Management of thrombocytopenia due to liver cirrhosis:A review

Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment of liver cirrhosis,limiting the ability to administer therapy and delaying planned surgical/diagnostic procedures because of an increased risk of bleeding.Multiple factors,including splenic sequestration,reduced activity of the hematopoietic growth factor thrombopoietin,bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents,and antiviral treatment with interferon-based therapy,can contribute to the development of thrombocytopenia in cirrhotic patients.Of these factors,the major mechanisms for thrombocytopenia in liver cirrhosis are(1)platelet sequestration in the spleen;and(2)decreased production of thrombopoietin in the liver.Several treatment options,including platelet transfusion,interventional partial splenic embolization,and surgical splenectomy,are now available for severe thrombocytopenia in cirrhotic patients.Although thrombopoietin agonists and targeted agents are alternative tools for noninvasively treating thrombocytopenia due to liver cirrhosis,their ability to improve thrombocytopenia in cirrhotic patients is under investigation in clinical trials.In this review,we propose a treatment approach to thrombocytopenia according to our novel concept of splenic volume,and we describe the current management of thrombocytopenia due to liver cirrhosis.

Solid-pseudopapillary pancreatic tumor,mimicking submucosal tumor of the stomach:A case report

Solid-pseudopapillary tumors of the pancreas(SPTs) are comparatively rare and have low malignancy,with a predilection for young women.Diagnosis is difficult when a SPT develops in a boundary region with other organs.Here,we report a 42-year old woman with a SPT of the pancreas mimicking a submucosal tumor of the stomach on imaging.She was admitted to our hospital complaining of abdominal pain.We suspected a submucosal tumor of the stomach from the f indings of endoscopy,endoscopic ultrasonography and abdominal computed tomography.However,angiography showed that some of the tumor vessels arose from the pancreas.Intraoperative f indings revealed the tumor originated from the pancreas.Therefore,distal pancreatectomy was performed.The pathological diagnosis was SPT of the pancreas.

Cutaneous metastases secondary to pancreatic cancer

AIM: To evaluate prognoses after cutaneous metastases, derived from pancreatic cancer. METHODS: We treated two patients with cutaneous metastases from pancreatic cancer. We reviewed 40 reported patients in addition to our cases and analyzed clinical features of cutaneous metastases from pancreatic cancer. RESULTS: The median survival time (MST) was 5 mo after diagnoses of cutaneous metastases. The cumulative 2-year survival rate was 3.5%. The most frequent site of cutaneous metastases was the umbilicus. The MST of patients who were treated with chemotherapy or chemoradiotherapy (CRT) was 6.5 mo, which was statistically longer in comparison to patients without treatment. Prognoses of cutaneous metastases are similar to other metastatic sites from pancreatic cancer. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.CONCLUSION: The prognoses of cutaneous metastases are similar to other metastatic pancreatic cancers. Receiving chemotherapy or CRT was the only prognostic factor of cutaneous metastases from pancreatic cancer.

Pancreatic pseudocyst-portal vein fistula

Pancreatic pseudocyst-portal vein fistulae are extremely rare, and cause serious complications, including life-threatening sepsis. We report a 57-year-old man with pancreatic pseudocyst who was admitted to our hospital complaining of prolonged abdominal pain. A pancreatic duct tube was placed into the main pancreatic duct, as the pseudocyst was communicated to the pancreatic duct. He fell into septic shock state two weeks later. An ultrasonography-guided percutaneous drainage of the pseudocyst was performed. The amylase level of drained pus was 80,000 U/l. Pancreatic pseudocyst-portal vein fistula was demonstrated by fisterography. Symptoms disappeared immediately after drainage. No recurrence was observed afterward.

Curative resection of leiomyosarcoma with resection and reconstruction of inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVC) is a rare tumor, and it needs complete surgical resection for cure. In addition, the reconstruction of IVC is necessary in many cases. Herein, we indicate the case of a 57-year-old female with leiomyosarcoma in segment I of the IVC, which grew deep into vascular lumen. She underwent complete en bloc resection of the tumor and IVC reconstruction by an artificial pericardium patch.

Perforation of the duodenum during the retrograde cholangiopancreatography treated without surgery

Perforation after endoscopic retrograde cholan- giopancreatography (ERCP) is a rare but severe complication. Management of ERCP-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. We describe the case who developed perforation of the duodenum and gas in the retroperitoneal cavity after ERCP. There was no sign of peritonitis, pancreatitis or sepsis. The patient was treated by conservative therapy without operation, and finally, fully re- covered from perforation.

