdominal pain. Firstly, she was diagnosed of a giant liver hemangioma. Left lobe hepatectomy was performed without incidences. Later, the patient developed a DLH with compressive symptoms, so liver transplantation from brain death donor was performed. Postoperative course was uneventful, and after 8 years there has been no incidences. The second case is a 41 year old patient who presented painless hepatomegaly, coagulopathy and thrombocytopenia. DLH with portal vein thrombosis was diagnosed in imaging tests, and the patient is currently on the waiting list for liver transplantation. Conclusions: Difusse liver hemangiomatosis without extrahepatic lesions is extremely rare in adults. The presence of symptoms suggesting extrinsic compression of adjacent structures should be considered for surgical resection. Liver transplantation must be indicated in patients with symptomatic and unresectable disease.

MORPHOLOGICAL BASIS OF AUTOIMMUNE MANIFESTATIONS IN VIRAL HEPATITISES

The purpose of the study - to study morphological basis of extrahepatic lesions and autoimmune manifestations in chronic viral hepatitises Methods of performance. By indirect immunofluorescence ASMA, AMA, ANA, by enzyme immunoassay - the Anti-LKM-1 were determined. Cryoglobulins (CG) have been revealed with the use of qualitative visualization method, rheumatoid factor (RF) was determined in serum by semiquantitative latex agglutination on a slide. Patients underwent liver biopsy. A punction liver biopsy according to Mengini was performed with the subsequent histologic and morphological research of obtained liver bioptates with the use of an immunohistochemKal and immunocytochemical methods. Results. In patients with chronic viral hepatitis autoimmune manifestations (RF, CG, ASMA, ANA, AMA, anti-LKM-1) were identified at the same rate regardless of the degree of histological activity. In the liver bioptate in patients with chronic viral hepatitises the complex of regulatory T cells (CD4 + CD25 +), which indicates to the presence of morphological and functional basis for the formation of autoimmune manifestations against persistent viral infection was detected. Conclusion. Identified by ourselves autoimmune manifestations in the blood serum be embodied in the morphological changes of the liver tissue, at that the morphological changes characteristic of autoimmune hepatitises, are observed mainly in patients with chronic viral hepatitis B and C, with moderate and high histological activity.

Experience in primary hepatic neuroendocrine tumor

We aimed to analyze the clinical characteristics, pathologic features, treatment approaches, and prognostic factors of primary hepatic neuroendocrine tumor. We retrospectively analyzed the clinical characteristics, pathologic features, treatment approaches, and prognostic factors of 9 patients with primary hepatic neuroendocrine tumor treated in our hospital from January 2003 to January 2010. The clinical manifestations were nonspecific and variable. The most common clinical manifestation was distention or right upper quadrant pain. Radiological findings are not specific and cannot distinguish primary hepatic neuroendocrine tumor from hepatocellular carcinoma. Diagnosis of primary hepatic neuroendocrine tumor was confirmed immunohistochemically and by the absence of extrahepatic primary sites. No extrahepatic primary lesions were found by ultrasonography, computed tomography, magnetic resonance imaging or positron emission tomography scan either preoperatively or during the follow-up period in our research. Immunohistologically, synaptophysin, chromogranin A and CD56 should be used as markers to precisely diagnose primary hepatic neuroendocrine tumor. The outcome of primary hepatic neuroendocrine tumor is mostly related to its resectability. Total resection of the neoplasm is most commonly proposed. A multimodality of treatments, including chemotherapy, transarterial chemoembolization and radiofrequency ablation, should be used preor postoperatively to improve the survival. Primary hepatic neuroendocrine tumor is a rare entity, and its diagnosis is difficult. Preoperative fine needle biopsy is strongly recommended, and primary surgery integrated with chemotherapy, transarterial chemoembolization or radiotherapy is considered to be an effective modality for primary hepatic neuroendocrine tumor.

