Cholangiocellular and gallbladder carcinoma

Risk factors for cholangiocellular and gallbladder carcinomas are bile stones and chronic inflammation of the biliary system. Gallbladder cancer and intrahepatic cholangiocellular carcinomas can be diagnosed with a high sensitivity by ultrasonography, CT and MRI, while the most sensitive diagnostic methods for perihilar or distal cholangiocellular carcinomas are ERC or MRC. The only curative option for patients with gallbladder- or bile duct cancer is surgical resection. Outside clinical studies there is currently no indication for neoadjuvant or adjuvant chemotherapy or radiochemotherapy. Gallbladder and bile duct carcinomas are moderately chemotherapy-sensitive tumors. The objective response rates in phase II studies with 5-FU or gemcitabine monochemotherapy are between 10 - 30 %. Higher response rates between 20 - 50 % have been observed in phase II studies with combination chemotherapy, in particular with the combination of gemcitabine/cisplatin. Because of the low incidence of gallbladder and bile duct carcinomas there are currently no large phase III trails investigating the impact of chemotherapy on survival and quality of life or comparing the activity of different chemotherapy protocols. Patients in good general physical conditions or with tumor-associated symptoms should be treated with palliative chemotherapy (whenever possible in clinical studies), while chemotherapy should be avoided in patients with severe non-tumor-associated morbidity. Endoscopic procedures, such as PTC- or ERC-stenting and photodynamic therapy, are important supportive therapies which can help to maintain the bile flow and consequently improve survival and quality of life of patients with malignant bile duct obstructions.     

Current options for palliative treatment in patients with pancreatic cancer

Palliative treatment is often the only remaining option in the management of pancreatic carcinoma, but its efficacy is poor due to low tumor sensitivity and inadequate treatment protocols. There are several options of palliative treatment with antitumor or supportive intention. Classical end points of palliative treatment are survival, tumor response, and quality of life. A decade ago, palliative chemotherapy consisted mainly of 5-fluorouracil as the standard agent in combination with either other agents and/or radiotherapy. Only the new antineoplastic drug gemcitabine, which was introduced simultaneously with the definition of novel end points of chemotherapy such as clinical benefit, allowed to achieve some progress. However, while gemcitabine monotherapy appeared to be superior to 5-fluorouracil and improved important parameters of quality of life, it could not provide a significant improvement of survival. A novel concept, therefore, is to improve this beneficial cytostatic response in pancreatic carcinoma using a gemcitabine-based protocol by combining it with antineoplastic drugs such as taxanes or platin analogs. This strategy may have the potential to improve the outcome in palliative chemotherapy of pancreatic carcinoma patients with advanced tumor growth or metastases. Best supportive care in pancreatic cancer consists of the treatment of symptoms, such as pain, jaundice, duodenal obstruction, weight loss, exocrine pancreatic insufficiency, and tumor-associated depression.     

125I粒子植入联合吉西他滨化疗治疗胰腺癌临床受益疗效评价

目的 评价EUS引导下125I粒子植入联合吉西他滨化疗治疗胰腺癌的临床收益疗效.方法 41例不能手术切除的胰腺癌患者按完全随机法分为放射性125I粒子植入联合吉西他滨化疗组(21例)和单纯吉西他滨化疗组(20例).吉西他滨化疗方案为1 000 mg/m2,1次/周,静脉滴注,连用3周,休息1周;联合组在125I粒子植入后1周行化疗.评价临床受益疗效(CBR).结果 125I粒子联合吉西他滨化疗组临床受益率为57.1%,达到CBR的中位时间为1周,临床受益疗效持续的中位时间为21周;单纯化疗组分别为25%、4周和15周,两组前2项相差非常显著(P<0.05),而临床受益疗效持续的中位时间无显著差异(P>0.05).结论 EUS引导下125I粒子组织间植入联合吉西他滨化疗治疗不能手术切除的胰腺癌的CBR明显优于单纯吉西他滨化疗组.     

