HLA Class I Expression Is Associated with DNA Damage and Immune Cell Infiltration into Dysplastic and Neoplastic Lesions in Ulcerative Colitis

Human leukocyte antigen class I (HLA-I) is considered a genetic pathogen for ulcerative colitis (UC). This study aimed to investigate the significance of DNA damage and HLA-I expression in infiltrating immune cells and immune checkpoint protein PD-L1 expression in dysplasia/colitic cancer (CC) and sporadic colorectal cancer (SCRC). We performed immunohistochemical staining for HLA-I, PD-L1, γH2AX (DNA damage marker), and immune cell markers such as CD8, FOXP3, CD68, and CD163 (in surgically resected specimens from 17 SCRC patients with 12 adjacent normal mucosa (NM) and 9 UC patients with 18 dysplasia/CC tumors. The ratio of membrane HLA-I-positive epithelial cells in UC and dysplasia/CC tissues was significantly higher than that in NM and SCRC. High HLA-I expression in dysplasia/CC was associated with high positivity of γH2AX and PD-L1 expression compared to SCRC. The infiltration of CD8-positive T cells and CD68-positive macrophages in HLA-I-high dysplasia/CC was significantly higher than in UC and SCRC. Dysplasia/CC specimens with DNA damage exhibited high levels of HLA-I-positive epithelial cells with high CD8- and CD68-positive immune cell infiltration compared to UC and SCRC specimens. Targeting DNA damage in UC may regulate immune cell infiltration, immune checkpoint proteins, and carcinogenesis by modulating DNA damage-induced HLA-I antigen presentation.

Surgical Techniques and Stoma-related Complications Associated With Emergency Stoma Creation

BACKGROUND/AIM

Determination of risk factors for stoma-related complications associated with emergency stoma creation may impact on reducing complications and improving the quality of life of ostomy patients; however, there are only few reports on stoma-related complications associated with emergency stoma creation. Our study aimed to identify risk factors associated with stoma-related complications after emergency surgery, and evaluate surgical techniques for good stoma creation in the emergency setting.

PATIENTS AND METHODS

A retrospective analysis of patient and surgical characteristics was performed in 104 consecutive patients who underwent ileostomy or colostomy as emergency surgery between January 2020 and December 2022 at the Gunma University Hospital.

RESULTS

Preoperative stoma site marking was performed in 70 (67.3%) patients. Colostomies and ileostomies were performed in 78 (75.0%) and 26 (25.0%) patients, respectively. The skin bridge technique was used in 13 (12.5%) patients. Stoma-related complications were diagnosed in 62 (59.6 %) patients, with peristomal skin disorders (47.1%) as the most common complication, followed by mucocutaneous separation (31.7%), and stoma retraction (19.2%). In the multivariate analysis, body mass index (BMI) [odds ratio (OR)=5.570, 95% confidence interval (CI)=1.233-25.167, p=0.026], skin bridge technique (OR=0.144, 95% CI=0.031-0.670, p=0.014), and stoma height (OR=0.134, 95% CI=0.038-0.469, p=0.002) were independent risk factors for stoma-related complications after emergency stoma creation.

CONCLUSION

In emergency stoma creation, higher BMI and lower stoma height are associated with stoma-related complications. Using the skin bridge technique could reduce the risk of stoma-related complications after emergency stoma creation.

Significance of Lipopolysaccharides in Gastric Cancer and Their Potential as a Biomarker for Nivolumab Sensitivity