Multiple Recurrent Extrahepatic Metastases from Hepatocellular Carcinoma Successfully Treated with Resection over a 10-Year Period

Purpose: Metastatic hepatocellular carcinoma (HCC) carries a poor prognosis, with median survival measured in months. The worldwide incidence of HCC is increasing due to the rising incidence of cirrhosis. While novel strategies for intrahepatic lesions have been established, there are few treatments for HCC with extrahepatic metastases. We present a case of recurrent metastatic HCC successfully treated with resection of extrahepatic metastases. A 61 y/o white male with hepatitis C cirrhosis underwent successful orthotopic liver transplantation in 8/2002. The explant liver showed grade 1-2 HCC with two tumor masses (diameters 3.3 and 3.5 cm). The resection margins were negative and there was no lymphovascular invasion. In 2003, the patient was treated for his hepatitis C and achieved a sustained virologic response. He was monitored in six-month intervals for recurrent HCC with abdominal ultrasounds and alpha-fetoprotein (AFP) measurements. In 1/2006, his AFP rose from <5 to 93.8 ng/mL. A CT scan showed a single 7 × 7 cm pericaval lymph suspicious for metastatic disease; the patient was referred for resection as no further evidence of disease was seen. Pathology was consistent with metastatic HCC. After resection, the AFP fell to <7 ng/mL. The patient did well for over three years, but in 6/2009 the AFP again started rising to >12 ng/mL. Repeat imaging showed a 1.5 × 2 cm right retroperitoneal mass that was again resected, and the AFP fell to <7 ng/mL. Three months post-operatively, he was advised to start sorafenib (multikinase inhibitor) but refused as he was feeling well. He did agree to start sirolimus (mTOR inhibitor) as part of his immunosuppressive regimen. The patient's course was uneventful for almost three years when he again had rising AFP (22.4 ng/mL) in 1/2012. Repeat imaging revealed a new, 1.8 cm anterior diaphragmatic lymph node which was resected, and pathology was consistent with HCC. The patient's synthetic liver function has been preserved throughout his post-transplant course. He still refuses sorafenib but continues on sirolimus. He is now ten years post-transplant with recurrent HCC. Metastatic HCC carries a poor prognosis, but there are few case reports of patients who successfully undergo resection of single extrahepatic metastatic lesions. While sorafenib is the only approved targeted agent used in the treatment of metastatic HCC, it is speculated that using mTOR inhibitors for post-transplant immunosuppression may provide some benefit due to their anti-proliferative properties. In patients with preserved synthetic liver function and good performance status, resection of isolated extrahepatic metastases should be considered, possibly in conjunction with systemic therapy.

SY6-8 - Special Remarks on HCC Treatment

ABSTRACT The consensus based treatment algorithm recommended by Japan Society of Hepatology consists of extrahepatic lesions, hepatic functional reserve, vascular invasion, number of tumors, and tumor diameter. Treatment is classified into curative treatment (resection, local ablation), TACE, arterial infusion chemotherapy, liver transplantation, and best supportive care. A consensus-based algorithm is not always based on evidence, but involves routinely employed treatment of which a consensus has been reached in Japan. Initially, resection or local ablation therapy should be carried out to treat three or less tumors measuring >3 cm in diameter without extrahepatic lesions/vascular invasion in which the liver function is good. In this group, the prognosis of curative treatment may be favorable. In three or less lesions measuring 13 cm in diameter, resection or TACE is recommended. Curability may be improved by adding ablation therapy to previous transarterial treatment. Secondly, TACE and arterial infusion chemotherapy are recommended to treat four or more lesions. However, arterial infusion chemotherapy is carried out based on expert experience, but there is no solid evidence because there is no randomized, controlled trial. The combination of local ablation therapy and TACE/arterial infusion chemotherapy for five to six or less lesions is beneficial in some cases. Furthermore, resection may be considered for such lesions if possible. In young Child-Pugh A/B hepatic functional reserve patients with early recurrence, liver transplantation is sometimes the choice of treatment when they meet the Milan criteria. In the presence of vascular invasion, resection is carried out for patients with third or fourth branch of portal venous invasion if possible. In such patients, TACE can be a choice of treatment. In patients with main trunk or first branch of portal vein, arterial infusion chemotherapy, in addition to hepatic arterial infusion chemotherapy with implanted port, is a choice of treatment.