The Number of Positive Tumor Marker Status Is Beneficial for the Selection of Therapeutic Modalities in Patients with Hepatocellular Carcinoma

Hepatic resection (HR) and radiofrequency ablation (RFA) are popular local therapies for early-stage hepatocellular carcinoma (HCC).Alpha-fetoprotein,Lens culinaris agglutininreactive fraction of alpha-fetoprotein,and des-c-carboxy prothrombin are well-known and useful tumor markers for HCC.The positive number status of these tumor markers has recently been demonstrated as beneficial for predicting outcome for HCC patients treated with local therapy.Although the normal ranges reported have differed by institution,the positivity of tumor markers is consistent and can easily be assessed.Kumamoto and Wakayama's group clearly demonstrated the following:1) Regardless of the degree of tumor stage,a triple-positive tumor marker profile can predict poor outcome in HCC patients undergoing HR;2) For RFA alone,HCC patients with double-and triple-positive status,having less than three lesions and lesions ≤3 cm in diameter show comparably insufficient outcomes;3) For HCC patients with lesions ≤5 cm in Child-Pugh grade A,HR is preferred over RFA;4) Microvascular invasion rates increased even in the double-positive patients,while poorly differentiated HCC was frequently observed only in the triple-positive patients;and 5) RFA with chemoembolization,anatomical liver resection,and postoperative adjuvant chemoembolization or hepatic arterial chemotherapy might improve the outcome for patients with highly malignant HCC with multiple positive tumor markers.However,the impacts of these therapies still need to be evaluated in prospective comparative studies.

Epithelial-mesenchymal transition in gastroenterological cancer

Epithelial-mesenchymal transition(EMT)was first reported as an essential process in embryonic cells and later showed that cancer cells,regardless of the context,exhibited a similar phenomenon that was crucial for tumor progression.Epithelial cells lose their adhesive characteristic capacity which is necessary for their functions but gain a mesenchymal phenotype.This change from epithelial to the mesenchymal phenotype of cancer cells makes it difficult to understand the mechanism underlying cancer biology and tumor progression.A number of transcription factors involved in tumor cell EMT and microRNA-regulated EMT have been reported.This review discussed recent findings and new players in EMT in gastrointestinal cancers.Since the molecular mechanisms of tumor progression are sometimes context-dependent,the recent findings of EMT have been reviewed in a context-dependent manner.

Prognostic Impact of Surgical Margin Width in Hepatectomy for Colorectal Liver Metastasis

As for resection for colorectal liver metastasis (CRLM), secur-ing an adequate surgical margin is important for achieving a better prognosis. However, it is often difficult to achieve ade-quate margins for the resection of CRLM. So the current sur-vival impact of sub-centi/millimeter surgical margins in he-patectomy for CRLM should be evaluated. In the current era of multidisciplinary treatment options, this review focused on the prognostic impact of a sub-centi/millimeter surgical margin width in hepatectomy for CRLM. We systematically reviewed retrospective studies that clearly described the sur-gical margin width for hepatectomy for CRLM. We selected studies conducted since 2000 that involved patients diag-nosed as having CRLM. We focused on studies that investi-gated not only surgical margins, but also microscopic surgical curability such as R0 (microscopically complete resection) or R1 (microscopically incomplete resection), which clearly de-scribe their definitions. Based on our literature review, 1, 2, or 5 mm was considered the minimum surgical margin width for hepatectomy for CRLM. Although a surgical margin width of 1 mm is acceptable for hepatectomy for CRLM, submil-limeter margins, which are defined as R1 in many reports, are only acceptable for limited patients such as those who have undergone preoperative chemotherapy. Zero-mm mar-gins are also acceptable in limited patients such as those who show a good response to preoperative chemotherapy. New chemotherapy agents have been reported to reduce the prognostic impact of a narrow surgical margin width. The incidence of margin recurrence, which is a major concern regarding R1 resection of CRLM, is about 20-30% according to the majority of earlier reports. As evaluations of the actual prognostic impact of the surgical margin remain difficult, fur-ther study is warranted.

A novel comprehensive ALPPS preoperative risk assessment (CAPRA) score is beneficial in creating a treatment strategy for advanced liver malignancy

Curability and safety are essential for patients with advanced liver malignancy undergoing extended liver resection.If the future liver remnant(FLR)volume is insufficient,portal embolization with or without hepatic arterial or venous embolization or a conventional two-stage hepatectomy(TSH)can be performed(1,2).Associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)was introduced in 2007.

The impact of associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)on liver tumors with unusual indications

An associating liver partition and portal vein ligation for staged hepatectomy(ALPPS)has been developed as a novel surgical technique for patients with insufficient future liver remnant volume even after portal vein embolization(PVE)±hepatic arterial or venous embolization or conventional two-stage hepatectomy(TSH)(1-5).ALPPS was thought to be a breakthrough but high-risk procedure;however,it recently became a safer technique after the developing phase(1-3).Conversion surgery is strongly recommended for patients with initially unresectable liver tumors that are deemed resectable by systemic chemotherapy or hepatic arterial chemotherapy/embolization(6,7).The primarily targeted diseases are colorectal liver metastases(CRLM)and hepatocellular carcinoma(HCC).ALPPS is indicated for patients undergoing not only primary surgery but also conversion surgery.

Does laparoscopic liver resection for colorectal liver metastases provide a true survival benefit compared with open liver resection?

The recent Southampton consensus guideline and two previous international consensus meetings held in Louisville and Morioka in 2008 and 2014,respectively have recommended laparoscopic liver resection(LLR)as a standard procedure for selected patients with colorectal liver metastases(CRLM)(1-3).The Oslo-CoMet and LapOpHuva studies are the only two randomized controlled trials(RCTs)that have provided solid evidence showing that LLR is a safer,less invasive,and more cost-effective approach with higher health-related quality of life and oncological outcomes equivalent to those of open liver resection(OLR)for patients with CRLM(4-6).