Occurrence of hepatocellular and cholangiocellular carcinoma in different hepatic lobes

Separate hepatocellular and cholangiocellular carcinoma (double cancer) in the liver are extremely rare subtypes of primary hepatic carcinomas. We report a case of double primary liver carcinomas that were surgically resected simultaneously. A 66-year-old man was admitted because of elevation of serum levels of alpha-fetoprotein. Abdominal computed tomography and angiography showed two hypervascular masses in S4 and S8 hepatic segments. With the diagnosis of multiple hepatocellular carcinomas, the tumors were surgically resected. Histological examination showed that the tumor in S4 segment was moderately differentiated cholangiocellular carcinoma, the other in S8 segment was trabecular, moderately differentiated hepatocellular carcinoma. Immunohistochemically, a positive staining in carcinoembyonic antigen and cytokeratin 7 supported the diagnosis of cholangiocellular carcinoma for the tumor in S4 segment. The frequency of double cancer in the liver is much lower than mixed or combined cancer (0.1-0.5%). The different epithelial malignant tumors of hepatocellular carcinoma and cholangiocellular carcinoma, which were located in different hepatic lobes and resected simultaneously, has been reported in only two cases including the present case.     

Resected case of a double cancer,a hepatocellular carcinoma and a cholangiocellular carcinoma,and their spread to the skin

Combined hepatocellular and cholangiocellular carcinomas are rare. Moreover, double cancer cases of hepatocellular carcinoma and cholangiocellular carcinoma are very rare. This report describes a patient with double cancer. A correct clinical diagnosis was made with successful resection, and cutaneous metastases occurred near the exit site of an abdominal drain after the resection of the tumor. The patient, a 66-year-old man with chronic hepatitis C, was admitted to our hospital because he was suspected of having primary liver cancer. Two liver masses in the anteroinferior segment were detected by using angiography, computed tomography during angiography, and computed tomography during arterioportography. These clinical findings indicated that the tumor in the right lobe was hepatocellular carcinoma. A resection of the S5 subsegmentectomy was performed. One mass was diagnosed histologically as hepatocellular carcinoma, and the other mass was diagnosed as cholangiocellular carcinoma. One year after the operation, the patient palpated a hard subcutaneous nodule 4.0 cm in diameter in the right lower abdominal wall. A subcutaneous tumor was excised, and a histological examination revealed moderately differentiated hepatocellular carcinoma. The patient is currently doing well without further recurrence of hepatocellular carcinoma or cholangiocellular carcinoma, 18 months after subsegmentectomy and six months after excision of the subcutaneous tumor.     

Nonpercutaneous therapies of hepatocellular carcinoma

Treatment of hepatocellular carcinoma depends largely on local resources, the stage of the disease and the presence of cirrhosis, but is limited overall by the lack of efficient chemotherapy. Hepatic resection is the treatment of choice for the few patients with hepatocellular carcinoma and normal liver. Five-year survival without recurrence in patients with a tumor of mean diameter 8 cm was 33%. Liver transplantation is the best chance for cure in patients with cirrhosis and a single small tumor, but its widespread application is limited by a number of obstacles, including cost. Tumor size and number, and liver status were common guidelines for selecting patients. Five-year survival of transplant patients was > 50%, compared to 0% in historical untreated controls. Patients with well-preserved liver function and a small tumor at the periphery could equally benefit from hepatic resection, although cirrhosis entails the risk of morbidity due to portal hypertension and development of de-novo tumors. Another major drawback of hepatic resection is the early spread of tumor cells, facilitating early tumor recurrence after operation. For patients with compensated cirrhosis and a small tumor who were hardly eligible for surgery, transcatheter arterial chemoembolization appeared to be a cost-saving and effective treatment modality. Transcatheter arterial chemoembolization has been largely employed also for the palliative treatment of patients with large tumors, but the benefits on survival are doubtful. Conventional radiotherapy with external irradiation was not effective against hepatocellular carcinoma.     

