Portal Tumor Thrombus Research Articles

The surgical approach to HCC: our progress and results in Japan.

Due to the prevalence of hepatitis virus infection, the incidence of hepatocellular carcinoma (HCC) is very high in Japan. Many techniques have been devised by Japanese surgeons to reduce the mortality rate after hepatectomy for HCC: preoperative precise evaluation of hepatic functional reserve, portal venous embolization as preoperative preparation, anatomical and nonanatomical limited resections using intraoperative ultrasonography, and intermittent inflow occlusion during liver transection. Several challenging surgical procedures are also being tried for advanced HCC: HCC with portal and hepatic venous tumor thrombus, multiple and/or recurrent HCC, and HCC in the caudate lobe. As a result, the latest national survey of HCC revealed that operative mortality was 0.9% and the 5-year survival rate after surgery was 52%. Living-donor liver transplantation for adult patients with HCC is another surgical treatment developed in Japan. After the success of adult-to-adult living donor liver transplant using a left liver graft in 1993, a right liver graft, a left liver graft with caudate lobe, and a right lateral sector graft were developed. Indications for reconstructing the middle hepatic vein tributaries in right liver grafts were also proposed. Consequently, in our series of 36 patients with HCC who underwent living-donor liver transplantation, operative mortality was 3%, and the 2-year survival rate was 84%.

Multi-slice spiral CT three-dimensional portography in portal vein tumor thrombus of hepatic cancer

Objective: To study the clinical significance of multi-slice spiral CT 3-dimensional (3D) portography in portal vein tumor thrombosis of hepatocellular cacinoma.Methods: 57 cases undergoing 3D portography were collected, of which 6 cases were normal, 5 cases were subjected to cirrhosis and hypertension of portal vein, 42 cases had portal tumor thrombus of hepatic cancer, and the remaining 4 cases showed lymph node enlargment in hilar of liver. All data of the patients came from conventional multi-slice spiral CT double phase of liver. Contrast media was 1.5–2 ml/kg with the injection rate being 2.5–3 ml/s. Axis and 3D portography was analyzed and compared in 42 cases of portal tumor thrombus of hepatic cancer.Results: According to portal tumor thrombus position, 42 cases were fallen into three categories: left (13 cases), right (20 cases), main (9 cases) of potal vein. There was no difference between axis and 3D portography in displaying portal tumor thrombus of hepatic cancer (P>0.05), but 3D portography showing collateral branches was better than axis portography after main portal vein thrombus.Conclusion: Multi-slice spiral CT 3D portography can display the position and types of portal tumor thrombus of hepatic cancer. 3D combined with axis portography can better evaluate the portal tumor thrombus of hepatic cancer and guide to select the therapies.

Lamivudine therapy for hepatitis B virus reactivation in a patient receiving intra-arterial chemotherapy for advanced hepatocellular carcinoma

We describe a case of hepatitis B virus (HBV) reactivation that responded to lamivudine therapy in a 58-year-old man with advanced hepatocellular carcinoma (HCC). After seroconversion of hepatitis B e antigen to e antibodies by interferon therapy, the patient was found to have HCC with a portal tumor thrombus. A transarterial port was placed in the right femoral artery to permit infusion of epirubicin and cisplatin. After 3 months of arterial chemotherapy, the serum α-fetoprotein level had decreased and tumor staining diminished. Laboratory examinations suggested a flare-up of hepatitis B. Lamivudine was given to manage HBV reactivation. After 1 month, the serum HBV DNA level fell below the detection limit, and the alanine aminotransferase activity decreased to the normal range. With further arterial chemotherapy for HCC, no tumor staining was detected on computed tomography. Administration of lamivudine decreased serum HBV DNA levels for 7 months. Our findings suggest that HBV may be reactivated during chemotherapy for HCC, similar to other types of malignancies, and that lamivudine is effective for the management of HBV reactivation.

A case of liver fibrosis with resected hepatocellular carcinoma accompanied with main portal venous tumor thrombus via aberrant portal branch

A case of liver fibrosis with resected hepatocellular carcinoma accompanied with main portal venous tumor thrombus via aberrant portal branch

Peripheral bone metastasis from hepatocellular carcinoma: sonographic findings.