Discrimination and anatomical mapping of PET-positive lesions: comparison of CT attenuation-corrected PET images with coregistered MR and CT images in the abdomen

PET/MR has the potential to become a powerful tool in clinical oncological imaging. The purpose of this prospective study was to evaluate the performance of a single T1-weighted (T1w) fat-suppressed unenhanced MR pulse sequence of the abdomen in comparison with unenhanced low-dose CT images to characterize PET-positive lesions. A total of 100 oncological patients underwent sequential whole-body (18)F-FDG PET with CT-based attenuation correction (AC), 40mAs low-dose CT and two-point Dixon-based T1w 3D MRI of the abdomen in a trimodality PET/CT-MR system. PET-positive lesions were assessed by CT and MRI with regard to their anatomical location, conspicuity and additional relevant information for characterization. From among 66 patients with at least one PET-positive lesion, 147 lesions were evaluated. No significant difference between MRI and CT was found regarding anatomical lesion localization. The MR pulse sequence used performed significantly better than CT regarding conspicuity of liver lesions (p < 0.001, Wilcoxon signed ranks test), whereas no difference was noted for extrahepatic lesions. For overall lesion characterization, MRI was considered superior to CT in 40% of lesions, equal to CT in 49%, and inferior to CT in 11%. Fast Dixon-based T1w MRI outperformed low-dose CT in terms of conspicuity and characterization of PET-positive liver lesions and performed similarly in extrahepatic tumour manifestations. Hence, under the assumption that the technical issue of MR AC for whole-body PET examinations is solved, in abdominal PET/MR imaging the replacement of low-dose CT by a single Dixon-based MR pulse sequence for anatomical lesion correlation appears to be valid and robust.

P-0059 is Radiofrequency Ablation is Effective for Metachronous Liver Metastasis from Gastric Cancer?

IntroductionRecurred or metastatic gastric cancer has a very poor prognosis and a combination chemotherapy is a standard treatment approach in advanced gastric cancer. The benefits of surgical resection or radiofrequency ablation (RFA) for liver metastasis from gastric cancer are poorly defined. The objective of this study was to evaluate the efficacy of RFA for the treatment of metachronous liver metastasis from gastric cancer. MethodsWe retrospectively reviewed 44 patients for whom RFA was performed for treating metachronous liver metastasis after resection of the primary gastric adenocarcinoma from January 2002 to November 2011. The primary endpoint of this study was overall survival (OS) and recurrence free survival (RFS) after RFA. ResultsForty patients received systemic chemotherapy after RFA. The OS of the patients was 14.7 months (95% CI 10.1-19.2) after RFA and the RFS was 6.1 months (95% CI 4.2-8.1) after RFA. At multivariate analysis, the factors independently associated with RFS were bilobar intrahepatic distribution (HR 3.9, 95% CI 1.5-9.9, P=0.001), and extrahepatic metastatic lesion (HR 3.6, 95% CI 1.6-7.8, P=0.003). The factors independently associated with OS were extrahepatic metastatic lesion (HR 12.6, 95% CI 3.7-42.9, P=0.001), no chemotherapy (HR 43.3, 95% CI 7.4-251.3, P=0.001), and tumor number (≥ 2) (HR 2.6, 95% CI 1.2-5.9, P=0.015). ConclusionThe efficacy of RFA for metachronous liver metastasis from gastric cancer was limited to the patients without extrahepatic metastatic lesion and combined systemic chemotherapy was very important to prolong the survival of the patients with metachronous liver metastasis from gastric cancer. [Display omitted]

Single-Incision Laparoscopic Hepaticojejunostomy Using Conventional Instruments for Neonates With Extrahepatic Biliary Cystic Lesions

Single-incision laparoscopic surgery has been increasingly adopted in pediatric surgery. Nevertheless, its feasibility and safety in neonates with congenital biliary malformations is unclear. This study reports successful single-incision laparoscopic hepaticojejunostomy (SILH) for neonates with extrahepatic biliary cystic lesions. Ten neonates with extrahepatic biliary cystic lesions (choledochal cyst/correctable biliary atresia: 6/4) who underwent SILH between May 2011 and September 2011 were reviewed. Ultrasonography, upper gastrointestinal contrast studies, and laboratory tests were performed during the follow-up period. Mean operative time, postoperative hospital stay, time to full feeding, and duration of drainage were comparable to our historic open-control groups of 15 neonates with choledochal cysts and 7 patients with correctable biliary atresia. Median follow-up duration was 6.0 months. They regularly took medical treatments during the follow-up periods. The jaundice subsided or liver function was normalized within 3 months postoperatively. So far, no mortality or morbidity of cholangitis, bile leak, anastomotic stenosis, and intrahepatic reflux were encountered. In experienced hands, SILH for neonates with extrahepatic biliary cystic lesions is feasible and safe. It provides a new alternative for neonatal hepatobiliary surgery.