Hepatic intraarterial chemotherapy with gemcitabine in patients with unresectable cholangiocarcinomas and liver metastases of pancreatic cancer: a clinical study on maximum tolerable dose and treatment efficacy

Purpose To define the maximum tolerated dose (MTD) of hepatic intraarterial chemotherapy with gemcitabine, administered with and without starch microspheres, in patients with inoperable intrahepatic cholangiocarcinomas and liver metastases of pancreatic carcinomas.Methods Gemcitabine was administered on days 1 and 8 with intervals of 2 weeks between the cycles. In group A the initial gemcitabine dose of 1,000 mg/m² (without microspheres) was increased in 200-mg/m² steps up to a maximum dose of 2,000 mg/m². In group B the MTD with microspheres was assessed by giving an additional microsphere dose according to tumor extent and body weight, increasing gemcitabine starting from a dose-step below the MTD with microspheres. The MTD was evaluated via clinical and laboratory findings.Results Twenty-four patients were enrolled (12 males, 12 females, mean age 59.17 years; intrahepatic cholangiocarcinoma: n = 17, liver metastases of pancreatic carcinoma: n = 7). The MTD of gemcitabine without microspheres was reached at 1,400 mg/m², and of gemcitabine with microspheres at 1,800 mg/m². The comparative evaluation revealed statistically significant better data for the time to progression (p < 0.01) and survival for the group with microspheres (6.8 and 20.2 months) in comparison to the group without microspheres (4.2 and 13.5 months).Conclusion This clinical study indicates that the intraarterial application of gemcitabine with doses higher than the recommended 1,000 mg/m² is well tolerated if combined with microspheres, and yields respectable results in patients who do not respond to systemic chemotherapy.Albert Scheller has recently died.     

Percutaneous microwave coagulation therapy for superficial hepatocellular carcinoma on the surface of the liver

BACKGROUND/AIMS: This study was performed to evaluate the efficacy and safety of percutaneous microwave coagulation therapy for superficial hepatocellular carcinoma located on the surface of the liver. METHODOLOGY: Among 58 cirrhosis patients with 71 hepatocellular carcinomas measuring < or = 20 mm in greatest dimension, 18 patients had a solitary superficial lesion located on the liver surface (superficial hepatocellular carcinoma group) and the other 40 patients had 53 lesions that were not in contact with the liver surface (non-superficial hepatocellular carcinoma group). All patients were treated by percutaneous microwave coagulation therapy alone and the response was assessed by using contrast-enhanced CT. The survival, tumor recurrence, and adverse effects were compared between the superficial and non-superficial hepatocellular carcinoma groups. RESULTS: The 4-year survival rates of the superficial hepatocellular carcinoma group (64.2%) and the non-superficial hepatocellular carcinoma group (58.9%) were not significantly different, and neither were the 4-year local recurrence rates (27.1% vs. 29.8%). Although there was a significantly higher incidence of severe pain during microwave irradiation in the superficial hepatocellular carcinoma group (23/47) when compared with the non-superficial hepatocellular carcinoma group (25/148), there were no differences between them in the incidence of fever or the changes in liver function after treatment. There were no serious adverse effects, such as hemorrhage or tumor cell seeding, in either group. CONCLUSIONS: Percutaneous microwave coagulation therapy can be performed safely, even in patients with superficial hepatocellular carcinoma and cirrhosis, so this method is effective for treating hepatic neoplasms regardless of the tumor location.     

Treatment of HCC with pravastatin, octreotide, or gemcitabine--a critical evaluation

BACKGROUND/AIMS: New perspectives in the treatment of advanced hepatocellular carcinomas have recently been inaugurated with the application of hydroxymethylglutaryl coenzyme A reductase inhibitors i.e. pravastatin, the somatostatin analogue octreotide, or the cytidine analogue gemcitabine. The present study aimed to evaluate these substances in patients with progressive tumor growth. METHODOLOGY: A total of 58 patients either received 3 x 200 microg/day octreotide for 2 months followed by 20mg octreotide LAR every 4 weeks (n=30) or 40-80 mg pravastatin (n=20) or 80-90 mg/m2 gemcitabine over 24 hours weekly in cycles of 4 weeks (n=8). Kaplan-Meier survival curves and the log-rank test were used for univariate comparison of sur vival. RESULTS: The median overall survival of patients receiving octreotide was 5 months, of patients receiving pravastatin 7.2 months and of patients receiving gemcitabine 3.5 months. The difference between the pravastatin and the gemcitabine groups was significant. No WHO grade 3 or 4 side effects were seen in either group of patients. CONCLUSIONS: These results do not confirm those of former studies. Neither pravastatin, nor octreotide, nor gemcitabine did prolong the patients' median overall survival as compared to control groups reported by other authors. New therapeutic strategies have to be found for patients with advanced hepatocellular carcinomas.     

