We examined the immunohistochemical expressions of HSC73 RB protein and Ki-67 in samples of esophageal squamous cell carcinoma from 64-cases, and these expressions were studied along with clinicopathologic factors and the survival rate. The expressions of the HSC73 and RB were recognized in 47.9%and 70.4%respectively, while the average of Ki-67 positive ratio was 53.3%. The expressions of HSC73 were more prominent in well differentiated or moderately differentiated carcinomas in comparison with those in poorly differentiated cancers. Survival rate was significantly worse in the patients with HSC73 negative tumors than in those with HSC73 positive tumors. The expression of RB did not relate to histologic classification, growth pattern, and lymphatic invasion. The RB positive and HSC73 negative groups revealed the lower Ki-67-PI than RB positive and HSC73 positive proups. We guessed that cell cycle regurators were stabilized with HSC73 in squamous cell carcinoma of the esophagus.

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To evaluate the effects of preoperative chemotherapy for advanced gastric cancer, we histopathological effects, the changes in the nuclear area (NA) and the coefficient of variation (NACV) of residual cancer cells. Thirty patients were treated by continuous i. v.5FU injection (300mg/m²/day) until the day before the operation (FU group). Forty-twopatients were treated with C. I.V 5FU by i. v. injection of low a dose of CDDP (15mg/m²/day) on day 1 and 2 (CF group). These compared with two groups were given a no treatment group (20cases). According to the Japanese classification of gastric carcinoma, the histological effects were as follow: FU group (Gr0, 9; Gr1a, 13; Gr1b, 5 and Gr2, 3.) and CF group (Gr0, 10; Gr1a, 21; Gr 1b, 5; Gr2, 5; and Gr3, 1.). These were no nignificant histological differences between the FU and CF groups. The values of NA were as follows: control (47. 6μm²), FU group (Gr0, 50. 5; Gr1a, 58. 8; Gr1b, 65. 2; and Gr2, 72. 6.) and CF group (Gr0, 70. 2; Gr1a, 64. 2; Gr1b, 49. 8; and Gr2, 33. 8.). The values of NACV were as follows: control (27. 0%), FU group (Gr0, 27. 9; Gr1a, 30. 7; Gr1b, 38. 4; and Gr2, 30. 5.) and CF group (Gr 0, 32. 1; Gr1a, 34. 6; Gr1b, 50. 8; and Gr2, 50. 3.). Low a dose CDDP causes a decrease in NA and an increase in NACV in patients with a high-grade response to preoperative 5FU chemotherapy. These findings suggest that a valuation of NA and NACV in useful for the prediction of chemosensitivity and that low a dose CDDP isan important factor as not only an effector but also a modulator in biochemicall modulation of 5FU chemotherapy

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Gastric stump carcinoma originating after Billroth-II(B-II)reconstruction sometimes has lymph node metastasis in the mesojejunum (MJ). We studied the significance of lymph node dissection of the jejunal mesentery from 20 stump carcinomas after B-II reconstruction surgically removed at Kanazawa Medical University. The initial diseases were benign in 15 andmalignant in 5 patients. The incidence of lymph node metastasis was microscopically 30% in MJ, 25% in no. 10, 15% in nos. 1, 3, 4and11, 10% in nos. 2, 9, 15, 16, and, 5% in nos. 7and 14. Consequently, as for the degree of lymph node metastasis according to Japanese Classification, 6 patients were n0, 4 were n1-2, 5were positive in MJ(nMJ)and 5 were n4. All of 7 patients with t1-2 are alive, but 13 patients with t3-4 died within 5 years. Five-year survival was 56% in n0 and 60% in nMJ, while n0 5-year survival was seen in n1-2or n4. In 14 patients with nodal metastasis, none had survived more than 3 years except two with positive MJ nodes and one with para-aortic node metastasis. These results suggest that, for patients with cancer invading the jejunum, it is important to select appropriate surgical procedures according to the tumor stage, including mesojejunal node dissection

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The aim of the study was to elucidate the clinical assessment after total gastrectomy for gastric cancer. The records of 24 patients who underwent resection without apparent residual tumors were evaluated to compare two reconstruction procedures, Roux-en-Y esophagojejunostomy (R-Y, n=15) and jejunal pouch according to double tract reconstruction (JPD, n=9).No anastomotic leakage was found in either group. Length of operation time for JPD was shortened using stapling devices. The nutritional status (including white blood cell and lymphocyte counts, hemoglobin, total protein, serum albumin and total cholesterol levels), and bodyweight were assessed from the preoperative period to three years after operation. Nodifference between the nutritional status of R-Y(n=11)and JPD(n=6) in patients with curative resections was found. From three months to two years after operation, bodyweight loss of JPD(n=6, 4.5±6.5-6.1±5.5%) were lower than that of R-Y(n=11, 11.3±2.9-15.6±3.9%) in patients with curative resections (p<0. 05). These results suggest that the JPD procedure is an acceptable reconstruction method after total gastrectomy for gastric cancer.