We reviewed medical and radiologic records of five patients with bone metastasis from hepatocellular carcinoma (HCC) to evaluate the role of sonography (US) in the diagnosis of this bone metastasis. The metastatic lesions were clearly visualized by US as expansive, homogeneous, soft tissue masses with bony destruction, and color Doppler US showed fine vessels within the lesions. After treatment, US showed a decrease in tumor size with an increase in echogenicity and a decrease in blood flow. Hepatic US at the time of bone metastasis showed a portal tumor thrombus in all cases. When US detects a portal venous tumor thrombus in HCC patients, attention should be directed not only to the liver but also to bone to improve patient care. US is useful not only in detecting the metastatic lesion but also in evaluating the treatment effect.

Ultrasonographic findings of portal tumor thrombus secondary to gastric cancer: Report of three cases

Case 1, Borrmann's type 2 carcinoma detected by endoscopy in the body of the stomach of a 59-year-old man. Total gastrectomy with spenectomy was performed. Histologic examination revealed a poorly differentiated adenocarcinoma with marked venous invasion. Follow-up ultrasonography showed the tumor thormbi in the splenic vein to be progressively distended to the superior mesenteric vein and the peripheral branches of the intrahepatic portal vein.

Portal tumor thrombus due to gastrointestinal cancer.

We studied the clinical data of seven patients with portal tumor thrombus (PTT) due to gastrointestinal (GI) cancer to determine the radiologic patterns and clinical implications of this rare complication. (a) PTT was located along the entire splenic vein in three cases, at the splenomesenteric confluence in one case, and in the superior mesenteric vein in one case. Intrahepatic PTT occurred in two of four cases with liver metastasis. (b) One cirrhotic case was complicated by the occurrence of colon cancer associated with PTT in the splenic vein; the esophageal varices became rapidly enlarged and poorly controlled, and the patient died due to repeated variceal rupture. (c) In all patients, abdominal sonography (US) detected PTT and color Doppler sonography confirmed the US findings. The splenic vein should be meticulously observed by color Doppler sonography to check for PTT in patients with GI cancer to improve patient care.

Immunolocalisation of PIVKA-II in paraffin-embedded specimens of hepatocellular carcinoma.

Although serum PIVKA-II has been widely used as a tumor marker for hepatocellular carcinoma (HCC), little information is available concerning tissue PIVKA-II, and detection of tissue PIVKA-II in paraffin-embedded tissue specimens of HCC is also considered difficult. Paraffin-embedded HCC tissues obtained at autopsy from 22 patients were subjected to immunohistochemical staining using the antibody MU-3 (Eisai Co., Ltd.) after microwave antigen retrieval. PIVKA-II was mainly detected in the cytoplasm of HCC cells. The intensity of tissue PIVKA-II staining was not correlated with serum PIVKA-II levels or with the histotogical differentiation of HCC. However PIVKA-II staining tended to be more intense in tissue from patients with portal tumor thrombus, distant metastases, or a longer duration of HCC. This method of immunohistochemical staining is easy and simple to use and may be helpful for detecting tissue PIVKA-II in paraffin-embedded HCC specimens.

Nine-Year survivor after resection of cholangiocellular carcinoma with tumor thrombi in the main portal trunk

We report a patient with cholangiocellular carcinoma with tumor thrombi in the main portal trunk who has survived for 9.5 years after hepatic resection. A 57-year-old woman underwent an extended left lobectomy, and resection of the caudate lobe plus the main portal trunk for a liver tumor that had a portal tumor thrombus in the main portal trunk. The portal vein was reconstructed with an autologous vein graft obtained from the external iliac vein. Histological examination of the resected specimen revealed moderately differentiated tubular adenocarcinoma compatible with cholangiocellular carcinoma. Factors contributing to the patient's long-term survival are discussed. Aggressive surgical resection can be effective even for such an advanced case of cholangiocellular carcinoma.