Proposal for a morphological classification of intraductal papillary neoplasm of the bile duct (IPN‐B)

We propose a morphological classification of intraductal papillary neoplasm of the bile duct (IPN-B). A retrospective analysis of 16 patients with IPN-B who had undergone surgical resection was conducted. These 16 cases were classified into three types based on the primary lesion's anatomical location: branch duct type (6 cases), main duct type (5 cases) and mixed type (5 cases). In this paper we have analyzed the characteristics of IPN-B according to our new classification. All branch duct type IPN-B was located in the left lobe and 5 of them were resected by left hepatectomy without extrahepatic bile duct resection (EBDR). On the other hand, all patients with main duct and mixed type IPN-B underwent EBDR in addition to hepatectomy or pancreatoduodenectomy. Microscopically, 2 of 6 patients with branch duct type IPN-B had no malignant component and, in the remaining 4 patients, cancer invasion was restricted to within the ductal wall. There were no cases of branch duct type IPN-B with lymph node metastasis and superficial intraductal tumor spread. In contrast, all patients with main duct and mixed duct type IPN-B had the malignant component. In all cases, lymph node metastasis was not observed, but superficial intraductal tumor spread was frequently found in extrahepatic bile duct lesions: 3 of main duct type and 3 of mixed type. Four patients with superficial intraductal spread had non-curative resection due to a cancer-positive ductal margin. Most patients with IPN-B obtained a good prognosis, but two patients with a cancer-positive ductal margin developed local recurrence. Our classification vividly reflects clinical and pathological characteristics of IPN-B and is useful to determine appropriate surgical strategy.

Efficacy of infusional 5-fluorouracil, doxorubicin, and mitomycin-C (iFAM) chemotherapy and analysis of prognostic factors in previously treated advanced hepatocellular carcinoma.

269 Background: In advanced HCC, the role of salvage chemotherapy after failure of prior chemotherapy including sorafenib has not been fully studied. The aims of this study were to evaluate the efficacy of infusional 5-fluorouracil (5-FU), doxorubicin, and mitomycin-C (iFAM) as salvage regimen in advanced HCC and to identify the prognostic factors in a salvage setting. Methods: Eligibility included the following: 1) age &gt; 18 years; 2) Diagnosed as HCC; 3) previously treated with palliative chemotherapy; 4) ECOG PS 0-2; 5) Child-Pough Class A or B; and 6) adequate BM and renal function. iFAM consisted of 5-FU 800 mg/m2 over 10 hours on days 1-5, doxorubicin 30 mg/m2 on day 1 and mitomycin-C 8 mg/m2 on day 1, every 4 weeks. Response evaluation was done every 8 weeks with RECIST criteria. Results: A total of thirty-five patients were enrolled. The median age was 50.2 years (range: 23.3-74.7). ECOG PS was; PS 0-1 (80%) and PS 2 (20%). The etiology of HCC was; HBV (82.8%), HCV (2.9%) and others (14.3%). Liver function was; Child Pough A (91.4%) and B (8.6%). Nine patients had macrovascular invasion and all had extrahepatic metastatic lesion. Prior chemotherapies were sorafenib or 5-FU based regimens. A total of 94 cycles of iFAM were delivered (median 2: range 1-7). There were 2 PR and 6 SD, resulting in RR 5.7% (95% CI, 1.6-18.6%) and DCR 22.9% (95% CI, 12.1-39%). The PFS and OS were 2.4 months and 8.6 months, respectively. The 6- and 12-month survival rates were 67.7% and 35.3%, respectively. Grade 3/4 hematologic toxicity was neutropenia (14.3%). Frequent non-hematological toxicities were; anorexia (45.7%), alopecia (40%), stomatitis (20%), all of which were grade 1/2. In multivariate analysis, PS and serum α-FP were significantly associated with OS. Patients were classified into 3 risk groups based on the number of prognostic factors (0 vs. 1 vs. 2). This classification was well-correlated to OS (16.1 months vs. 10.5 months vs. 3.8 months, respectively; p &lt; 0.0001). Conclusions: iFAM is an effective and tolerable treatment option in advanced HCC and could be considered as salvage regimen. PS and α-FP are significant prognostic factors in a salvage setting.