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The antimetastatic effect of FR-118487 was investigated in rabbit colon cancer models. Spontaneous liver metastases were induced by VX2 tumor cell implantations into ascending colonic walls. FR-118487 was administered for one week at a dose of 1mg/kg/day via the hepaticartery (IA group) or the portal vein (IP group) after resection of the primary lesion. Thenumber of metastatic foci tended to be less in the IA and IP groups than in the control group. The weight of metastatic foci were significantly less in the IA and IP groups than inthe control group (p<0. 01 and p<0.05, respectively). Immunohistological study by factor VIII related antigen staining showed that microvessel density of metastatic foci were significantly less in the IA and IP groups than in the control group (p<0.05). The continuous infusion of FR-118487 suppressed liver metastasis by inhibiting angiogenesis without any adverse effects. The incidence of liver metastasis was 40%, 71%and100%, in the IA, IP and control groups, respectively. These results suggest that delivery of FR-118487 is more effective via the IA route than the IP route for preventing liver metastasis after resection of primary lesion.

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Since 1988, Niigata Cancer Center Hospital has performed intraoperative peritoneal washingcytology (CY) of the Douglas pouch was in 673 patients (pts) with gastric cancer to diagnose latent peritoneal dissemi nation. Patients were classified as follows: 461 pts in P0, CY-; 40 pts in P0, CY+; 71 pts in P1; 44 pts in P 2; and 57 pts in P3. Usually, Papanicolaou's staining method was used and immunocytochemical staining of CEA was carried out to make the definitive diagnosis. There were 155 pts (23. 0%) in CY+, and the incidence of CY+was 8. 0% in P0, 46. 5% in P1, 65. 9% in P2 and 93. 0% in P3, respectively. The 5-yearsurvival rate was 55. 9% in P0, CY-, 16. 7% in P0, CY+, 11. 6% in P1, 2.7% in P2, and the survival curve of P0, CY+ was similar to that of P1. The survival of P0, CY+ pts and P1 pts who had undergone curative surgery was better than that of those with non-curative surgery, but there was no difference between curative and non-curative sur-gery in P2 and P3 pts. The positive rate of immunocytochemical staining of CEA was 66. 7% in 24 pts of P0, CY+, and 28. 6% in 28 pts of P+, CY-. CEA staining was useful for discriminating between cancer cells and benign reactive mesothelial cells. Prognostic factors were determined in 496 pts with advanced gastric cancer without liver metastasis by multivariate analysis.Curability of gastric resection, depth of tumor invasion, lymph node metastases, histological type and CY were independent prognostic factors. In conclusion, CY can be evaluated todetect latent peritoneal dissemination and can serve as an independent predictor of prognosis for pts with advanced gastric cancer.

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We present a case of Mallory-Weiss syndrome (MWS), induced by rapid colonic preparation, and review the previous literature. A 58-year-old female developed nausea and hematemesis immediately after ingestion of 1. 8 liters of colonic lavage solution over a period of about 30 min. Endoscopy revealed active bleeding distal to the esophago-gastric junction, however, endopscopic hemostasis was unsuccessful. Since melena was followed, laparotomy was attempted. Since hard induration was palpated in the cardia of the stomach, proximal gastrectomy was performed. Histologically, the muscular layer was completely distrupted and yet absent of malignancy. Preservation of the stomach was considered to be possible by transgastric hemostasis. Rapid colonic lavage-induced MWS has been reported in 8 cases in Japanese literature and in 7 cases elsewhere in other countries. We should be aware of this uncommon complication associated with colonic preparation. Physicins should be informed that alarge volume of lavage solution should be given at a rate slower than 1 li-ter/hr, and advised that adnministration should be discontinued if repeated emesis develops, and that thepatient should be placed under medical observation.

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A 59-year-old man was admitted in May 1996 due to esophageal cancer of the upper thoracic esophagus, of a protruding, superficial, expanding type that was unstained by iodine. After neoadjuvant chemotherapy with a combination of cisplatin and 5-FU for 2 weeks, a radicaloperation with 3-field lymphadenectomy was performed. A digestive reconstruction was made by intrathoracic esophago-gastrostomy. On the fourth post-operative day, the patient demonstrated vital instability caused by severe mediastinitis due to an anastomotic leak. A thoracotomy was redone and the proximal one-third of the substituted stomach was confirmed tohave necrosis and perforation because of comression of the right bronchial artery and the azygos arch. Resection of the necrotic part of the stomach and plueral lavage were performed and a cervical esophagostomy was made. The patient's condition improved despite transitional multiple organ failure about three months later. A diges-tive reconstruction was performed using the left colon while the patient was stable and he was discharged seven months later. Although intrathoracic esophago-gastrostomy has been considered a safe option, this report seems to be the first case of such a severe complication. We must consider the anatomical positions of the substituted stomach and the right bronchial artery and azygos arch when we performe a digestive recon-struction following surgery for esophageal cancer.