Hepatectomy with microwave tissue coagulation for hepatocellular carcinoma

From 1984 through 1994, 99 consecutive patients with hepatocellular carcinoma (HCC) underwent hepa-tectomy with microwave tissue coagulation (MTC). We performed limited resection (Hr0) in 28 patients, subsegmentectomy (HrS) in 25 patients, segmentectomy (Hr1) in 21 patients, and lobectomy or extended lobectomy (Hr2) in 25 patients. The patients were divided into two groups: group A, 86 patients with tumors smaller than 1 kg and no tumor thrombi in the main portal trunk; and group B, 13 patients with a tumor 1 kg or larger, or with macroscopic tumor thrombi in the main portal trunk. In group A, mean blood loss was 838 ml for Hr0, 1948 ml for HrS, 1765 ml for Hr1, and 1325 ml for Hr2. The mean operative time in group A ranged from 3 h 43 min for Hr0 to 4 h 57 min for Hr2. In group B, the mean operative time was 6 h 3 min and mean blood loss was 6053 ml. Our MTC method was associated with an in-hospital mortality rate of 3% and a major complication rate of 13.1%. The 5-year survival and disease-free survival rates were 43.4% and 25.4%, respectively. The 5-year survival rate of patients without portal tumor thrombi (50.9%) was significantly better than that of patients with portal tumor thrombi (11.9%) (P < 0.001). The 5-year survival rate of patients who underwent curative resection (58.1%) was significantly better than that of patients who underwent noncurative resection (22.9%) (P < 0.001). The 5-year survival rates of patients in group A without portal tumor thrombi did not differ between those who had cancer-negative margins (54.0%) and those with cancerpositive margins (49.6%) at resection. Recurrence and local recurrence rates did not differ in patients with cancer-positive margins (63.6% and 7.3%, respectively) and patients with cancer-negative margins (56.5% and 8.7%, respectively). These results suggested that microscopic residual cancer in the resected margin was coagulated by MTC. Blood loss, operative time, and clinical outcome in this series of 99 consecutive hepatectomies were comparable with values in earlier reports in which such hemostatic methods as the Pringle maneuver were used. We conclude that hepatectomy with MTC is useful and safe and produces consistent results.

Primary lymphoma of the liver with bile duct invasion and tumoral occlusion of the portal vein: report of a case

A 55-year-old woman presented to hospital with epigastric pain and jaundice. Diagnostic imaging studies revealed a biliary stricture of the hepatic confluence and a hepatic tumour of the left and caudate lobes with a portal tumour thrombus, which occupied the main portal trunk, the umbilical portion of the left portal vein, and the right anterior and posterior portal branches. Left hepatic trisegmentectomy, caudate lobectomy, portal tumour thrombectomy, bile duct resection and bilioenteric anastomosis were performed. There were no other lesions, and so it was diagnosed as a primary lumphoma of the liver (B-cell, diffuse, large cell type). The patient underwent postoperative chemotherapy and has remained well for 4.5 years after surgery. Primary lymphoma of the liver is very rare, and this is the first case report with bile duct invasion and tumoral occlusion of the portal vein.

Fas antigen expression in hepatocellular carcinoma tissues.

Fas antigen belongs to the tumor necrosis factor receptor family and is known to induce apoptosis. This protein is abundantly expressed in hepatocytes, especially in acute and chronic hepatitis. To elucidate the clinical significance of Fas in hepatocellular carcinoma (HCC), we investigated its expression in 50 HCC having various characteristics. Fas was comprehensively expressed in non-cancerous hepatocytes as well as bile ducts. It was moderately expressed in histiocytes in the stroma rather than in infiltrating lymphocytes. In HCC, Fas expression was significantly reduced when there was poor differentiation (p<0.001), portal tumor thrombus and extracapsular invasion (p<0.05) according to univariate analysis. Multivariate analysis revealed statistical significance between Fas expression and the degree of differentiation (p=0.0002). These results suggest that HCC, like non-cancerous hepatocytes, express Fas antigen, when they are well or moderately differentiated but lose this ability when they become poorly differentiated as the carcinoma advances.

