Shinmatsudo Central General Hospital

Introduction: Radiofrequency ablation (RFA) generally involves the insertion of a radiofrequency electrode into the hepatocellular carcinoma (HCC) nodule under ultrasonography (US) guidance. However, the procedure is often not feasible for patients whose HCC is undetectable on conventional US. Advances in imaging technology, such as fusion imaging (FI) and cone-beam computed tomography (CBCT), may enhance treatment precision and efficacy for these challenging cases. This study assessed the efficacy of RFA guided by FI and CBCT in managing HCC poorly visualized on US. Methods: HCC nodules were classified into GOOD (clearly delineated), POOR (poorly delineated), and NONE (undetectable) based on US visualization. All nodules underwent RFA guided by FI and CBCT either in combination with transcatheter arterial chemoembolization (TACE) or without TACE. The technical success rate and local tumor progression post-RFA were evaluated using dynamic contrast-enhanced imaging. Between-group differences were analyzed retrospectively. Results: A total of 420 patients with 595 HCC nodules were enrolled. Complete ablation rates were 91.4%, 94.9%, and 86.2% in the GOOD, POOR, and NONE groups, respectively. For nodules with over 50% lipiodol accumulation, the complete ablation rates were 91.5%, 96.5%, and 88.8%; for those with less than 50% lipiodol accumulation, they were 95.5%, 100%, and 62.5%; and for those without lipiodol accumulation, they were 89.5%, 77.8%, and 82.4% in the GOOD, POOR, and NONE groups, respectively. Significant factors associated with complete ablation included larger nodule size and lipiodol accumulation. Cumulative local tumor progression rates at 1 year were 4.5%, 0%, and 3.8%, with no significant differences among groups. Conclusion: FI and CBCT guidance effectively achieve local control for HCC, including nodules poorly visualized on US, with outcomes comparable to US-visible nodules, especially for those with lipiodol accumulation.

A 67-year-old woman was referred to our hospital because of chest X-ray abnormalities. Chest computed tomography revealed a lobulated lung mass in the right lower lobe and multiple scattered nodules in both breasts. The lung mass was diagnosed as anaplastic lymphoma kinase (ALK) rearrangement-positive pulmonary adenocarcinoma through a transbronchial biopsy. Histological findings of bilateral needle biopsy of breast nodules were nearly identical to that of lung nodule, and fluorescence in situ hybridization showed ALK rearrangement. These results confirmed the diagnosis of ALK rearrangement-positive pulmonary adenocarcinoma with bilateral scattered breast metastases and its metastatic form of lung adenocarcinoma, which is rare.

Racial and ethnic disparities exist for hepatitis C virus (HCV) treatment and hepatocellular carcinoma (HCC) survival. To evaluate the impact of HCV treatment on such disparities. In a retrospective cohort study, we analysed 6069 patients with HCV-related HCC (54.2% Asian, 30.1% White, 8.5% Black, and 7.3% Hispanic) from centres in the United States and Asia. The mean age was 61, 60, 59 and 68, respectively, for White, Black, Hispanic and Asian patients. Black patients were most likely to have Barcelona Clinic Liver Cancer stage D, vascular invasion and distant metastasis (23% vs. 5%-15%, 20% vs. 10%-17% and 10% vs. 5%-7%, respectively; all p < 0.0001). Treatment rate with direct-acting antiviral agents (DAA) was 35.9% for Asian, 34.9% for White, 30.3% for Hispanic (30.3%), and 18.7% for Black patients (p < 0.0001). Among those untreated or without sustained virologic response (SVR), 10-year survival rates were 35.4, 27.5, 19.3 and 14.0, respectively, for Asian, Hispanic, White and Black patients (p < 0.0001). There were no statistically significant differences among those with SVR (p = 0.44). On multivariable analysis adjusted for relevant confounders, there was no statistically significant association between survival and being Hispanic (aHR: 0.68, p = 0.26) or Black (aHR: 1.18, p = 0.60) versus White. There was a significant association between being Asian American and survival (aHR: 0.24, p = 0.001; non-U.S. Asian: aHR: 0.66, p = 0.05), and for SVR (aHR: 0.30, p < 0.0001). DAA treatment rates were suboptimal. Racial and ethnic disparities resolved with HCV cure. Early diagnosis and improved access to HCV treatment is needed for all patients with HCV infection.