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A 73-year-old man was transferred to our hospital because of right abdominal pain. Upper gastrointestinal endoscopy and colonoscopy demonstrated double cancers of an early gastric and advanced ascending co-loncancer. A bone marrow biopsy performed for pancytopenia led to the diagnosis of myelodysplastic syndrome (MDS) associated with refractory anemia with excess of blasts in transformation. Right hemicolectomy was performed with partial resection of the abdominal wall, where the ascending colon cancer had invaded and formed abscess. Postoperatively, the patient was managed in a portable sterile bed and received transfusions of packed red blood cells and platelets, and antibiotics, and not granulocyte colony stimulating factor (G-CSF). His postoperative course was uneventful. After discharge, the patient underwent endoscopic micro-wave coagulation therapy for gastric cancer. He died ofsepsis secondary to pneumonia three months after surgery.

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We experience 2 cases of distal gastrectomy with splenectomy for gastric cancers combined with idiopathic thrombocytopenic purpura (ITP) and hereditary spherocytosis (HS) respectively. One patient was a 72-year-old woman with a diagnosis of ITP and gastric cancer in thestomach body (3'T₃N₁M₀). The other patient was a 62-year-old man with a diagnosis of HS, cholelithiasis, choledocholithiasis, hepatolithiasis and gastric cancer in the anterior wall of the stomach angle (0'-IIC T₁N₀M₀). In both cases, distal gastrectomy with splenectomy, with ligature of the left gastric artery at its trunk, preserving the short and posterior gastric vessels was performed. The course after the operation showed no serious complications such as ischemic necrosis of the gastric remnant or leaks from disruption of the suture line

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A gastrointestinal stromal tumor (GIST) of the duodenum in a 56-year-old woman, detected by gastric endoscopy, is reported. The examinations revealed a hemispheric submucosal tumor, 3cm in diameter with delles and a bridging fold. Gastrectomy was performed. Histologicalfindings of the resected specimen showed that the tumor was composed of spindle cell proliferation. Immunohistochemically, the tumor cells was negative for smooth muscle antigen and S-100 protein, but was positive for vimentin. The mitotic index was 1-3/10 high power fields. The concept of GIST has not yet been established, and so we reported this case with consideration of the literature.

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We report a case of malignant lymphoma of the duodenum accompanied with obstructive jaundice. A 76-year-old woman was admitted to our hospital with complaints of back pain and jaundice. On endoscopic examination, a giant irregular elevated lesion lesion accompanied by ulceration was found from the duodenal bulb to the 2nd portion of the duodenum. Histological examination of a biopsy specimen revealed non Hodgkin's lymphoma. Complete obstruction of the common bile duct (CBD) was observed by percutaneus transhepatic cholangiography. Computed tomography revealed a thickened wall of the duodenal bulb, with no evidence of distant metastasis. Pancreaticoduodenectomy was carried out. The size of the tumor was 9×5cm. Pathological examination demonstrated non Hodgkin's lymphoma (B cell type), medium sized cell type. The tumor invaded the CBD and the pancreatic head. Regional lymph nodes were also involved. She received chemotherapy (vincristine, cyclophosphamide, mercaptopurine, prednisolone), and was discharged 81 days after the operation. There are 72 reports regarding malignant lymphoma of the duodenum in Japan.

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We diagnosed and treated a case of traumatic stenosis of the biliary tract with portal vein stenosis which was sucessfully managed with the use of a tube stent for percutaneous transhepatic endoprosthesis of the biliary tract. A 23-year-old man received a hard blow to his abdomen by a staring wheel of a truck. On the 22nd day after the accident, he began to have a xanthochromtic change of the skin and vomiting and was admitted to our hospital. On admission, mild anemia, impaired hepatic function and jaundice were observed. Abdominal ultrasonography revealed a dilatation involving intrahepatic to common bile duct. Abdominal CT visualized the dilated common bile duct and hematom a extending from the hepatoduodenal mesentery to the superior margin of the pancreatic head. Endoscopic retrograde cholongiography (ERCP) showed a smooth stenosis of the common bile duct 20mm in length. Angiography revealed a smooth stenosis of the portal vein. From these findings, we made a diagnosis of biliary stenosis due to abdominal blunt trauma. For the purpose of percutaneous transhepatic endoprosthesis of the biliary tract, the intrahepatic bile duct was punctured, and a 7.2Fr tube stent was placed. Then internal fistulization was achieved by increasing the diameter of the stent to 14Fr. Adequate flow was confirmed by fluoroscopic imaging. The indwelling biliary tube was removed on the 35th hospital day. Although the case was associated with portal vein stenosis, this improved with hepatic function and absorption of the hematoma surrounding the common bile duct. Since then, the clinical course has been uneventful and the patient is followed on an ambulatory.