Successful resection of cholangiocellular carcinoma with tumor thrombus in the main trunk of the portal vein

A space-occupying lesion in the right hepatic lobe, with dilated peripheral bile ducts, was observed by ultrasonography and computed tomography in a 50-year-old man with right upper quadrant abdominal pain. One month later, this lesion evidenced rapid growth and a tumor thrombus, which completely occluded the main trunk and the left primary branch of the portal vein, had developed. The tumor was diagnosed as a cholangiocellular carcinoma with an unusual pattern of intravascular extension. The primary tumor and the portal tumor thrombus were resected via a right hepatic trisegmentectomy combined with resection of the portal vein and extrahepatic bile duct, using a superior mesenteric vein—left femoral vein catheter bypass (SMV—FV bypass). The SMV—FV bypass was found to effectively reduce intraoperative hemorrhage.

Adenosquamous carcinoma of the gallbladder with tumor thrombus in left portal trunk

We report a surgically resected case of adenosquamous carcinoma of the gallbladder accompanied by portal tumor thrombosis, which is regarded as a rare complication. A 73-year-old man was admitted to our hospital because of epigastralgia. Preoperative examinations led to a diagnosis of advanced gallbladder carcinoma with liver metastasis, and operation was performed. Since intraoperative ultrasonography showed a tumor thrombus in the left main portal trunk originating from the metastatic lesion in the left medial segment of the liver, extended left lobectomy with extrahepatic bile duct resection and lymph node dissection was performed, instead of right trisegmentectomy, as proposed preoperatively. Histological examination revealed adenosquamous carcinoma of the gallbladder with medullary growth that was similar to the hepatocellular carcinoma, most notably in the metastatic lesion of the liver and in the portal tumor thrombus. We discuss the relation between portal tumor thrombosis and medullary tumors, and note the atypical operative method employed.

Immunohistochemical studies on endothelial cell phenotype in hepatocellular carcinoma.

To examine the phenotype of the sinusoidal endothelial cells (SECs) surrounding tumor cells and the process of capillarization in hepatocellular carcinoma (HCC), 51 primary HCCs, 4 adrenal metastases, and 3 portal tumor thrombi were immunohistochemically stained with monoclonal antibodies (MAbs) for CD4, CD14 (lipopolysaccharide-binding protein complex receptors), and CD32 (Fc gamma receptor II), which are specifically found on the SECs in normal liver, but not on ordinary vascular endothelial cells (ECs). Immunostaining was also performed for CD36 (thrombospondin receptors), EN4 antigen (Ag) (a pan-vascular endothelial cell Ag), PAL-E Ag (a venous and capillary EC Ag), factor VIII-related Ag (FVIIIRAg), and laminin. MAb 25F9, which identifies macrophages, was simultaneously used with the other MAbs to distinguish macrophages from SECs in HCCs (HCC SECs). CD4, CD14, and/or CD32 were found on HCC SECs only in 12 well-differentiated primary HCCs showing a thin trabecular or pseudoglandular tumor cell arrangement. These 12 tumors were smaller than those without CD4-, CD14-, and/or CD32-positive SECs (P < .05). Among them, 7, 5, and 11 tumors were negative or only partially positive for laminin, PAL-E Ag, and FVIIIRAg, respectively. Staining for laminin and PAL-E Ag showed an inverse relationship to the expression of CD4, CD14, and CD32 on HCC SECs and the tumor differentiation. In conclusion, the phenotypes of the SECs in early and well-differentiated HCC are thought to be similar to those of the SECs in normal liver. With progressing tumor dedifferentiation the HCC SECs lose the phenotypes peculiar to liver SECs and acquire the characteristics of capillary ECs, though both types of phenotypical change occur independently of each other.

High malignancy of hepatocellular carcinoma in alcoholic patients with hepatitis C virus

Background . We investigated the relationships between alcohol consumption, the degree of malignancy evaluated histologically, and tumor-free survival rates. Methods . In 80 male patients with the hepatitis C virus and small hepatocellular carcinomas (diameter of main tumor, 3.0 cm or less), 38 patients had drunk 86 gm or more of ethanol per day for at least 10 years until the detection of hepatocellular carcinoma (group 1), whereas the remaining 42 patients were nondrinkers or occasional drinkers (group 2). Results . Differences in the results of liver function tests between the groups were not statistically significant. The operative methods used in the groups were comparable. The proportion of well-differentiated hepatocellular carcinoma was lower in group 1 than in group 2 (p < 0.0001). The prevalences of extracapsular invasion, portal tumor thrombi, and intrahepatic metastasis were higher in group 1 than in group 2 (p = 0.0085, p = 0.0319, and p = 0.0428, respectively). The tumor-free survival rate after operation was lower in group 1 than in group 2 (p = 0.041 by the log-rank test; p = 0.032 by the generalized Wilcoxon test). Conclusions . These findings indicate that in group 1, even though tumors were small, the carcinomas were advanced and the outcomes after surgery were poor, suggesting that alcohol affects the grade of malignancy of this disease.