Lipopolysaccharides are a type of polysaccharide mainly present in the bacterial outer membrane of Gram-negative bacteria. Recent studies have revealed that lipopolysaccharides contribute to the immune response of the host by functioning as a cancer antigen. We retrospectively recruited 198 patients with gastric cancer who underwent surgery. The presence of lipopolysaccharides was determined using immunohistochemical staining, with the intensity score indicating positivity. The relationship between lipopolysaccharides and CD8, PD-L1, TGFBI (a representative downstream gene of TGF-β signaling), wnt3a, and E-cadherin (epithelial-mesenchymal transition marker) was also investigated. Thereafter, we identified 20 patients with advanced gastric cancer receiving nivolumab and investigated the relationship between lipopolysaccharides and nivolumab sensitivity. After staining for lipopolysaccharides in the nucleus of cancer cells, 150 negative (75.8%) and 48 positive cases (24.2%) were found. The lipopolysaccharide-positive group showed increased cancer stromal TGFBI expression (p < 0.0001) and PD-L1 expression in cancer cells (p = 0.0029). Lipopolysaccharide positivity was significantly correlated with increased wnt3a signaling (p = 0.0028) and decreased E-cadherin expression (p = 0.0055); however, no significant correlation was found between lipopolysaccharide expression and overall survival rate (p = 0.71). In contrast, high TGFBI expression in the presence of LPS was associated with a worse prognosis than that in the absence of LPS (p = 0.049). Among cases receiving nivolumab, the lipopolysaccharide-negative and -positive groups had disease control rates of 66.7% and 11.8%, respectively (p = 0.088). Lipopolysaccharide positivity was associated with wnt3a, TGF-β signaling, and epithelial-mesenchymal transition and was considered to tend to promote therapeutic resistance to nivolumab.

Two-team Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection Using Transanal Approach for Rectal Cancer: A Retrospective Study

BACKGROUND/AIM

Lateral lymph node dissection is a locally advanced rectal cancer treatment option. Despite its complexities, such as prolonged operative time and increased blood loss, a transanal approach with an abdominal approach may help mitigate these drawbacks.

PATIENTS AND METHODS

Between July 2013 and June 2022, 40 patients underwent radical laparoscopic surgery with lateral lymph node dissection for rectal cancer. Among them, 29 and 11 patients underwent total mesorectal excision and lateral lymph node dissection without transanal approach (conventional surgery) and with transanal approach (two-team surgery), respectively. The clinical findings, surgical outcomes, pathology results, and prognoses of conventional and two-team surgeries were retrospectively compared.

RESULTS

Compared to conventional surgery, two-team surgery involves increased organ and nerve resections, shorter operation time (286 vs. 548 min, p<0.001), and less blood loss (20 vs. 158 ml, p<0.001). Although postoperative complications were similar between groups, the two-team surgery group had a shorter hospital stay (p=0.006). Pathologically, all patients who underwent two-team surgery had a distal resection margin of at least 20 mm, and no recurrence was observed. With conventional surgery, 63.6% of patients had a 10-19 mm margin, and 36.4% had a margin of ≥20 mm, except for abdominoperineal resection.

CONCLUSION

Total mesorectal excision and lateral lymph node dissection with the transanal approach as a two-team surgery are safe and feasible. Two-team surgery resulted in better outcomes than conventional surgery regarding operative time, blood loss, shorter postoperative hospital stay, and adequate distal resection margin.

Infiltration of Gastric Cancer Stroma by Tumor-Infiltrating Lymphocytes Correlates with Mechanistic Target of Rapamycin Signaling

INTRODUCTION

We investigated whether the infiltration of tumor-infiltrating lymphocytes (TILs) in gastric cancer (GC), as evaluated by hematoxylin and eosin (H&E) staining, could be a prognostic marker. We also explored on the relationship between TILs and mechanistic target of rapamycin (mTOR) and how it regulates immune effector responses in GC.

METHODS

A total of 183 patients with available data on TIL were included. TIL infiltration was evaluated using H&E staining. We also conducted immunohistochemistry to determine mTOR expression.

RESULTS

Positive TIL infiltration was defined as TILs ≥20%. There were 72 (39.3%) and 111 (60.7%) positive and negative cases, respectively. TILs positivity significantly correlated with both absence of lymph node metastasis (p = 0.037) and negative p-mTOR expression (p = 0.040). TIL infiltration correlated with a significantly better overall (p = 0.046) and disease-free (p = 0.020) survival.

CONCLUSION

mTOR possibly suppresses TIL infiltration in GC. H&E staining is an effective tool for evaluating the immune status of GC patients. H&E staining may be used in clinical practice to monitor treatment response in GC.