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We report a case of pancreatic cancer which was initially detected as a subcapsular splenic hematoma and was surgically resected. A 48-year-old man who complained of upper abdominal pain and constipation was admitted to our department. Computed tomography (CT) showed a hematoma in the lateral part of the spleen. We diagnosed it as a subcapsular splenic hematoma of unknown origin and performed a lapalotomy. A subcapsular splenic hematoma and intraperitoneal abscess were noted and abdominal lavage and drainage were performed. After the surgery, the inflammatory reaction and serum amylase continued to be at a high level according the laboratory findings and the pancreatic juice was drained from the incised splenic capsule site. Three months after surgery CT showed a mass 12mm in size at the pancreatic head. An endoscopic retrograde pancreatogram showed that the main pancreatic duct was stenotic and the second branch of the pancreatic duct was encased at the pancreatic head, and the distal pancreatic duct was dilated. These finding strongly suggested chronic pancreatitis and pancreatic head cancer and pacreatoduodenectomy was performed. The operative findings revealed a pancreatic tumor with 2.0×1.5-cm and advanced pancreatic cancer of stage III. The subcapsular splenic hematoma in this case was due to pancreatitis as a complication of pancreatic cancer. In such a case, an appropriate assessment of the etiology can support early detection followed by early resection of pancreatic cancer.

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A case of adult Hirschsprung's disease with obstructive colitis is reported. A 28-year-old woman hed been suffering from severe constipation and abdominal distension since childhood. Although constipation tendency continued, she was able to have a bowel movement without cathartics after several days. Recently constipation gradually worsened, and she was admitted to our hospital complaining of abdominal distension and vomiting. Barium enema examination revealed a typical change in caliber and dilatation of the sigmoid colon with partial stenosis. Colonscopy revealed a narrowed rectum, a dilatated sigmoid colon with segmental stesosis and a map-like ulcer, and normal mucosa lying between the narrow rectum and the ulcer. Manometry revealed loss of anorectal reflex. Microscopic findings of the map-like ulcer showed a nonspecific inflammation and ganglion cells were present in the dilatated sigmoid colon, but absent in the rectum. In addition, acetylcholine esterase staining revealed the presence of hypertrophied nerve fibers in the rectal biopsy specimen.

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Until December, 1997, 654 HCC patients received hepatic resection (A), 109 had percutaneous transhepatic ethanol injection therapy (PEIT)(B), and 701 had transcatheter arterial embolization therapy (TAE)(C). The long-term outcomes of the patients who received the therapies were compared at the same tumor and clinical stages. Among the stage I HCC patiets with clinical stage I, the 5-and 10-year survivals of A were 76% and 50%, and those of B were 46%, 0%, respectively (A to B; NS). In stage I HCC patients with clinical stage II, the 5- and 10-year survivals of A were 61%, 10%, those of B were 47%, 35%, and those of C, 27%, 0%, respectively (A to C, B to C; p<0. 05, A to B; NS). Of stage II painets, the 5- and 10-year survivals were 57%, 33% in A, 0%, 0%in B, 19%, 0% in C (A to B, C; p<0.0001). In stage III patients with both clinical stages, although the 5-year survival of A was significantly better B, no significant differences were recognized about 10-year survivals. In the comparison of the 5-year survivals of the stage IV patients who had 3 or less tumors with less than 3cm in size, the 5-year survivals were 53% in A, 66% in B, 26% in C, resepectively (A to B to C; NS). Hepatic resection showed the better outcome than the other treatment groups in stage I, II and III patients with relatively good liver function. The patients in stage II are the most suitable for hepatic resection. In the stage IV patients with small and a few HCCs, PEIT may be recommended as the first choice therapy.

