br Discussion Vascular invasion is a

Vascular invasion is a critical prognostic factor for patients with HCC. Previous articles from the literature have reported that the median survival time of patients with major vascular invasion is 9–12 weeks if left untreated. To improve the dismal prognosis, various treatments have been applied to patients with advanced HCC. Pawlik and colleagues reported results from a multicenter study which suggested that patients with HCC and major vascular invasion derived survival benefit from surgical resection, with an overall 5-year survival rate of 10%.
TACE has been shown to improve survival compared with supportive care in recent meta-analyses. Although TACE has been frequently used in the treatment of unresectable HCC, its limitations are also well known, especially in large tumors. Previous studies have suggested a benefit of combining motilin receptor agonist therapy (RT) and TACE in patients with advanced HCC.
Historically, RT has played a minor role in the management of patients with unresectable liver cancer, primarily because of the low tolerance of the whole liver to RT. However, recent advances have allowed the safe delivery of higher dose external beam RT to liver tumors, such as advanced imaging to improve tumor definition, three-dimensional radiation planning techniques to deliver high doses that conform tightly to the tumor, image-guided radiotherapy to localize the tumor at the time of treatment, tumor immobilization and organ tracking to account for organ motion due to breathing, and improved knowledge of the partial volume tolerance of the liver to radiation. These advances have revived RT as an additional treatment option in primary liver malignancies.
The resected specimen in our case showed 95% necrosis in the main tumor while the left sided tumor, which did not receive any downsizing treatment, only showed 30% tumor necrosis attributed to the natural tumor biology. The fact that the main tumor received both TACE and RT makes the causative factor for tumor shrinkage and necrosis difficult. However, the IVC-TT showed 100% necrosis with significant shrinkage after RT. Furthermore, microscopic examination of the irradiated non-tumor liver tissue showed sinusoidal lining cell injury causing so-called veno-occlusive disease in the microcirculation. This effect might block tumor angiogenesis and be responsible for tumor shrinkage. These facts have led us to believe that RT was the main causative factor for downsizing and tumor necrosis.
The anterior approach is the preferred technique for extended right-sided hepatic resection for large HCC. This is because of the challenging right side liver mobilization with an increased risk of tumor rupture and higher blood loss associated with the classic approach. Our blood loss was limited to 400 mL with no need for transfusion because of this approach. Furthermore, we resected a part of the right diaphragm to limit the risk for tumor spillage and blood loss.
The patient died of leukemia 3 years postoperatively. Whether this was linked to RT remains controversial but secondary cancers induced by RT have become a clinically significant issue. This increase in risk has to be balanced against the generally high spontaneous cancer risk in these individuals and the benefits accruing from radiotherapy.


Case report
A 59-year-old female patient presented with a 3-year history of recurrent and symptomatic UTIs. She had been receiving antibiotics at a local clinic during this time. Unfortunately, dysuria and lower abdominal soreness were not resolved by this treatment and her symptoms continued to bother her. Because of her continued symptoms, she visited our urology outpatient department (OPD) for a second opinion. Urinalysis revealed microscopic hematuria [red blood cell count: 21–25/high-power field (HPF)] and pyuria (white blood cell count: 31–35/HPF), both of which are indicative of cystitis. An abdominal X-ray of the kidney–ureter–bladder (KUB) revealed a radiopaque shadow in the right pelvic cavity (Figure 1); therefore, a cystoscopy was performed, which revealed a bladder stone about 3 cm in size that was located in the right lateral wall of the urinary bladder (Figure 2). The stone was immobile and appeared to be fixed to the bladder wall; the patient was then admitted for a cystolithotripsy. The stone was cracked in to pieces using a pneumatic Swiss lithoclast (EMS, Swiss). During the operation, a blue thread was determined to be the core of the stone at one end; this thread was attached to the bladder wall at the other end. After the complete removal of the stone fragments, the blue thread was extracted from the bladder wall using foreign body forceps (Olympus, Germany). Some resistance was encountered during the extraction process. Because the patient had undergone a sling operation for stress incontinence approximately 20 years previously, the blue thread was believed to be a part of the sling material that had since migrated and eroded through the bladder wall, thus resulting in the formation of the stone. Careful examination showed that the extracted thread was a type of nonabsorbable braided suture such as Ethibond, i.e., a nonabsorbable suture made of polyester polyethylene terephthalate and coated with polybutilate. The patient’s UTI symptoms were resolved within a few days following the operation, and the patient was uneventfully discharged. Follow-up urinalysis at OPD was normal and the patient was symptom-free.