With the development of molecular-targeted agents, such as sorafenib and lenvatinib, and immunotherapies, such as atezolizumab+bevacizumab and durvalumab+tremelimumab, systemic therapy for hepatocellular carcinoma has become mainstream. Molecular-targeted agents are selected when immunotherapy is not required or is ineffective. Selecting the appropriate treatment strategy needs to consider the patient's condition, expected treatment response, and adverse events. Perioperative adjuvant therapy after curative treatment for early-stage disease, combined therapy with transarterial chemoembolization for intermediate-stage disease, and newer agents and combined regimens as first- or second-line treatments for advanced-stage disease are currently being developed. Systemic therapy is now available for any disease stage. Previously, local therapy used to be the main treatment strategy for hepatocellular carcinoma; however, systemic therapy is now being actively tried in combination with local therapy. Systemic therapy is currently the main focus of developing novel treatments for hepatocellular carcinoma.

We investigated the efficacy of endoscopic biliary drainage for hepatocellular carcinoma with obstructive jaundice due to bile duct invasion or retraction. We observed 20 cases of hepatocellular carcinoma with obstructive jaundice from January 2008 to March 2023 and included 16 men and 4 women with an average age of 75±8 years. The extent of portal vein invasion was Vp0/Vp2/Vp3 (13/3/4 cases), and stent insertion occurred in 16 cases. Those who underwent stent insertion had a significantly longer overall survival (OS) (p < 0.001). There was no significant difference in OS between those who received PS (n = 7) and SEMS (n = 9) (p = 0.218). A significant difference was observed in the total bilirubin levels before and after endoscopic biliary drainage (p = 0.001). Endoscopic biliary drainage is useful for obstructive jaundice in advanced hepatocellular carcinoma with poor liver function and should be considered based on the patient's general condition.

This is a case of a 68-year-old man who sought consultation with a local physician due to pain in his right back. He was referred to our hospital and a liver mass was found. The diagnosis of hepatocellular carcinoma was established with multiple lymph nodes and bone metastases. Thereafter, Atezolizumab/bevacizumab combination therapy (ATZ+BV) was initiated. On the 16th day, after the start of the therapy, he developed impaired consciousness of JCS 10. Blood ammonia level and head magnetic resonance imaging showed no abnormalities; however, cerebrospinal fluid examination showed a minimal increase in cell number and protein cell dissociation. Autoimmune encephalitis was then suspected. On the same day, he was started on steroidal pulse therapy. His consciousness remarkably improved, and the patient was discharged on the 39th hospital day without sequelae. On follow-up, no relapse of encephalitis was noted, and lenvatinib was introduced as a second-line treatment on the 60th day after the start of ATZ+BV, which is still ongoing.

The patient was a man in his 30s. During childhood, he underwent Fontan surgery for complete transposition of the great arteries type III. On July 20XX, he was referred to our hospital because of multiple hepatic masses detected by abdominal ultrasonography. Contrast-enhanced computed tomography revealed multiple hepatocellular carcinoma of up to 13 cm (Barcelona Clinic Liver Cancer Stage B). Despite the absence of signs of portal hypertension such as splenomegaly and no liver morphological abnormalities were obvious on imaging, a liver biopsy revealed a congestive hepatic fibrosis score of 3, indicating the progression of fibrosis. Surgery and RFA were not indicated because of intrahepatic multiple lesions. Furthermore, since the largest tumor protruded outside the liver and he was at risk of intra-abdominal rupture, transarterial chemoembolization was performed first. Thereafter, various anticancer drug treatments were performed according to recurrence, and the patient survived. Although the images did not suggest liver fibrosis, the special hemodynamics after Fontan surgery may have induced the progression of liver fibrosis; thus, this case emphasizes the importance of liver cancer surveillance.

A 63-year-old woman who underwent left mammectomy in February 2022 was admitted for further examination of acute liver failure.

The intraoperative histological findings were as follows: invasive lobular carcinoma (ILC): ILC pT3 (54 mm), N3a (14/15) M1 ER: (> 95%), PgR: Low positive (5%), and HER2: Negative (score 0) Ki-67 21%.

Imaging studies, including positron emission tomography, computed tomography, and magnetic resonance imaging failed to detect liver metastasis despite the continuous increase in tumor markers, such as cancer antigen 15-3.

Contrast-enhanced ultrasound and color Doppler imaging, including the time intensity curve suggested portal flow decrease caused by various hepatic outflow or intrasinusoidal obstructions.

Transjugular liver biopsy revealed intrasinusoidal diffuse infiltration of the breast ILC resulting in carcinomatous cirrhosis.

Immunohistochemistry showed positive results for estrogen receptor in the cancer cytoplasma and negative results for E-cadherin in the cancer cell membrane.

She died of liver failure 10 days following admission.

Continuation of activities is important for the hepatitis medical care coordinators to fulfill their functions, which must be supported by regional core centers for liver disease management. Thus, we conducted a questionnaire survey among coordinators in Kumamoto Prefecture to identify factors that motivates them to continue their activities. Results showed that coordinators were mainly motivated by a sense of social contribution. The factors considered important in the continuation of their activities are self-evaluation and of others, resolution of concerns about their activities, and the presence of peers/consultants. The regional core centers should actively provide a place and means for the coordinators to be active.

In eight regional core centers for liver disease management, we evaluated the status of HBs antigen (HBsAg) and anti-hepatitis C virus antibody (anti-HCV) testing from 2016 to 2020. Among nonhepatology departments, ophthalmology had the highest number of HBsAg and anti-HCV tests, followed by obstetrics and gynecology, and orthopedics. The highest positive rates of HBsAg were in orthopedics (1.27%), gastroenterological surgery (1.23%), and ophthalmology (1.04%), and those of anti-HCV were in gastroenterological surgery (2.71%), orthopedics (2.57%), and ophthalmology (2.51%). Thus, ophthalmology and orthopedics obtained the highest number of tests and positive rates, with no rate decrease over time. While the Japan Ophthalmologists Association has already commercialized measures against hepatitis, similar measures are needed urgently in orthopedics.