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Establishment of the first entry therapy of hepatocellular carcinoma (HCC) requires a prospective randomized control study. However, these are some of the medical moral considerations that we must take into account. Hence, it is necessary a comparison between the therapeutic outcome of HCC patients among independent surgical and medical institutes of the same geographic region. We investigated the comparative cumulative survival outcomes evaluating retrospectively 107 HCC patients who underwent hepatic resection in our institute and 158 patients who underwent minimally invasive non-surgical treatments in the 3rd Department of Internal Medicine, Tohoku University School of Medicine since 1973, according to numbers of tumors, diameter of the main tumor and their clinical stages. The latter treatment consisted mainly of transcatheter arterial embolization therapy (TAE) and percutaneous ethanol injection therapy (PEI). Five-year survival rate in the hepatic resection group, with mean tumor diameter measuring up to 3.0cm and number of tumors less than three was 57.8%, that with solitary tumor diameter between 3.1and5.0cm was 53.7%and that with mean tumor diameter over5.1cm was 37.0%. Even though the outcome of non-surgical treatments for HCCs has been gradually improving, these investigations revealed appreciably better results for the surgical approach compared to non-surgical minimally invasive therapy. For the HCC patients who have good liver function, the systematic and anatomical surgical hepatic resection results in more favorable long-term outcome with a superiority of the local curability than non-surgical treatments. Therefore, surgical resection should be considered the first entry therapy and represent the gold standard strategy for HCC therapy.

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The survival and disease-free survival curve of 534 patients with solitary hepatocellular carcinoma (HCC) who underwent hepatectomy were applied to parametric survival analysis models. The 3-, 5-, 10-years survival and the 3-, 5-, 10-years disease-free survival rate of the patients were 76, 60, 34% and 46, 32, 16%, re-pectively. Both of the curves were well applied to Weibull and Log-logistic model. The significant coefficients which affect the survival curve were preoperative ICG R15 and tumor size. Lower ICG R15 and smaller tumor size improved survival rate. Similarly, preoperative ICG R15, tumor size and resected segment were significant coefficients for the disease-free survival curve. Lower ICG R15, smaller tumor size and larger hepatectomy prolonged disease-free period. Although, the extension of hepatectomy improves disease-free survival, better survival is obtained by better liver function rather than larger hepatectomy. It is concluded that the optimum hepatectomy preserving liver function is important for long term QOL of HCC patients.

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This study was undertaken to investigate the correlation between the prognosis and the quality of life (QOL) after hepatectomy in 203 patients with primary hepatocellular carcinoma (HCC), who received curative resections between 1980 and 1997. One-hundred eleven patients who survived more than 1 year following the operation answered our original questionnaire.
The results obtained were as follows:
1) The QOL, especially physical condition, was relatively satisfactory 1 year after hepatectomy, however, informed consest at initial surgery or recurrence was important.
2) The QOL in the patients with recurrence deteriorated when the disease free period was less than 1 year, or when receiving therapy for recurrent HCC.
3) The prognosis and QOL was much better in patients with normal, that is chronic persistent hepatitis (CPH), however, in patients with chronic active hepatitis (CAH), the high incidence of early recurrence and the therapies for recurrence or for hepatitis impaired their social and/or psychological functions. Patients with liver cirrhosis (LC) also showed high recurrence rates and 50% had multicentric occurrence. Patients with severe postoperative complications tended to develop long-term (2-7year) impaired performances. Given these considerations, curative resection in patients with normal CPH liver was effective, however, strategies to prolong the disease free survival period in CAH patients and treatments for primary or recurrent HCC in LC patients should be selected with the most favorable prognosis and the best QOL for each patint as the goal.

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We evaluated clinicopathological factors, survival rate and quality of life (QOL) of repeat liver resection for intrahepatic recurrence of hepatocellular carcinoma (HCC) after hepatectomy. Of 153 patients who had radical hepatic resection during the past 15 yaers, 73 patients (48%) had intrahepatic tumor recurrence. Eighteen patients (25% of intrahepatic recurrences) received one or more hepatectomies for intrahepatic recurrence. Second, third and fourth hepatectomies were carried out on 13, two and three patients, respectively. Of these 18, there were 11 men and 7 women. Ages ranged from 55 to 76 years (mean 68 years). Their preoperative ICG-R15 values measured from 3% to 37%(mean 21%). The following operative procedures were performed more than subsegmentectomy, three, isolated entire caudate lobectomy, two, anatomical limited resection, 18, and nonanatomical wedge resection, two. The number of resected tumors per operation ranged from one to five (mean 1.8). The size of resected tumors measured from 0.7cm to 4.4cm (mean 2.0cm) in diameter. Operation time was from 240 min to 660 min (mean 420 min). Blood loss volume ranged from 500 g to 4, 600 g (mean 1, 470 g). Postoperative hospital stay ranged from 11 days to 50 days (mean 26 days). Only one operative death occured after a second hepatectomy due to drug induced shock, but all other patients were restored to good QOL. The 5-year survival rate after the second hepatectomy was 67% in these 18 patients, and was almost the same value in 50% of all 153 patients' 5-year survival rate after the first hepatectomy. The present study has shown that repeat hepatectomy for recurrent HCC can result in early recovery of QOL, improved long-term outcome and short hospital stay. Therefore, we think that repeat hepatectomy is the most effective procedure for resectable recurrent HCC.