Lipiodol-CT for hepatocellular carcinoma

Lencioni et al. have nicely presented a positive predictive value of Lipiodol CT for intrahepatic metastasis of hepatocellular carcinoma (HCC) based on 32 consecutive patients undergoing hepatectomy [1]. Lipiodol-CT has been generally regarded as a highly sensitive examination to detect intrahepatic metastases because these mostly occur in hypervascular HCC (advanced or classic HCC, histopathologically moderately or poorly differentiated) and have a similarly hypervascular character. However, there has been no direct confirmation of high sensitivity and specificity by this method. Theoretically and clinicopathologically, Lipiodol is distributed in loci according to their vascularity. Long-term deposits are noted in the necrotic area of the tumor and liver parenchyma, especially after embolization [2]. Thus, any hypervascular nodular lesion such as small cavernous hemangioma and focal nodular hyperplasia and nontumorous area such as focal inflammation and arterioportal shunt could be false-positive cases of intrahepatic metastasis, although the durations of deposit are different case by case [2]. Such cases have been sporadically reported [3, 4]. Lencioni et al. have defined a positive finding of intrahepatic metastasis at Lipiodol-CT as a small, rounded, well-delineated retention less than 2 em in diameter but have not described any pathologic definition or finding. In general, intrahepatic metastases are present in cases with HCC associated with portal tumor thrombus, multiple in number, small in size, and located adjacent to the main tumor [5]. However, intrahepatic metastasis is not a self-evident lesion, especially in patients at high risk for HCC who often have multicentricoccurring tumors of different or same subtype. Even when using DNA analysis, pathologists cannot necessarily confirm whether or not a particular lesion is an intrahepatic metastasis [5, 6].

Long-term survival cases of hepatocellular carcinoma with portal tumor thrombus by repeated arterial infusion chemotherapy using implantable port system

Long-term survival cases of hepatocellular carcinoma with portal tumor thrombus by repeated arterial infusion chemotherapy using implantable port system

THE RELATIONSHIP BETWEEN HISTOPATHOLOGICAL FINDDINGS OF HEPATIC METASTATIC FOCI OF THE COLORECTAL CANCER AND PROGNOSIS AFTER HEPATECTOMY-A CLINICAL STUDY-

A histopathological study of resected livers was conducted in order to clarify the mechanism of recurrence in the residual liver following resection of hepatic metastases of colorectal cancer. The main parameters of the investigation included various type of invasive proliferation such as infiltration into the simusoidal space at the periphery or the presenting portion of the metastatic foci, portal system tumor thrombus, biliary tumor thrombus, and (peri) neural invasion. The relationship between the positive findings rate by pathology, including period, number, and extent of hepatic metastases, and the prognosis after resection of the hepatic metastases was investigated. Positive findings rates were 82% for sinusoidal infiltration, about 29% for portal thrombus, about 9% for biliary thrombus, and about 5% for (peri) neural invasion. There was no significant difference inthe positive rate by period of hepatic metastases, new micrometastases from the foci of hepatic metastases were considered highly likely, and the prognosis of cases with positive micrometastases was poor compared to cases with negative micrometastases. Such micrometastases are therefore considered an important factor in the recurrence arising in the residual live after resection of hepatic metastases. It is thought that we should select a procedure of resection for metastatic foci of the residual liver and a type of postoperative adjuvant chemotherapy in consideration of these histopathological findings.

Contrast enhanced color Doppler sonography in a hepatocellular carcinoma case with portal tumor thrombus

Contrast enhanced color Doppler sonography in a hepatocellular carcinoma case with portal tumor thrombus