Effectiveness of gemcitabine as second-line chemotherapy in non-small cell lung cancer

The role of a second-line chemotherapy after an initial treatment with a platinum-based regimen remains largely undefined. In this retrospective clinical effectiveness study, gemcitabine as monotherapy was evaluated in the second-line chemotherapy in 34 non-small cell lung cancer (NSCLC) cases that had been previously received chemotherapy and did not respond to the treatment or presented with relapses. Gemcitabine was given intravenous at a dose of 1250 mg/m2 on days one, eight every three weeks. Median age was 50 years and squamous cell carcinoma was the most common malignancy (44.1%). No patient had a complete response, 7 (20.6%) patients had a partial response. The median survival was 29 weeks. The 1-year survival probability was estimated at 26.5%. Median time to disease progression was 13 weeks. Gemcitabine was well tolerated in this patient population. Among totally 119 chemotherapy cycles, we observed grade 3 and 4 toxicities only in 2.5% of cycles. As a result of the study, single agent gemcitabine is found to be tolerable and to have moderate effectiveness in the second-line chemotherapy in NSCLC. It should be placed among treatment options.     

Capecitabine for treatment of advanced hepatocellular carcinoma

BACKGROUND/AIMS: Patients with advanced hepatocellular carcinoma (HCC) face a dismal prognosis, as no effective palliative chemotherapy exists. Moreover, treatment of patients with hepatocellular carcinoma presents a major challenge, because associated cirrhosis limits the choice of chemotherapeutic agents. We evaluated the activity and toxicity of capecitabine in patients with advanced hepatocellular carcinomas. METHODOLOGY: The authors performed a retrospective analysis of all patients with HCC who were treated with capecitabine. The medical records of patients with HCC who were treated at our institution between October 2002 and July 2005 were reviewed. RESULTS: A total of eleven patients were treated with capecitabine. Eight patients had liver cirrhosis and Child-Pugh scores of A and B. Capecitabine was administered twice daily for 14 days at a total daily dose of 2000 mg/m2. Treatment was repeated every 21 days. Each patient received 2-16 treatment cycles. One partial response was observed (9%; 95% confidence interval (CI) 0.2-41.3%) and 3-month progression free survival rate was 27%. The median time to tumor progression and median overall survival were 2.2 months (95% CI 1.7-2.7 months) and 10.1 months (95% CI 3.0-17.2 months), respectively. The therapy was well tolerated, with hand-foot syndrome as the main toxicity. Grade 3 diarrhea occurred in one patient. Grade 3/4 hyperbilirubinemia was seen in five patients, but was mainly due to tumor progression. No other significant toxicities were observed. CONCLUSIONS: Capecitabine was found to be safe for treatment of patients with HCC, including those with compensated cirrhosis. However, the objective response rate was limited.     

Surgery for mixed hepatocellular and cholangiocellular carcinoma

BACKGROUND/AIMS: Mixed tumors composed of hepatocellular carcinoma and cholangiocellular carcinoma are rare. In this report, the clinicopathologic characteristics and treatment outcome of four patients with mixed hepatocellular and cholangiocellular carcinomas are described. METHODOLOGY: Of 539 patients with primary liver cancer who underwent hepatic resection in our department over a 17-year period, 4 were diagnosed with mixed hepatocellular and cholangiocellular carcinoma. The clinicopathological features and treatment outcomes of these 4 patients were investigated. RESULTS: All 4 patients were positive for hepatitis C virus antibody and had hypervascular tumors. Tumor resection was performed for all patients. Three underwent lymph node dissection. At the time of this study, 1 patient was alive without recurrence 12 months after surgery. The other patients died within 28 months of surgery. CONCLUSIONS: Mixed tumors should be considered in patients with a liver mass and increased serum carcinoembryonic antigen and carbohydrate antigen 19-9 concentrations, a low alpha-fetoprotein concentration, and hypervascularity. The cholangiocellular carcinoma component appears to determine the prognosis.     