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The safety and antitumor effect of microwave coagulation therapy (MCT) as a local treatment was evaluated in thirty-two patients who had advanced hepatocellular carcinoma (HCC) with severe associated liver dysfunction. Hepatectomy was not performed on these patients for the following reasons: severe liver dysfunction (14 patients), multi nodular HCC in both lobes (15 patients), renal failure (2 patients) and age (1 patients).The number of patients in clinical stage I, II and III were 2, 16 and 14, respectively. The number of patients in stage I, II, III and IV-A were 2, 6, 8 and 16, respectively. The average tumor diameter was 3.2 cm and the average number of tumors was 2. 5. In 19 patients, the tumor was recurrent HCC. The one-and three-year cumulative survival rates were 46. 5%and 37. 2%, respectively. Using univariate analysis, significantly longer survival rates were noted in patients who had tumors that were smaller than 3 cm in diameter, or who had fewer than 2 tumors (p<0. 05).There was no mortality as a result of treatment and neither postoperative bleeding nor abscess formation occurred. MCT was performed without severe complication even in patients with high grade liver dysfunction. Furthermore, in cases having small HCC tumors, good clinical results were achieved.

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The aim of this study was to determine quality of life (QOL), predictive factors of tumor response, and long-term outcome in 36 patients with Stage IV hepatocellular carcinoma (HCC) treated by percutaneous isolated hepatic perfusion (PIHP).Thirsy-one patients had Stage IV_A and the remaining 5 had IV_B disease. Seventeen patients were HBs-Ag positive, while 15 others were HCV-Ab positive. Excluding one nonevaluable patient, the overall response rate reached 60%: 6 CR and 15 PR. When responders (CR+PR) and nonresponders (SD+PD) were compared, no factors predictive of a tumor response were identified. However, when modes of tumor response were compared, a distinct type of response (CR+PD) was more frequently seen in HBs-Ag positive patients, whereas an intermediate type of response (PR+SD) was predominant in HCV-Ab positive patients. The 5-year actuarial survival rate was 32% in all 36 patients. Long-term survivals in patients with Stage IV_A vs IV_B and V_P (-) vs V_P (+) disease were 36% vs 0% and 47% vs 23%, respectively, at 5 years. Except for 2 early patients with fatal complications, QOL was excellent in all patients. These results indicate that PIHP is a minimally invasive surgery, and the first-line treatment for patients with Stage IV_A hepatocellular carcinoma.

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Adjuvant therapy after surgical resection of hepatocellular carcinoma (HCC) should be tried based on the prediction of intrahepatic recurrence pattern. The purpose of this study was to identify patients with intrahepatic recurrence due to the residual intrahepatic metastatic foci (Rec: im) or multicentric carcinogenesis (Rec: mc) and to evaluate the effectiveness of combination therapy with an anticancer drug and interferon α(IFNα). The disease-free survival curve was obtained by the Kaplan-Meier method in 294 patients with resectable HCC. The regression line (Y=-aX+b) was drawn by SAS LIFE TEST PROCEDURE in the early (Y1; within two years: Rec: im+Rec: mc) and late (Y2; 4 years later: Rec: mc) periods and the incidence of Rec: im (b1-b2) was determined. The incidence of Rec: im in stage 1 was 40% in relative curative cases, and in stage 2 were 22% and 42% in relative curative and relative noncurative cases, respectively. In stage 3 and 4, all patients but one had recurrence within 4 years. Tumor marker levels were markedly decreased in 4 of 5 patients following the combination therapy of anticancer drug and IFNα. In conclusion, Rec: im was frequent, and therefore, adjuvant therapy was indicated in patients with stage 1 (relative curative), stage 2 (relative noncurative), stage 3 and stage 4. A combination of chemotherapy and systemic IFNα administration may be a promising postoperative adjuvant therapy.

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Invasive ductal cancer of the pancreas was resected in 170 patients between September 1974 and December 1997, and clinical manifestations, operative procedures, pathological findings, and treatment methods were investigated as features characterizing the 15 patients who had survived for 5 years. The operative procedure was pancreatoduodenectomy in 13 patients, and total pancreatectomy and distal pancreatectomy in one patient each. Portal resection was performed in 6 patients, 5 of the PD patients and the 1 TP patient. The JPS stage was stage I in 1 patient, stage II in 4 patients, stage III in 3 patients, stage IVa in 6 patients and stage IVb in 1 patient. All of the patients underwent macroscopically curative resection, but three of the patients were microscopically invasion (+) at the cut surface of the tissue around the pancreas. Treatment modalities consisted of surgery alone in 4 cases, chemotherapy in 3 cases, extracorporeal radiation in 2 cases, and in the most recent cases, portal catheterization in 6 patients and intraoperative radiation in 4 of these 6. At the present time, we think that if macroscopically curative surgery is initially possible, even in advanced cases, such as portal invasion cases and lymph node-positive cases beyond the peripancreatic nodes, it should be performed in the hope of achieving a histologically curative resection.

