Hepatobiliary and Pancreatic Oncology

　Introduction

　　Doctors in the Hepatobiliary and Pancreatic Oncology Group use ultrasonography and treat patients with tumors in the liver, biliary system, and pancreas. These tumors are often difficult to treat with a single treatment alone. The therapeutic strategies need to be fully discussed by surgeons, radiologists and our medical oncologists. We, therefore, are trying newly developed or multimodality treatments under close cooperation with surgeons and radiologists.

　Routine Activities

　　Abdominal ultrasonography is used for both screening and thorough examinations for hepatobiliary and pancreatic malignancies. Color Doppler ultrasonography, including the power Doppler method, enables visualization of blood flow. Because of this, it is useful for differentiating small hepatocellular carcinomas (HCCs) from the other hepatic nodules and the diagnosis of abnormal hemodynamics in the abdomen, such as cancer invasion into vessels or abnormal arteriovenous shunting. We perform this ultrasonography as a routine examination. In 1998, a total of 7,022 patients were examined by conventional ultrasonography and 514 by color Doppler ultrasonography. Percutaneous biopsy under ultrasonography for the differential diagnosis of abdominal tumors was carried out in 136 patients. We performed percutaneous transhepatic biliary drainage, cholangiography and cholangioscopy in patients with obstructive jaundice, and a total of 214 patients were treated with this procedure.
　　During 1998, we treated 21 patients with HCC with percutaneous ethanol injection (PEI) and 36 with percutaneous microwave coagulation therapy (PMCT). PEI or PMCT is carried out as a standard treatment for small HCC, when the number of tumors is 3 or less and each tumor is smaller than 3 cm in diameter. In the case of advanced HCCs, patients undergo multimodality treatment in combination with either PEI, transcatheter arterial embolization (TAE) or radiation therapy.
　　Patients with unresectable advanced bile duct cancer receive radiation therapy combined with external beam radiation therapy (EBRT) with intraluminal radiotherapy, and those with locally advanced pancreatic cancer receive chemoradiotherapy with intraoperative radiation therapy (IORT) + EBRT with injection of 5-fluorouracil (5-FU).
　　Systemic chemotherapy is performed as a clinical trial or a practical treatment for patients with hepatobiliary and pancreatic cancer with distant metastases. Hepatic arterial infusion of 5-FU is indicated for patients with hepatic metastases from pancreatic or colorectal cancer.

　New Developments

1.　Three-dimension ultrasonography (3D-US): We introduced newly developed software (3D-US) which reconstructs color Doppler images in three-dimensions. We can observe B-mode and blood flow information on a 3-D image at the same time with this equipment. A comparative study between 3D-US and angiography in HCC cases revealed that arteries feeding HCC were clearly visualized with 3D-US like angiography.
2.　PMCT: We introduced this technique for the treatment of small HCC instead of PEI in April 1998. It shortens the hospital stay of patients compared to PEI. The optimum coagulation time and field selection by tumor size are currently being investigated.
3.　Intraluminal radiotherapy with ¹⁹²Ir for portal vein tumor thrombus in HCC: Our previous study certified that radiotherapy was effective for portal vein tumor thrombus. But one of the major problems was damage to the surrounding hepatic parenchyma. The above results indicate that intraluminal radiotherapy with ¹⁹²Ir is effective, with reduced hepatic damage. We started a phase I study of this new therapeutic approach.
4.　Clinical trials with anticancer drug: A phase II study of chemoradiation with IORT+EBRT and 5-FU is ongoing for patients with locally advanced pancreatic cancer. A phase I study of Gemcitabine for patients with advanced pancreatic cancer is also ongoing as a multicenter trial.

　Statistics

Number of Inpatients

	HCC	Biliary tract	Pancreas	Liver metastasis from colon ca.
PMCT alone	36
PEI alone	21
TAE alone	43
TAE+PEI	7
HAI alone		1		2
RT alone	8	4	1
RT+TAE	6
RT+HAI			5
Chemoradiotherapy			8
Systemic chemotherapy		12	4	2
Supportive care	11	9	10
Total	132	26	28	4

HCC, hepatocellular carcinoma; PMCT, percutaneous microwave coagulation therapy;
PEI, percutaneous ethanol injection; TAE, transcather arterial embolization; HAI,
hepatic arterial infusion; RT, radiation therapy.

(J. Furuse)　

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