Patients with liver cancer suitable for sorafenib evaluation registry (LIVER) in Poland.

194 Background: Due to chronic hepatitis and cirrhosis as main risk factors of HCC – patients in Poland can be treated either by oncologists or by gastroenterologists. As no data exist on HCC patient flow between these specialities, this registry was set up. We also wanted to know the differences in both specialities’ approach to targeted therapies. Methods: Data of patients treated by oncologists (LIVER 2) and gastroenterologists (LIVER 1) were recorded. Descriptive statistical methods and U-Mann-Whitney and Fisher tests were used. Results: 478 patients were included into registry from 2009 until the end of 2010. 70% of patients were male. In 42% cases HCC was caused by HCV and in 24% by HBV. LIVER 2 recorded more patients with unknown HCC aetiology than LIVER 1 (35% vs 15%). The HCC diagnosis was made based on CT scan (80%, ns), US scan (74% in LIVER 1 vs 47% in LIVER 2, p&lt;0,0001) or biopsy (72% LIVER 2 vs 48% LIVER 1, p&lt;0,0001). Patients with advanced stage of HCC according to BCLC scale and poor performance status were more frequently seen by oncologists (LIVER 2), similar prevalence in Child Pugh status was observed in both groups (p&lt;0,05 for all). Registry showed differences in frequency of extrahepatic lesions (10% LIVER 1 42% in LIVER 2, p&lt;0,05). Most common co morbidities were diabetes (32%), liver disorders (39%), hypertension (61%), coronary disease (24%). Median AFP level was 100 ng/ml in LIVER 1 and 219 in LIVER 2 (p=0,057). Registry showed that for gastroenterologists reasons to consider sorafenib as next step in therapy was in 47% cases HCC progression, in 51% good performance status and in 55% sorafenib was found as the only one therapy suitable due to contraindications for other treatments. Oncologists consider sorafenib therapy in 56% cases due to HCC progression and in 72% cases due to good performance status. Among patients considered for targeted therapy, approximately 20% presented Child Pugh B status. Conclusions: This is the first detailed HCC registry in Poland covering the different therapeutic area specialists. Patients with more advanced HCC and worse performance status are more frequently treated by oncologists (p&lt;0,05). The data shows need of early HCC detection interdisciplinary system referring patients to the oncologist.

Diagnostic Utility of CD10 in Benign and Malignant Extrahepatic Bile Duct Lesions

CD10, a cell surface enzyme with neutral metalloendopeptidase activity, is a marker for intestinal epithelial brush border. It is also present in normal bile ducts and gallbladder epithelia but is absent in cholangiocarcinomas. However, the expression profile of CD10 in benign and malignant extrahepatic biliary lesions has not been studied. In this study, 69 biopsies, 9 resections, and 9 cell blocks prepared from fine-needle aspirations of the extrahepatic bile ducts from 86 patients were studied immunohistochemically for CD10 expression. The majority of cases contained normal biliary epithelium (NL, n=64), along with foci of benign or malignant lesions in various combinations. Benign lesions included reactive atypia (n=35), low-grade dysplasia of unknown significance (n=21), and bile duct adenoma (BDA, n=1). Malignant lesions included high-grade dysplasia (HGD, n=45) and invasive adenocarcinoma (IC, n=30). As expected, the NL showed strong continuous staining at the apical surface in all cases. Benign lesions were also CD10 positive in all but 3 cases; however, the staining pattern was discontinuous, with positive cells varying from 20% to 80%. None of the malignant lesions showed CD10 immunoreactivity, except for 2 HGD cases and 1 IC case, which exhibited focal staining. The Pearson χ2 and Fisher exact tests showed significant statistical difference in CD10 expression among the study groups (P<0.001). Our findings suggest that absence of CD10 expression in strips of atypical biliary epithelial cells may be a phenotype associated with malignant transformation and may serve as a useful marker to aid in the evaluation of bile duct biopsies, in which distinction between benign and malignant lesions on biopsies or cytology specimens can be extremely challenging because of limited sampling, crush artifact, and frequent inflammatory/reactive changes.