Sigmoid colon schwannoma difficult to distinguish from peritoneal dissemination 13 years after pancreatic neuroendocrine tumor surgery

BACKGROUND

Schwannoma, which clinicians sometimes struggle to diagnose, is a tumor arising from Schwann cells of peripheral nerves, often in the soft tissues and rarely in the gastrointestinal tract. Pancreatic neuroendocrine tumor (PNET) is rare among pancreatic tumors, and recurrence can occur long after resection. Here, we were presented with a case where a sigmoid colon schwannoma was difficult to distinguish from a postoperative recurrence of PNET and was diagnosed after laparoscopic resection.

CASE PRESENTATION

A 51-year-old man was diagnosed with PNET (NET G2) after a distal pancreatectomy (DP) 13 years ago. The patient underwent hepatectomy due to liver metastasis 12 years after initial radical surgery. The follow-up magnetic resonance imaging (MRI) after hepatectomy showed pelvic nodules, and laparoscopic surgery was performed for both diagnosis and treatment because peritoneal dissemination of PNET could not be ruled out. Since the tumor was in the sigmoid colon, a partial colon resection was performed. The histopathological diagnosis was a schwannoma, and the patient was discharged on the seventh postoperative day.

CONCLUSIONS

We experienced a case of sigmoid colon schwannoma that was difficult to differentiate from peritoneal dissemination of PNET and was later diagnosed after laparoscopic resection. In addition, this case involved a long-term postoperative recurrence of PNET that was amenable to radical resection, further establishing the importance of long-term imaging follow-up.

Albumin-derived Neutrophil-to-Lymphocyte Ratio Score as a Marker of Nivolumab Treatment Sensitivity in Gastric Cancer: A Multicenter Study

BACKGROUND/AIM

Establishment of powerful and easy-to-evaluate biomarkers that can predict immune checkpoint inhibitor sensitivity in patients with gastric cancer (GC) would be highly useful. The albumin-derived neutrophil-to-lymphocyte ratio (Alb-dNLR) score reportedly is an excellent measure of both immunity and nutritional status. However, the association between nivolumab treatment sensitivity and Alb-dNLR in GC has also not been adequately investigated. This multicenter retrospective study was designed to evaluate the association of Alb-dNLR with therapeutic sensitivity of nivolumab in GC patients.

PATIENTS AND METHODS

This was a retrospective multicenter study with patients from five sites. The data from 58 patients who received nivolumab for postoperative recurrent or unresectable advanced GC between October 2017 and December 2018 were analyzed. Blood tests had been performed before nivolumab administration. We analyzed the correlation between the Alb-dNLR score and clinicopathological factors, including best overall response.

RESULTS

Of the 58 patients, 21 (36.2%) comprised the disease control (DC) group and 37 (63.8%) comprised the progressive disease (PD) group. The nivolumab treatment responses were subjected to receiver operating characteristic analysis. The cutoff value was set to 2.90 g/dl for Alb and to 3.55 for dNLR. All eight patients in the high Alb-dNLR group had PD (p=0.0049). The low Alb-dNLR group had significantly better overall survival (p=0.0023) and progression-free survival rates (p<0.0001).

CONCLUSION

The Alb-dNLR score was a very simple and sensitive predictor of nivolumab therapeutic sensitivity and has very good biomarker properties.

Examining the Efficacy of Nivolumab for Gastric Cancer Focusing on Using an Inflammation-based Prognostic Score: A Multicenter Retrospective Study

BACKGROUND/AIM

To discover the positive therapeutic effects of nivolumab in patients with advanced gastric cancer (AGC), it is necessary to establish a useful biomarker to predict therapeutic efficacy. This multicenter retrospective study sought to evaluate the predictive impact of inflammation-based prognostic score (IBPS) on the therapeutic efficacy of nivolumab in patients with AGC.

PATIENTS AND METHODS

In this retrospective study, we evaluated 58 AGC patients treated with nivolumab from October 2017 to November 2018 at five institutes. Patients were categorized follows: progressive disease (PD) or disease control (DC). Blood chemistry tests were performed immediately before and after two courses of nivolumab; the correlation between best overall response and IBPS was investigated. Transition of each blood serum marker was also assessed.