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We examined 46 patients who had resection for invasive ductal adenocarcinoma of the pancreas. Of these 17 survived more than 5 years after operation, and 29 died due to tumor recurrence within a year after operation. In patients without tumor invasion to the retroperitoneal tissue (rp), D₁+α lymphadenectomy with dissection of the retroperitoneal nerve plexus was performed in most cases, but no tumor invasion to the extrapancreatic nerve plexus was found. The incidence of lymph node metastasis was significantly lower in longterm survivors, 33%, Liver metastasis was most frequently observed in patients dead by tumor recurrence, 75%.In patients with rp, either D₁+α or D₂ lymphadenectomy with dissection of the retroperitoneal nerve plexus was performed. In long-term survivors with up, the incidence of lymph node metastasis was significantly lower, 38%, Liver metastasis and retroperitoneal recurrence were 68% and 40%, respectively, in patients dead by tumor recurrence. Quality of life (QOL) was poor in patients dead by tumor recurrence. In conclusion to increase the number of long-term survivors of invasive ductal adenocarcinoma of the pancreas, D₁+α lymphadenectomy and other effective measures to inhibit liver metastasis are necessary in patients without rp, further more, D₂ lymphadenectomy with dissection of the retroperitoneal nerve plexus and other effective measures to inhibit local recurrence and liver metastasis are necessary in patients with rp.

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In order to eradicate locoregional recurrence after pancreatectomy for adenocarcinoma of the pancreas, we have widened the range of lymphatic and connective tissue clearance (from D1 to D2α).As a result, the 5-year survival rate improved from 9% to 29% for stage III-cancer and from 0% to 3% for stage IV-cancer. When at least one posive node was detected, no long-term survivors were obtained by the D1-procedure, but were found by the D2α-procedure. When liver perfusion chemotherapy was added to the D2α-procedure, the 5-year survival rate for stage IV-cancer improved to 20%, because of a decrease in the incidence of hepatic recurrence. For t3-cancer, no 5-year survivors were found in the D2α-group, however, two patients (22%) were found in the group of D2α+liver perfusion chemotherapy. Among 33 patients who survived more than three years without cancer recurrence after D2α-procedure, weight loss and severe diarrhea were the main causes that lowered patients' QOL. However, these patients were convinced that they would recover their health within 2 years after the D2α-procedure. Thus, the D2α-procedure in combination with liver perfusion chemotherapy should be more frequently performed for n1-/t2-cancers. On the other hand, for more advanced cancers such as n2-/t3-cancers, D2α-procedure should not be performed without using adjuvant therapies which are effective in preventing both hepatic metastasis and local recurrence.

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We investigated standards for determining surgical treatment of pancreatic cancer accordng to the surgical results in Kurume University Hospital from 1965 to 1997, using the classification of pancreatic carcinoma (JPS). A significant difference (p<0.001) was noted in the cumulative survival rate between the resection and the non-resection groups. Furthermore, the 50% survival time and the 1- and 3-year survival rates were 1.00 years, 50.0%, and 13.4%in trhe resection group, and 0.39 years, 10.6%, and 0.7% in the non-resection group, respectively. As for Stage 4b, no difference in the survival rate between the resected and the non-resected cases was found. The survival rates varied greatly with the degree of curability, so that, long-term survival required a curability of A or B. There was no difference in the survival rate according to lymphnode dissection degree and intraoperative radiation therapy. Therefore, we concluded the following: 1) in stage 1, 2 and 3, extended operation is required; 2) in stage 4a, if extended operation obtains a curability more than B, the pancreas should be resected, or else should be resected; 3) in stage 4b, another therapy is needed.

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In our Department, extended operations including extended lymph node dissection with portal vein resection, has been performed for advanced pancreatic cancer, In this study, we examined the reasonable treatment for pancreatic cancer with respect to prognosis and quality of life of the patients. Ninety-nine patients who underwent resection of pancreatic cancer in our department from 1967 to 1997 were analyzed. We found that extended lymph node dissection contributed to the prolongation of patient survival. Also, local recurrence rate decreased when combined with resection of the portal vein. However, liver metastasis was not inhibited by our isolation method. Pylorus preserving pancreaticoduodenectomy was recommended for pancreatic head cancer because of its superior outcome with respect to post-operative nutrition and pancreatic function. Extended operation is indicated only for pancreatic cancer at surgical stages I, II, III, and IVa.