Ischemia-Reperfusion Injury and Ischemic-Type Biliary Lesions following Liver Transplantation

Ischemia-reperfusion (I-R) injury after liver transplantation (LT) induces intra- and/or extrahepatic nonanastomotic ischemic-type biliary lesions (ITBLs). Subsequent bile duct stricture is a significant cause of morbidity and even mortality in patients who underwent LT. Although the pathogenesis of ITBLs is multifactorial, there are three main interconnected mechanisms responsible for their formation: cold and warm I-R injury, injury induced by cytotoxic bile salts, and immunological-mediated injury. Cold and warm ischemic insult can induce direct injury to the cholangiocytes and/or damage to the arterioles of the peribiliary vascular plexus, which in turn leads to apoptosis and necrosis of the cholangiocytes. Liver grafts from suboptimal or extended-criteria donors are more susceptible to cold and warm I-R injury and develop more easily ITBLs than normal livers. This paper, focusing on liver I-R injury, reviews the risk factors and mechanisms leading to ITBLs following LT.

Diagnostic Utility of CD10 in Benign and Malignant Extrahepatic Bile Duct Lesions

Diagnostic Utility of CD10 in Benign and Malignant Extrahepatic Bile Duct Lesions

Extrahepatic biliary cancer: New staging classification

Tumor staging defines the point in the natural history of the malignancy when the diagnosis is made. The most common staging system for cancer is the tumor, node, metastases classification. Staging of cancers provides useful parameters in the determination of the extent of disease and prognosis. Cholangiocarcinoma are rare and refers to cancers that arise from the biliary epithelium. These tumors can occur anywhere along the biliary tree. These tumors have been previously divided into extrahepatic and intrahepatic lesions. Until recently the extrahepatic bile duct tumors have been considered as a single entity per American Joint Commission on Cancer (AJCC) staging classification. The most recent changes to the AJCC classification of bile duct cancers divide the tumors into two major categories: proximal and distal tumors. This practical classification is based on anatomy and surgical management. High quality cross-sectional computed tomography (CT) and/or magnetic resonance (MR) imaging of the abdomen are essential information to accurately stage this tumors. Imaging plays an important role in diagnosis, localization, staging and optimal management of cholangiocarcinoma. For example, it helps to localize the tumor to either perihilar or distal bile duct, both of which have different management. Further, it helps to accurately stage the disease and identify the presence of significant nodal and distant metastasis, which may preclude surgery. Also, it helps to identify the extent of local invasion, which has a major impact on the management. For example, extensive involvement of hepatic duct reaching up to second-order biliary radicals or major vascular encasement of portal vein or hepatic arteries precludes curative surgery and patient may be managed by palliative therapy. Further, imaging helps to identify any anatomical variations in the hepatic arterial or venous circulation and biliary ductal system, which is vital information for surgical planning. This review presents relevant clinical presentation and imaging acquisition and presentation for the accurate staging classification of bile duct tumors based on the new AJCC criteria. This will be performed with the assistance of anatomical diagrams and representative CT and MR images. The image interpretation must include all relevant imaging information for optimum staging. Detailed recommendations on the items required on the radiology report will be presented.

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Results of Hepatic Arterial Infusion Chemotherapy in Patients with Unresectable Liver Metastases

Background: Colorectal cancer most commonly metastasizes to the liver. However, in patients with liver metastases precluding radical resection, we still have no other choice but to depend almost completely on anticancer chemotherapy. We report the results of hepatic arterial infusion chemotherapy (HAIC) in patients with multiple unresectable metastases throughout the liver and likely to develop liver failure in the near future. Patients and Methods: A total of 284 advanced colorectal cancer patients were treated. Of these patients, 40 and 24 had synchronous and metachronous liver metastases, respectively. Of these liver metastasis patients, 27 had unresectable metastases. 14 of the patients with unresectable liver metastases (likely to develop liver failure in the near future) but without extrahepatic lesions underwent HAIC. The chemotherapy regimen consisted of 5-fluorouracil 600 mg/m² and leucovorin 250 mg/m². Results: HAIC resulted in a complete response, partial response, stable disease, and progressive disease in 2, 7, 3, and 2 patients, respectively. The 1- and 2-year survival rates were 79 and 50%, respectively. Conclusion: Colorectal cancer patients with unresectable liver metastases without extrahepatic lesions and likely to develop liver failure in the near future showed relatively good results with no serious side effects. We suggest that HAIC is an effective treatment in selected patients.