Surgical resection of hepatocellular carcinoma. Retrospective study of 42 cases

We studied the results 42 liver resections performed for hepatocellular carcinoma. Thirty-three patients underwent major liver resections. Hepatocellular carcinomas were associated with cirrhosis in 30.9 p. 100 of cases. The overall operative mortality was 24.3 p. 100: 60 p. 100 in patients with cirrhosis who underwent major liver resections and 12.5 p. 100 in patients with cirrhosis undergoing limited resections. The overall 5-year survival rate was 14.8 p. 100; the 5-year survival rate in patients with hepatocellular carcinoma without cirrhosis was 20 p. 100 whereas no patient with associated cirrhosis of the liver survived at 3 years. We conclude that surgical resection of hepatocellular carcinoma must be performed whenever possible: a limited resection should be done if the tumor is small, especially in patients with cirrhosis; a major liver resection must be proposed when the tumor is large and if the remaining liver parenchyma is normal.     

Comparison of tumor marker CA 242 with CA 19-9 and carcinoembryonic antigen (CEA) in pancreatic cancer

BACKGROUND/AIMS: Although there are a variety of tumor markers used for diagnosis of pancreatic carcinoma, the sensitivity and specificity of those markers have not yet reached an ideal level. The aim of this study was to compare the diagnostic value of CA 242 with CA 19-9 and CEA in the patients with pancreatic cancer. METHODOLOGY: Serum CA 242, CA 19-9 and CEA levels were determined in 135 subjects in the following groups: Pancreatic cancer (n = 40), cholangiocellular carcinoma (n = 15), hepatocellular carcinoma (n = 10), cirrhosis (n = 7), chronic active hepatitis (n = 7), choledochal stone (n = 12), chronic pancreatitis (n = 9), acute pancreatitis (n = 6), and healthy controls (n = 29). RESULTS: An elevated serum CA 242 concentration (> 20 U/mL) was found in 30 out of 40 (70%) (mean; 2163 +/- 838 U/mL) patients with pancreas cancer, in 11 out of 15 patients with cholangiocellular carcinoma (93.3%) (mean 916 +/- 529 U/mL), in none of patients with hepatocellular carcinoma and healthy controls. Slightly elevated CA 242 concentration was found in 6 out of 41 patients with benign hepatobiliary and pancreatic disease (range 0.4-97.8 U/mL) (1 acute pancreatitis, 2 chronic pancreatitis, 1 cirrhosis, 2 choledochal stone). Mean serum CA 242, CA 19-9 and CEA levels of the pancreas cancer group were significantly higher than those of the other groups except the cholangiocellular carcinoma group. There was no significant difference between the stage of pancreas cancer regarding mean serum CA 242, CA 19-9 and CEA level. There was positive correlation between serum CA 242 and CA 19-9 level. In the pancreas cancer, the sensitivity of CA 242, CA 19-9 and CEA was 75%, 80%, 40%, respectively and the specificity of those markers was 85.5%, 67.5% and 73%, respectively. CONCLUSIONS: In conclusion, the advantage of CA 242 compared to CA 19-9 is that its specificity is higher than that of CA 19-9 in the diagnosis of pancreas cancer.     

Transarterial embolization of metastatic mediastinal hepatocellular carcinoma

This paper introduces an innovative treatment for extrahepatic metastasis of hepatocellular carcinoma. A 71-yearold patient had a stable liver condition following treatment for hepatocellular carcinoma, but later developed symptomatic mediastinal metastasis. This rapidly growing mediastinal mass induced symptoms including cough and hoarseness. Serial sessions of transarterial embolization (TAE) successfully controlled this mediastinal mass with limited side effects. The patient’s survival time since the initial diagnosis of the mediastinal hepatocellular carcinoma was 32 mo, significantly longer than the 12 mo mean survival period of patients with similar diagnoses: metastatic hepatocellular carcinoma and a liver condition with a Child-Pugh class A score. Currently, oral sorafenib is the treatment of choice for metastatic hepatocellular carcinoma. Recentstudies indicate that locoregional treatment of extrahepatic metastasis of hepatocellular carcinomas might also significantly improve the prognosis in patients with their primary hepatic lesions under control. Many effective locoregional therapies for extrahepatic metastasis, including radiation and surgical resection, may provide palliative effects for hepatocellular carcinoma-associated mediastinal metastasis. This case report demonstrates that TAE of metastatic mediastinal hepatocellular carcinoma provided this patient with tumor control and increased survival time. This finding is important as it can potentially provide an alternative treatment option for patients with similar symptoms and diagnoses.     