RESULTS

Of 58 patients, 37 (63.8%) were in the PD group and 21 (36.2%) in the DC group. No positive correlation was noted between IBPS and therapeutic efficacy of nivolumab both immediately before and after two courses of nivolumab. However, the neutrophil-lymphocyte ratio (NLR) (p=0.045) and prognostic index (PI) (p=0.0042) before nivolumab and NLR (p=0.025), PI (p=0.0030) and Glasgow prognostic score (GPS) (p=0.043) after nivolumab were significantly correlated with treatment sensitivity. Furthermore, a decrease in PNI was an independent prognostic factor to predict nivolumab resistance on univariate analyses (p=0.0051).

CONCLUSION

Although no association between IBPS and therapeutic sensitivity was found, it is important to focus on the transition of PNI to predict therapeutic efficacy of nivolumab.

Preoperative Risk Factors and Prognostic Impact of Postoperative Complications Associated with Total Gastrectomy

INTRODUCTION

We evaluated the risk factors for patients with gastric cancer (GC) undergoing total gastrectomy (TG) that predict postoperative complications, including anastomotic leakage, postoperative pneumonia, and heart disease.

METHODS

We collected 106 patients who received TG for GC between May 2009 and May 2017 at Gunma University Graduate School of Medicine, including clinicopathologic, surgical, postoperative complication, laboratory test, and physiologic test data.

RESULTS

Of 106 patients, 92 (86.8%) had no complications, and 14 (13.2%) had complications. Univariate analyses revealed that a high American Society of Anaesthesiologists physical status (ASA-PS) and neutrophil-lymphocyte ratio (NLR) of ≥3.5 significantly correlated with postoperative complications. Multivariate analyses showed that high ASA-PS was an independent prognostic factor of postoperative complications. The cancer recurrence rate was 34.8% in the noncomplication group and 71.4% in the complication group.

CONCLUSION

Patients with postoperative complications are prone to recurrence and poor prognosis. For patients with high-risk GC with poor ASA-PS and high NLR, more thorough perioperative management is essential.

Significance of routine preoperative prone computed tomography for predicting intractable cases of inguinal hernias treated by transabdominal preperitoneal repair

Physical examination is the standard diagnostic approach for adult inguinal hernias. We aimed to evaluate the clinical utility of routine preoperative computed tomography scans in the prone position for predicting intractable cases of inguinal hernias before performing transabdominal preperitoneal repairs. We retrospectively analyzed 56 lesions in 48 patients with inguinal hernias who underwent prone computed tomography scans prior to transabdominal preperitoneal repairs. To assess the ability of prone computed tomography to enable the accurate preoperative diagnosis of inguinal hernias, we compared preoperative hernia types as classified through hernia computed tomography and intraoperative diagnosis. We also analyzed the relationship between operation time and hernia type in unilateral cases (n = 40). The overall hernia computed tomography detection and classification accuracy rates were 81.0% and 83.9%, respectively, using the Japan Hernia Society classification system (2009 version) and 84.3% and 91.2%, respectively, using the European Hernia Society classification system. There were no differences in the hernia type frequencies between the shorter (n = 20) and longer (n = 20) operation time groups. Two patients had sliding inguinal hernias with prolapsing bladders, both of which were detectable using preoperative prone computed tomography. Although transabdominal preperitoneal repairs were completed in both cases, the operation times were exceptionally long (185 and 291 minute). Preoperative prone computed tomography is useful for predicting intractable cases of inguinal hernias. Prone computed tomography can play a significant role in not only typing and differentiating hernias from other diseases, but also in helping surgeons appropriately treat unexpected intractable cases with laparoscopic surgery.

Clinical characteristics and outcomes of pheochromocytoma crisis: a literature review of 200 cases

PURPOSE

Pheochromocytoma crisis is a life-threatening endocrine emergency that requires prompt diagnosis and treatment. Because of its rarity, sudden onset, and lack of internationally uniform and validated diagnostic criteria, pheochromocytoma crisis remains to be fully clarified. Therefore, we aimed to describe the clinical characteristics and outcomes of pheochromocytoma crisis through a literature review.