Treatment of recurrent hepatocellular carcinoma after liver transplantation

Liver transplantation (LT) is a curative treatment for localized hepatocellular carcinoma (HCC), but the recurrence rate after LT is about 10-20%, with a dismal prognosis. Little data exist as to the natural history, treatment outcome and optimal treatment of recurrent HCC after LT. We reviewed various treatment modalities given to patients with recurrent HCC after LT. Among 132 patients who underwent LT for localized HCC, we retrospectively reviewed medical records of 39 of the 132 patients who developed recurrent HCC after LT. We analyzed the clinical outcome of various treatment modalities and treatment-related adverse events. A total of 39 (29%) of the original 132 patients had recurrent HCC, most recurrences (82%) having occurred within 1 year after LT and involved extrahepatic lesions. Only seven patients had recurrent disease limited to the liver. The median overall survival from the initial treatment of all relapsed patients was 6.9 months. There were various initial treatment modalities, namely palliative systemic chemotherapy, trans-catheter arterial chemo-embolization/infusion (TACE/I), radiation therapy (RT), surgical resection and no treatment. The median overall survival was 9.5 months for first-line chemotherapy, including those who had prior local therapy, 6.3 months TACE/I and 6.9 months for RT. Various clinical approaches have been used to treat patients with recurrent HCC after LT in a clinical setting. More effective strategies and clinical guidelines for recurrent HCC following LT must be established.

Hepatoid adenocarcinoma in stomach: a case report

We reported a case with AFP produced gastric hepatoid adenocarcinoma. A male patient, 77 year-old, was admitted to our hospital due to an unreasonable elevation of serum AFP. The tumors were revealed by PET-CT, but until the tumors were removed during the surgery, we did not recognize the primary lesion was the gastric cancer. Radical distal gastrectomy was performed. The gastric lesion was confirmed by histology as a hepatic adenocarcinoma in its early stage. The rare etiology of the AFP elevation should be kept in mind in clinic, extrahepatic lesions should be excluded.

Abstract 3218: High pathological CR rate and low recurrence rate was observed in liver metastasis of colorectal cancer after preoperative bevacizumab plus FOLFOX therapy

Abstract [Background] We reported the effectiveness of intraoperative contrast-enhanced ultrasonography using perflubutane (SONAZOIDTM) for complete resection of liver metastasis from colorectal cancer (CRC) after Bevacizumab (Bmab)+FOLFOX therapy (Annual meeting of AACR, 2010). In this study, we report pathological CR (pCR) rate of resected liver tumors and recurrence rate of disappeared lesions that were not resected. [Material and methods] Sixteen patients of advanced CRC with liver metastasis only (no extrahepatic lesion) were treated with Bmab+FOLFOX therapy. Response rate of chemotherapy was 81%. Among the 16 patients, 8 (50%) were underwent liver resection after chemotherapy. We study 6 of the 8 patients, who were followed up longer than a year (20-33 months). [Result] By CT angiography, 47 liver metastases were detected before chemotherapy. By intraoperative contrast-enhanced ultrasonography, 26 liver tumors were detected and resected. In histological examination, 11 (42%) were without viable cancer cell (pCR). Among 21 lesions that were not detected by intraoperative ultrasound and not resected, only 2 lesions were re-detected in follow up period and both lesion were resected. [Conclusion] High pCR rate and low recurrence rate was observed in liver metastasis of colorectal cancer after preoperative Bmab + FOLFOX therapy. Contrast-enhanced ultrasonography was effective for complete resection of liver metastases, as well as low recurrence rate of disappeared lesion after chemotherapy. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3218. doi:10.1158/1538-7445.AM2011-3218