抗抑郁药米氮平对吉西他滨治疗胰腺癌模型的辅助作用

目的 探讨抗抑郁药米氮平对吉西他滨治疗的胰腺癌移植瘤裸鼠进食量、体重和肿瘤生长的影响.方法 24只胰腺癌裸鼠皮下移植瘤模型随机分为对照组、吉西他滨组(术后第1、4、7、10天腹腔注射吉西他滨100 mg/kg体重)和联用组(吉西他滨组+米氮平10 mg·kg~(-1)·d~(-1)灌胃,持续21曲,每组8只.术后21 d处死裸鼠,比较3组动物体重、进食量、肿瘤体积的变化.结果 吉西他滨组具有显著的抗肿瘤生长作用,但存在显著的胃纳减少和体重降低等不良反应.术后第21天,联用组和吉西他滨组胰腺癌移植瘤体积无明显差异,抑瘤率分别为69.13%和71.60%(P>0.05);联用组进食量(3.12±0.11)g、体重(14.68±0.42)g,稍高于吉西他滨组的(2.96±0.14)g和(14.38±0.61)g(P值均>0.05),但显著低于对照组的(4.65±0.13)g和(17.46±0.52)g(P值均<0.05).结论 吉西他滨化疗具有显著的抗胰腺癌作用,米氮平虽无显著增效作用,但可在一定程度上减轻大剂量吉西他滨化疗的不良反应.     

Initial experience from a combination of systemic and regional chemotherapy in the treatment of patients with nonresectable cholangiocellular carcinoma in the liver

AIM: In nonresectable cholangiocellular carcinoma (CCC) therapeutic options are limited. Recently, systemic chemotherapy has shown response rates of up to 30%. Additional regional therapy of the arterially hyper vascularized hepatic tumors might represent a rational approach in an attempt to further improve response and palliation. Hence, a protocol combining transarterial chemoembolization and systemic chemotherapy was applied in patients with CCC limited to the liver. METHODS: Eight patients (6 women, 2 men, mean age 62 years) with nonresectable CCC received systemic chemotherapy (gemcitabine 1 000 mg/m2) and additional transarterial chemoembolization procedures (50 mg/m2 cisplatin, 50 mg/m2 doxorubicin, up to 600 mg degradable starch microspheres). Clinical follow-up of patients, tumor markers, CT and ultrasound were performed to evaluate maximum response and toxicity. RESULTS: Both systemic and regional therapies were tolerated well; no severe toxicity (WHO Ⅲ/Ⅳ) was encountered. Nausea and fever were the most commonly observed side effects. A progressive rarefication of the intrahepatic arteries limited the maximum number of chemoembolization procedures in 4 patients. A median of 2 chemoembolization cycles (range, 1-3) and a median of 6.5 gemcitabine cycles (range, 4-11) were administered. Complete responses were not achieved. As maximum response, partial responses were achieved in 3 cases, stable diseases in 5 cases. Two patients died from progressive disease after 9 and 10 mo. Six patients are still alive. The current median survival is 12 mo (range, 9-18); the median time to tumor progression is 7 mo (range, 3-18). Seven patients suffered from tumor-related symptoms prior to therapy, 3 of these experienced a treatment-related clinical relief. In one patient the tumor became resectable under therapy and was successfully removed after 10 mo. CONCLUSION: The present results indicate that a combination of systemic gemcitabine therapy and repeated regional chemoembolizations is well tolerated and may enhance the effect of palliation in a selected group of patients with intrahepatic nonresectable CCC.     

