Although hemihepatic portal vein embolization (PVE) has been used preoperatively to extend indications for hepatectomy in patients with colorectal metastases, the effects of this procedure on tumor growth and outcome remain controversial. To address this issue, we assessed the proliferative activity of intrahepatic metastases after PVE and the long-term outcome of this procedure. Eighteen patients with colorectal metastases underwent preoperative PVE between 1996 and 2000 (PVE group). Twenty-nine patients who underwent major hepatic resection without PVE served as control (non-PVE group). The hepatic parenchymal fraction of the left lobe had significantly increased from 38.1 ؎ 3.2% to 45.9 ؎ 2.9% 3 weeks after PVE (؉20.5%, P < .0001). Tumor volume and percent tumor volume had also significantly increased from 223 ؎ 89 mL to 270 ؎ 97 mL (؉20.8%, P ‫؍‬ .016) and from 13.7 ؎ 4.3% to 16.2 ؎ 4.9% (؉18.5%, P ‫؍‬ .014), respectively. There was no apparent correlation between the increase in parenchymal volume and that in tumor volume. The Ki-67 labeling index of metastatic lesions was 46.6 ؎ 7.2% in the PVE group and 35.4 ؎ 12.6% in the non-PVE group (P ‫؍‬ .013). Long-term survival was similar in the PVE and non-PVE groups, however, disease-free survival was significantly poorer in the PVE group than in the non-PVE group (P ‫؍‬ .004). We conclude that PVE increases tumor growth and probably is associated with enhanced recurrence of disease. Although PVE is effective in extending indications for surgery, patient selection for PVE should be cautious. (HEPATOLOGY 2001;34:267-272.)Hepatic resection provides the only chance for cure in patients with colorectal metastases. To extend indications for hepatectomy, hemihepatic portal vein embolization (PVE) has been performed in selected patients. 1-3 PVE induces homolateral atrophy of the portion of the liver scheduled for resection and contralateral compensatory hypertrophy of the remnant liver, thus decreasing the risk of postoperative liver failure. PVE is indicated when the remnant liver is expected to be very small, i.e., about 40% smaller than preoperative liver volume, or when tumor spread requires a right hemihepatectomy with partial resection of the left side of the liver. 4,5 The positive effects of PVE on hepatic function must be weighed against recent evidence suggesting that this procedure may promote oncogenesis. Elias et al., have reported that after PVE liver metastases may grow more rapidly than liver parenchyma. 6 This assumption was based on a study of only 5 patients who had tumors in the nonembolized lobe of the liver, rather than the embolized lobe. In addition, they focused on tumor growth in the nonembolized lobe. Consequently, their findings were considered too premature to warrant contraindication of PVE in patients with colorectal metastases. 7,8 When used in combination with arterial chemoembolization, PVE suppresses growth of hepatocellular carcinoma (HCC). 9 Long-term results of HCC resection after PVE have recently been shown to be better than or...

Lateral lymphatic flow from low-lying rectal cancer passes outside the boundaries of total mesorectal excision but within the range of curative surgery by three-space dissection.

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To test the clinical usefulness of hepatic asialogycoprotein receptor analysis in liver surgery, we have conducted univariate and multivariate analysis for the detection of cirrhotic patients and prediction of morbidity after hepatic resection. Liver scintigraphy using technetium 99m-labeled asialoglycoprotein analog (TcGSA), ICG test, and CT hepatic volumetry were undertaken in 158 surgical patients including 111 who underwent hepatic resection. Hepatic functional parameters including Child-Pugh score, indocyanine green retention at 15 minutes (ICG-R15), clearance index (HH15), receptor index (LHL15), receptor concentration ([R]0), total hepatic receptor amount (R0) and hepatic parenchymal volume (HPV) were compared among patients with normal, cirrhotic, and non-cirrhotic damaged liver. Preoperative hepatic functional parameters, resected parenchymal fraction (RPf), operative blood loss, and total receptor amount of the remnant liver (R0-remnant) were compared between patients with and without signs of postoperative liver failure. All parameters but HPV were significantly different among patients with normal, cirrhotic, and noncirrhotic damaged liver. The multivariate analysis selected two significant (p <0.05) parameters, [R]0 and Child-Pugh score for the detection of liver cirrhosis. Of the 111 patients who underwent resection, 14 developed transient signs of postoperative liver failure. Of the parameters tested, presence of liver cirrhosis, LHL15, R0, intraoperative blood loss, and R0-remnant were significantly different between patients with and without signs of postoperative liver failure (p <0.05). The multivariate logistic regression analysis selected only R0-remnant as a significant (p = 0.022) parameter for the prediction of liver failure. The morbidity rate in patients with R0-remnant under 0.05 mmoles was 100%, and the rate decreased in inverse proportion to R0-remnant. In conclusion, combining the ASGP-R concentration ([R]0) and the Child-Pugh score best detected liver cirrhosis in surgical candidates. Cirrhotic patients and patients with a low R0-remnant are at higher risk for postoperative liver failure. The present study confirms the usefulness of hepatic asialogycoprotein receptor analysis in liver surgery.

No. 8a and No. 12b nodes are principal nodes that should be palpated and sampled during liver resection to check the secondary lymphatic spread from liver metastases. Hepatic nodal involvement indicates the progression of disease beyond simple liver metastases and may not be the indication for simple surgical removal. Further study, including hepatoduodenal dissection and systemic adjuvant chemotherapy, may elucidate the survival benefit, if any, of liver resection in node-positive patients.

BACKGROUND Most surgeons consider esophageal carcinoma with lymph node involvement a systemic disease. However, it is possible that the disease may be localized in the earlier phases of lymphatic metastasis. The distribution of involved lesions in the initial phase of lymph node metastasis has not been thoroughly investigated yet. METHODS Among 329 patients that underwent curative (R0 International Union Against Cancer [UICC]) esophagectomy with systematic mesoesophageal dissection, 51 cases of patients with only 1 involved lymph node (solitary involvement) were retrospectively investigated and compared with patients with multiple involved lymph nodes. The regional lymph nodes were divided into the thoracocervical junction group (lower deep cervical and recurrent nerve lymph nodes), perigastric group, and intrathoracic group. RESULTS Lymph node involvement was limited to a solitary lymph node in 46% of lymph node positive patients with esophageal carcinoma confined to the wall (T1 and T2, UICC) and in 17% of lymph node positive patients with cancer that invaded the extramural layer (T3 and T4, UICC). Of patients with solitary involvement, 82% had a positive thoracocervical junction or perigastric lymph node. The 5‐year survival rate in solitary involvement cases was 61%, and 65% when solitary involvement was not intrathoracic. Most of the 5‐year survivors had involvement of a thoracocervical junction or perigastric lymph node and had not received systemic chemotherapy. CONCLUSIONS Solitary involvement was not rare and not directly associated with a disseminated disease. Solitary involvement was commonly located in the thoracocervical junction or abdomen that are accessible without thoracotomy. Systematic dissection of the regional lymph nodes including thoracocervical junction and perigastric groups is recommended for resectable esophageal carcinoma at this time. However, less extensive dissection may be performed in selected cases if the sentinel lymph node concept proves valid. Cancer 2000;89:1869–73. © 2000 American Cancer Society.

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