METHODS

We performed a systematic literature search of PubMed/MEDLINE database, Igaku-Chuo-Zasshi (Japanese database), and Google Scholar to identify case reports of pheochromocytoma crisis published until February 5, 2021. Information was extracted and analyzed from the literature that reported adequate individual patient data of pheochromocytoma crisis in English or Japanese. Cases were also termed as pheochromocytoma multisystem crisis (PMC) if patients had signs of hyperthermia, multiple organ failure, encephalopathy, and labile blood pressure.

RESULTS

In the 200 cases of pheochromocytoma crisis identified from 187 articles, the mean patient age was 43.8 ± 15.5 years. The most common symptom was headache (39.5%). The heart was the most commonly damaged organ resulting from a complication of a pheochromocytoma crisis (99.0%), followed by the lungs (44.0%) and the kidney (21.5%). PMC accounted for 19.0% of all pheochromocytoma crisis cases. After excluding 12 cases with unknown survival statuses, the mortality rate was 13.8% (26/188 cases). Multivariable logistic regression analysis revealed that nausea and vomiting were significantly associated with a higher mortality rate.

CONCLUSION

Pheochromocytoma can present with different symptomatology, affecting different organ systems. Clinicians should be aware that patients with nausea or vomiting are at a higher risk of death because of pheochromocytoma crisis.

PROX1 was associated with LGR5 and Wnt signaling and contributed to poor prognosis in gastric cancer

Introduction: We investigated prospero homeobox protein-1 (PROX1) expression in gastric cancer (GC) as a prognostic marker and its relationship with LGR5 and Wnt/β-catenin activity in GC. Methods: A total of 196 cases of patients who underwent GC surgery were retrospectively collected and reviewed. PROX1, LGR5, Wnt3a, and β-catenin expression was evaluated by using immunohistochemistry. The relationship between PROX1 expression and clinicopathological features was also evaluated. Results: The PROX1 low-expression group had 105 patients (53.6%) and the high-expression group 91 patients (46.4%). For LGR5, 76 patients (38.8%) had low expression and 120 (61.2%) high expression. The PROX1 low-expression group was significantly younger (p = 0.0095), had more intestinal type (p = 0.014), and smaller tumor size (p = 0.013). The PROX1 high-expression group significantly correlated with high LGR5 expression (p < .0001) and high Wnt3a expression (p = 0.012). There were more cases of postoperative recurrence in the PROX1 high-expression group (p = 0.013). Conclusion: Our findings show that PROX1 correlates with LGR5 and Wnt3a signaling in GC and has a poor prognosis with postoperative recurrence.

Changes in the Gustave Roussy Immune Score as a Powerful Prognostic Marker of the Therapeutic Sensitivity of Nivolumab in Advanced Gastric Cancer: A Multicenter, Retrospective Study

BACKGROUND

Identification of positive biomarkers for the effects of nivolumab on patients with advanced gastric cancer (AGC) is significant. The Gustave Roussy Immune Score (GRIm-s) is associated with therapeutic resistance of immune checkpoint inhibitors (ICIs) in other cancers. This multicenter, retrospective study was designed to analyze the association of GRIm-s with therapeutic sensitivity of nivolumab in patients with AGC.

METHODS

We reviewed 58 patients with AGC treated with nivolumab from October 2017 to November 2018 at five participating institutions. We performed blood tests before the start of nivolumab and after administration of two courses. We evaluated the correlation between the best overall response and GRIm-s. Additionally, we focused on the changes in GRIm-s before the start of nivolumab and after administration of two courses.

RESULTS

Of the 58 patients, 21 (36.2%) were classified into the disease control (DC) group and 37 (63.8%) into the progressive disease (PD) group. GRIm-s before nivolumab treatment did not correlate with the best therapeutic response (p = 0.086). However, GRIm-s after two courses of nivolumab showed that significantly more PD cases were in the high-risk group (p < 0.0001). After two courses of nivolumab, overall survival was significantly worse in the high-risk group (p < 0.0001). For progression-free survival, the high-risk group had a significantly worse prognosis both before (p = 0.04) and after two courses of nivolumab treatment (p < 0.0001).