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In this paper, long-term survival and quality of life after surgical treatment for patients with pancreatic carcinoma were studied, and the application of coresection of the portal and arterial systems was discussed. For the past decade, 126 patients with pancreatic carcinoma were admitted to our department 54% underwent total pancreatic resection. Coresection of only the portal system was performed in 36.8%, and coresection of both the portal and arterial systems in 8.8% of the resected cases. No statistical difference was found in the morbidity, mortality, and long-term survival between patients with coresection of the portal system only and those without coresection of vessels. However, a high ratio of morbidity and mortality was noticed in patients with coresection of both the portal and arterial systems. Long-term survival in these patients, with the mean of 7 months, was lower than in patients with tumor removal without coresection of vessels. Furthermore, no statistical difference was found when compared with the long-term survival of unresectable patients. Additionaly, postoperative, non-hospital days for patients with both portal arterial coresection were no more than for unresected patients. These facts indicate that the prognosis of patients with portal invasion of pancreatic carcinoma can be improved by coresection of only the portal system. However, the authors emphasize that coresection of both the portal and arterial systems should not be applied in patients with tumor involvment of both systems.

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Extended pancreatoduodenectomy, to remove a wide range of lymph nodes and nerve plexus, has been widely applied in pancreatic head cancer in Japan. However, long-term survivors were rare in advanced cases who frequently underwent non-curative resection and even aggressive extended operations. In addition, patients' quality of life (QOL) became worse by extended operation. Because curative resection may result in longer survival eventhough QOL may worser, candidates for extended operation should be carefully selected. In this study, 872 cases of pancreatoduodenectomy were analyzed. As tomor extended to large vessels and nerve plexus, the survival rate statistically declined. However in some cases with portal vein invasion, portal vein resection may prolong survival. There were statistical differences in the survival rate between the degree of lymph node dissection, D₀ to D₂, for n₁ cases. The survival rate after pylorus-preserving pancreatoduodenectomy (PPPD) was statistically better than after Whipple procedure. However there were no statistically significant differences in patients' backgrounds between these two groups. Furthermore, postoperative QOL after PPPD was better than after Whipple procedure. There fore, our preferred strategy for pancreatic head cancer is to perform extended PPPD, to remove a wide range of lymph nodes and nerve plexus, and to resect the portal vein in cases of portal vein invasion, to obtain curative resection.

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Since January 1990, 23 patients with pancreatic head carcinoma underwent pylorus-preserring pancreatoduodenectomy (PPPD), and since August 1995, six patients underwent pylorus-resecting pancreatoduodenectomy (PRPD) when the carcinoma involved the anterior superior capsule of the head of the pancreas or the first portion of the duodenum. Survival curves were calculated for patients undergoing PPPD/PRPD and for standard pancreatoduodenectomy (PD), which was performed in 53 patients before December 1989. No significant difference in survival was found between the PPPD/PRPD group and the PD group with a 1-year survival of 51% and 43%, and a 3-year survival of 7% and 13%, respectively. PPPD/PRPD is applicable to the treatment of patients with pancreatic head carcinoma from the viewpoint of survival time.

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The survival and quality of life in 88 patients with pancreatic ductal carcinoma who underwent radical operation are analyzed. The two groups of patients, I and II, who survived more than 3 years and less than one year, respectively, were characterized and compared clinicopathologically. In group I, most pancreatic carcinomas were diagnosed in association with acute pancreatitis, compared to only a few in group II. The survival rate depended on the grade of cancer invasion into the adjacent tissue including the portal vein, retroperitoneum and lymph nodes. No patient survived more than one year with cancer invasion into the lumen of the portal vein. Postoperative anti-cancer chemotherapy increased the 1-year survival rate.

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Results of extended resection for invasive ductal carcinoma of the pancreas were assessed to determine its indication and limits. From September 1979 to August 1998, 84 (48.8%) of 172 surgical patients underwent resection. The cases were divided as follows: 34 cases in the early period (through April 1981), which were treated by pancreatic resection limited to D1 lymph node dissection; 100 cases in the middle period (May 1991 through March 1993), which were treated by extended surgery and included either D2 lymph node dissection or combined resection of the portal vein; and 38 cases in the late period (April 1993 through August 1998), in which indication of resection included consideration of curability and patient QOL. The resection rate was 32.4% in the early period, which was significantly lower than 54.0% and 50.0%, respectively, in the middle and late periods. Curative resection rates were significantly higher in the middle (68.5%) and late periods (63.2%) than in the early period. The 3-year survival rates improved, from 9.1% in the early period, to 18.1%in the middle period and to 36.4% in the late period. For stage IV cancer, however, patients in whom extended resections proved to be noncurative had extremely poor prognosis, and showed very poor QOL and similar survival results to those who received palliative bypass surgery. Extended surgery should not be employed in all cases with advanced pancreatic cancer, and bypass procedures should be selected for cases in which curative resection is considered to be impossible.

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