Hepatic arterial blood flow in large hepatocellular carcinoma with or without portal vein thrombosis: assessment by transcutaneous duplex Doppler sonography

BACKGROUND: As liver cirrhosis progresses, the portal venous blood (PVBF) flow decreases, accompanied by an increase in hepatic arterial blood flow. Large hepatocellular carcinoma is a hypervascular tumour with a rapid growth, which seems to require an increase of the tumoral arterial blood flow. Furthermore, hepatocellular carcinoma is frequently associated with portal vein thrombosis, which subsequently impedes portal blood supply. METHODS: The purpose of our study was to estimate alterations in the hepatic arterial blood flow in large hepatocellular carcinomas occurring in liver cirrhosis, in comparison with liver cirrhosis and controls. Liver blood flow measurements were determined by duplex Doppler sonography in 47 patients with large hepatocellular carcinomas (13 with portal vein thrombosis and 34 without this thrombosis), 42 liver cirrhosis patients and 30 controls. The Doppler perfusion index was calculated as the ratio of hepatic arterial blood flow to total hepatic blood flow. RESULTS: The patients with liver cirrhosis had a significant increase of hepatic arterial blood flow as compared to controls (P < 0.001), accompanied by a significant reduction in PVBF (P < 0.005). As a result, the Doppler perfusion index was increased in patients with liver cirrhosis as compared to controls (P < 0.001). The hepatic arterial blood flow was increased in patients with hepatocellular carcinoma but without portal vein thrombosis as compared to the cirrhotic patients (P < 0.001), with a significant reduction of PVBF (P < 0.001). Hepatic arterial blood flow was also increased in patients with both hepatocellular carcinoma and portal vein thrombosis as compared to the patients without this thrombosis (P < 0.001). CONCLUSION: These results suggest that in large hepatocellular carcinomas there is a decreased PVBF, accompanied by an increased hepatic arterial blood flow. The hepatic arterial buffer response seems to be active in hepatocellular carcinomas and maintains liver perfusion to adequate levels.     

Does surveillance for hepatocellular carcinoma in HCV cirrhotic patients improve treatment outcome mainly due to better clinical status at diagnosis?

BACKGROUND/AIMS: Cirrhotic patients with hepatitis C virus infection are a group at higher risk for hepatocellular carcinoma. Conventional screening programs detect only few early hepatocellular carcinomas that are eligible for radical treatment. Our aim was to compare characteristics of patients, modality of treatment, and outcome in anti-HCV positive cirrhotics with hepatocellular carcinoma diagnosed during follow-up, or incidentally. METHODOLOGY: Sixty-one hepatocellular carcinomas were consecutively diagnosed in cirrhotic anti-HCV patients from 1993-1998 among which 34 during biannual ultrasonographic-biochemical follow-up and the others incidentally. Child-Pugh's score, alpha-fetoprotein levels, uni- or multifocality of the tumor, and treatment and survival of the patients were then analyzed on the basis of modality of diagnosis. RESULTS: Surgical treatment was feasible only in a minority of patients. Radical and palliative treatment was more frequent among patients with HCC diagnosed during follow-up. Child-Pugh's score was lower in these patients, moreover their survival rate was better. Analysis of survival of patients treated with the same procedure and grouped by modality of diagnosis did not demonstrate any differences. Regression analysis showed that patients with a lower Child-Pugh's score, one nodule, with a tumor diagnosed during follow-up and who were treated had a better survival rate. CONCLUSIONS: In our population surveillance did not detect a higher percentage of curable HCC. Nevertheless the results of palliative treatment and of curative treatment overlapped. Overall better outcome was observed in patients with preserved liver function whatever the treatment. Surveillance allowed us to diagnose HCC in patients with these characteristics thus leading to an improved survival rate.     

A long-term survival case underwent repeated hepatic arterial infusion chemotherapy with portal branch ligation and wrapping of the liver using sheets for hepatocellular carcinoma

Despite progress in therapeutic modalities for hepatocellular carcinoma, chemotherapy is the only remaining option for a considerable number of patients because of severe advanced disease and/or cirrhosis. Repeated hepatic arterial infusion chemotherapy with portal branch ligation and decollateralization using a silicone rubber sheet was performed for hepatocellular carcinoma. Tumor size and serum concentration of alpha-fetoprotein markedly decreased after hepatic arterial infusion chemotherapy. Although the patient had no recurrent tumor, he died of hepatorenal failure 7 years after treatment. Hepatic arterial infusion chemotherapy combined with portal branch occlusion and decollateralization is a new therapeutic method for unresectable hepatocellular carcinoma.