CONCLUSIONS

GRIm-s after two courses of nivolumab and its changes compared to pretreatment values proved beneficial in predicting nivolumab sensitivity.

Cytoplasmic localization of connexin 26 suppresses transition of β-catenin into the nucleus in intestinal- and mix-type gastric cancer

Background

Connexin is a basic molecule that forms gap junctions and undergoes localization changes to the cytoplasm in association with carcinogenesis. We aimed to investigate and clarify the significance of cytoplasmic Cx26 expression in gastric cancer.

Methods

We included 87 patients with intestinal- and mix-type gastric cancer and 111 patients with diffuse type gastric cancer who underwent surgery for gastric cancer between 1999 and 2006. Immunohistochemical staining for Cx26, β-catenin, and Wnt3a was performed and analyses of the relationship to clinicopathological factors were conducted based on the Lauren classification. In an in vitro study, the gastric cancer cell lines MKN7, MKN74, and MKN45 were used to evaluate the proliferative capacity using the water-soluble tetrazolium salt assay through forced expression of Cx26, and the relationship between Cx26 and β-catenin was investigated using proximity ligation assay (PLA) and co-immunoprecipitation. Additionally, functional analysis was performed by Cage analysis.

Results

In this study, high cytoplasmic Cx26 expression was associated with favorable prognosis in intestinal- and mix-type gastric cancer and could be an independent prognostic factor for overall survival. In terms of the mechanism, in in vitro experiments changes in Cx26 localization to the cytoplasm were shown to suppress the change of localization of β-catenin to the nucleus by binding to it in the cytoplasm.

Conclusions

Cytoplasmic Cx26 was found to be a prognostic factor in intestinal- and mix-type gastric cancer. Regarding the mechanism, in vitro studies revealed that cytoplasmic Cx26 inhibits the translocation of β-catenin to the nucleus.

Idiopathic pneumoperitoneum diagnosed following high-energy motor vehicular trauma:a case report

Intra-abdominal free gas is a finding of extra-intestinal gas in the abdominal cavity on radiography or CT, mainly suggesting gastrointestinal perforation and necessitating emergency surgery. Idiopathic pneumoperitoneum is diagnosed when there is no obvious gastrointestinal perforation, but there is presence of free gas in the abdominal cavity with an unidentifiable cause. Herein, we report a case of idiopathic pneumoperitoneum secondary to high-energy trauma following a car rollover accident. A 95-year-old man was transferred to our clinic after a car-to-car rollover accident. He had abrasions on his right upper arm and left abdomen that appeared to be the result of the accident;however, no other apparent traumatic injuries were noted. There was no pain in the abdomen, and peritoneal irritation symptoms were also not noted. A CT scan showed fine free air. Although idiopathic pneumoperitoneum could not be ruled out, considering the patient's background and the possibility of traumatic small bowel perforation, emergency surgery was performed. A thorough search of the abdominal cavity was performed;however, the surgery was completed without an obvious perforation site. Idiopathic pneumoperitoneum should be considered as a differential disease in cases who have free air on abdominal CT but clinically lack obvious inflammatory reaction findings. J. Med. Invest. 69 : 155-157, February, 2022.

ASO Author Reflections: Impact of the Ratio of the Visceral Fat Area (VFA) to Psoas Muscle Area (PMA) (V/P Ratio) on Survival for Patients with Surgically Resected Esophageal Cancer

PAST: The true impact of co-occurring muscle mass reduction and fat accumulation on patients with surgically resected esophageal cancer (EC) remains controversial. PRESENT: The current study defined reduction in muscle mass and excess body adiposity as the ratio of the visceral fat area (VFA) to the psoas muscle area (V/P ratio) on the same axial computed tomography slice at the third lumbar vertebra (L3). A high V/P ratio was associated with greater age (p = 0.03), higher body mass index (BMI) (p < 0.001), larger VFA (p < 0.001), and increased age-adjusted Charlson comorbidity index (ACCI) (p = 0.005). Multivariate analysis showed a high V/P ratio to be an independent prognostic factor for poor overall survival (OS) of EC patients who underwent surgery (p = 0.003). The prognostic value of the V/P ratio still was significant for EC patients with a BMI lower than 25 kg/m2. FUTURE: A high V/P ratio was an independent prognostic factor for OS of EC patients who underwent surgery, even BMI-defined non-obese EC patients. The V/P ratio as a surrogate marker of relative muscle mass reduction and fat accumulation may have prognostic value for EC patients regardless of body composition differences.