A Japanese multi-institutional prospective study was initiated to investigate the effectiveness and safety of accelerated partial breast irradiation (APBI) using strut-adjusted volume implant (SAVI) brachytherapy, with subjects registered between 2016 and 2021. Herein, we report the preliminary results on the feasibility of this treatment modality in Japan, focusing on the registration process, dosimetry, and acute toxicities. Primary registration was conducted before breast-conserving surgery (BCS) and the eligibility criteria included the following: age ≥ 40years, tumor unifocal and unicentric, ≤ 3cm in diameter, cN0M0, proven ductal, mucinous, tubular, medullary, or lobular carcinoma by needle biopsy. Secondary registration was conducted after BCS had been performed leaving a cavity for device implantation and pathological evaluations, and the eligibility criteria were as follows: negative surgical margin, tumor ≤ 3cm in diameter on gross pathological examination, histologically confirmed ductal, mucinous, tubular medullary, colloid, or lobular carcinoma, pN0, L0V0, no extensive ductal component, no initiation of chemotherapy within 2weeks of the brachytherapy APBI planning with SAVI was performed for the patients successfully entered in the study by the secondary registration process, and the treatment was administered at the dose of 34Gy in 10 fractions administered twice daily. Between 2016 and 2021, 64 women were enrolled in the study through primary registration, of which 19 were excluded from the secondary registration process, and in one, it was deemed impossible to comply with the dose constraints established during treatment planning. After the exclusion of these latter 20 patients, we treated the remaining 44 patients by APBI with SAVI. The dose constraints could be adhered to in all the patients, but re-planning was necessitated in 3 patients because of applicator movement during the treatment period. Grade 2 acute toxicities were observed in 18% of all patients, but more severe acute toxicities than Grade 2 were not observed in any of the patients. APBI with SAVI brachytherapy is feasible in Japan from the aspects of compliance with dose constraints and frequency of acute toxicities.

Abstract Background: Diffuse thoracic aortic aneurysm has been a challenge for cardiovascular surgeons as aortic arch and descending aortic aneurysm should be treated simultaneously somehow. The total arch replacement (TAR) using a frozen elephant trunk (FET) allows them to treat aortic arch and descending aortic pathology at once via median sternotomy. Besides, extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalization of FET prosthesis and facilitated distal anastomosis of TAR and spared the demanding Left subclavian artery (LSA) anastomosis in deep pericardial space. We investigated the efficacy of this debranching-first technique followed by total arch replacement using a frozen elephant trunk as a two-stage operation for extensive thoracic aortic aneurysm among high-risk patients. Methods: Forty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection receiving left common carotid to subclavian artery bypass followed by total arch replacement using a frozen elephant trunk and possible subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were demonstrated. Overall survival rate and 5-year aortic event-free survival, aortic reintervention rates were analysed. Results: The average score of European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7±2.5. The operative mortality rate was 4.1%, with no paraplegia events. The five-year overall survival, cumulative aortic related mortality were 76.8%, 2%, respectively. The five-year overall cumulative aortic reintervention rates including intended intervention were 31.3%. The 5-year cumulative rate of non-intended reintervention was 4.5%. Conclusions: The assessed technique enables a less invasive and less technically demanding surgery with reasonable outcomes. The 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm. Clinical registration number: 2022001

Background: The efficacy and safety of angiotensin receptor neprilysin inhibitor (ARNI) for patients with an estimated glomerular filtration rate (eGFR) &lt; 30 mL/min/1.73m2 have not been established. This paper reports three cases of low eGFR wherein ARNI was effective against heart failure and high blood pressure. Case: In case 1 (a woman in her 70 s), eculizumab was used to treat chronic kidney disease (CKD) because of an atypical hemolytic uremic syndrome. Surgery was performed for the exacerbation of chronic heart failure due to worsening mitral regurgitation. The postoperative course was stable. However, from the third disease day, her kidney failure exacerbated (eGFR decline from 16 to 10 mL/min/1.73 m2), heart failure flared up again (B-type natriuretic peptide [BNP] elevated from 500 to 1200 pg/mL), hemodialysis was performed, carperitide was added, and the diuretic stage was started. However, the drug could not be discontinued, and ARNI was initiated (50 mg once twice a day). Consequently, the eGFR was recovered (elevated from 10 to 18 mL/min/1.73 m2), the urine output was increased, and the heart failure was recovered (BNP declined from 1200 to 250 pg/mL). In case 2 (a man in his 80 s), CKD exacerbation due to diabetic nephropathy (eGFR of 18 mL/min/1.73 m2) led to heart failure, and hemodialysis therapy and ARNI (50 mg once two times a day) were initiated. Good diuresis became available, and hemodialysis could be withdrawn (BNP declined from 120 to 70 pg/mL, and the bodyweight from 95 to 75 kg). Since then, the urine output has been maintained, and peritoneal dialysis has been initiated and continued. In case 3 (a man in his 70 s), in whom 6 months had elapsed since the initiation of hemodialysis therapy for CKD caused by diabetic nephropathy, the dry weight was appropriate, but the blood pressure tended to increase (from 140/80 to 186/96 mmHg). Moreover, BNP levels had increased (BNP elevation from 70 to 180 pg/mL). When telmisartan 40 mg once a day was changed to ARNI (100 mg once a day) as an antihypertensive agent, the blood pressure was stabilized (from 186/96 to 140/80 mmHg), and the BNP decreased (BNP declined from 180 to 20 pg/mL). No adverse events were observed in all three cases. Discussion: These cases suggest that ARNI not only has diuretic effects but decreases blood pressure and BNP in patients with CKD, including those requiring dialysis. ARNI may be used relatively safely even in patients with reduced kidney function.