Impact of the Ratio of Visceral Fat Area (VFA) to Psoas Muscle Area (PMA) (V/P Ratio) on Survival for Surgically Resected Esophageal Cancer

BACKGROUND

The synergic effects of muscle mass reduction with excess body adiposity in surgically resected esophageal cancer (EC) patients remains controversial, especially in non-obese patients.

METHODS

One hundred and six patients with EC who underwent surgery between 2006 and 2014 were included in this study. Reduction in muscle mass and excess body adiposity were defined as the ratio of visceral fat area (VFA) to psoas muscle area (PMA) (V/P ratio) on the same axial computed tomography (CT) slice at the third lumbar vertebra (L3).

RESULTS

A high V/P ratio was associated with greater age (p = 0.03), higher body mass index (BMI) (p < 0.001), higher VFA (p < 0.001), and increased age-adjusted Charlson comorbidity index (ACCI) (p = 0.005). Multivariate analysis revealed a high V/P ratio to be an independent prognostic factor for poor overall survival (OS) in EC patients who underwent surgery (p = 0.003). The prognostic value of the V/P ratio was still significant in EC patients with a BMI < 25.

CONCLUSIONS

A high V/P ratio was associated with poor survival in surgically resected EC patients, even in non-obese patients. The V/P ratio as a surrogate marker of relative muscle mass reduction and fat accumulation may have prognostic value in EC patients regardless of body composition differences.

Salvage thoracoscopic esophagectomy after carbon-ion radiotherapy in a patient with esophageal squamous cell carcinoma: a case report

Background

Carbon-ion radiotherapy (CIRT) for esophageal cancer has been receiving significant attention given its high local control rates and minimal damage to normal tissues. However, the efficacy and safety of salvage surgery after CIRT for esophageal cancer remain unclear. We report the case of a patient who underwent salvage thoracoscopic surgery after CIRT.

Case presentation

A 51-year-old woman underwent upper gastrointestinal endoscopy and a type 0-IIa + 0-IIc esophageal squamous cell carcinoma located 27–29 cm from the patient’s incisors, classified as clinical stage I (T1bN0M0), was detected. She received CIRT (50.4 Gy [relative biological effectiveness, RBE]/12 fr) for localized esophageal cancer and achieved complete remission after 4 months. Six years after CIRT, follow-up endoscopic examination demonstrated a type 0-IIa + 0-IIc tumor in the previously treated area. In addition, a type 0-IIa lesion located 20–22 cm from the incisors was found. We diagnosed localized ESCC, classified as clinical stage I (T1bN0M0). Salvage thoracoscopic surgery was performed in the prone position with five access ports. Although the esophagus tightly adhered to the thoracic descending aorta and left main bronchus with severe fibrosis, the esophagus could be separated from the surrounding organs with careful forceps manipulation. The operation time and blood loss were 8 h 45 min and 253 mL, respectively. The patient was discharged from our hospital 17 days after the salvage surgery without any complications. Pathological findings revealed two squamous cell carcinomas. Both tumors were localized in the lamina propria mucosa, and lymph node metastasis was not detected. The tumors were diagnosed as pathological stage IA (pT1aN0M0) according to the TNM criteria. Moreover, pathological examinations showed severe fibrosis of the previously irradiated tissues compared to the normal esophagus located outside of the irradiation field. Following the surgery, the patient had no recurrence for 1 year and 6 months.

Conclusions

Thoracoscopic radical esophagectomy can be performed as salvage surgery. Careful and discreet surgery is integral to perform salvage surgery after CIRT since CIRT may cause severe adhesions and fibrosis in the irradiated field.

Clinical features as potential prognostic factors in patients treated with nivolumab for highly pretreated metastatic gastric cancer: a multicenter retrospective study

BACKGROUND

Although nivolumab (anti-programmed cell death-1 antibody) is a promising approach for advanced gastric cancer (AGC), the response rate remains limited. The aim of this multicenter retrospective study was to determine if clinical features could serve as prognostic factors of the efficacy of nivolumab in patients with AGC.

METHODS

Fifty-eight patients with AGC who were treated with nivolumab as a third or later line from October 2017 to December 2018 at any of five clinical sites were enrolled in the study. The correlation between the best overall response and clinical features was investigated. Overall survival and progression-free survival after initiation of nivolumab were calculated and clinical features that could be predictors of the prognosis were sought.

RESULTS

The disease control rate (DCR) for nivolumab was 36.2% and was significantly correlated with performance status (p = 0.021), metastasis to one organ (p = 0.006), and grade 2 or higher immune-related adverse events (p = 0.027). There was also a significant association between response to nivolumab and ability to receive subsequent chemotherapy (p = 0.022). In the analysis of overall survival, the following variables were identified as being significantly associated with a poor outcome: Eastern Cooperative Oncology Group performance status ≥1, prior treatment with trastuzumab, no immune-related adverse events, lack of a response to nivolumab, and inability to receive subsequent chemotherapy.

CONCLUSION

The findings of this study suggest that nivolumab may be ineffective for AGC in patients with poor performance status and those with a history of treatment with trastuzumab.

Current status of surgical treatment of Boerhaave's syndrome

BACKGROUND

Surgical treatment is usually required for Boerhaave's syndrome (post-emetic esophageal perforation), and the technique should be chosen based on the local infection status and patient's general condition. This study was performed to examine the current status of surgical treatment of Boerhaave's syndrome in Japan.

METHODS

Ninety-five patients with Boerhaave's syndrome who underwent surgical treatment from January 2010 to December 2015, obtained from a national survey were retrospectively analyzed. The details of each surgical treatment and the type of treatment performed according to the patients' characteristics were examined.

RESULTS

Primary closure was performed in 75 (78.9%) patients, T-tube insertion in 15 (15.8%), and esophagectomy in 5 (5.3%). The length of the postoperative stay was significantly shorter in patients who underwent primary closure (p = 0.0011). Esophagectomy tended to be performed more often in patients with a long perforation and was performed significantly more often in patients with a high C-reactive protein concentration (p = 0.0118). The postoperative hospital stay was significantly longer in patients with leakage of the primary closure site (p < 0.0001). As a result, leakage of the primary closure site was significantly correlated with a long duration from symptom onset to patient presentation (p = 0.042), diagnostic imaging of the intrathoracic perforation (p = 0.013), and abscess formation in the mediastinal cavity (p = 0.006).

CONCLUSIONS

Selection of an appropriate surgical procedure may contribute to reduced mortality rates in patients with esophageal rupture. With regard to primary closure, it is necessary to understand that leaks are likely to occur in patients with a long duration from symptom onset to presentation or with severe intrathoracic/mediastinal inflammation, and to select an appropriate surgical procedure in consideration of the degree of invasiveness and QOL.

The presurgical controlling nutritional status (CONUT) score is independently associated with severe peristomal skin disorders: a single-center retrospective cohort study

While nutritional interventions may potentially lower the risk of peristomal skin disorders (PSDs) and their exacerbation, no previous studies have evaluated the relationship between PSDs and nutritional status using the Controlling Nutritional Status (CONUT) score. The purpose of this study was to assess the impact of preoperative nutritional status on stoma health, and determine risk factors for postoperative PSDs, including severe PSDs. A retrospective analysis was performed of 116 consecutive patients with rectal cancer who underwent radical surgery with ileostomy or colostomy creation. PSDs were diagnosed in 32 patients (27.6%); including 10 cases (8.7%) that were defined as severe based on the ABCD-stoma score. Multivariable logistic regression showed that smoking (odds ratio [OR] 3.451, 95% confidence interval [CI] 1.240–9.607, p = 0.018) and ileostomy (OR 3.287, 95% CI 1.278–8.458, p = 0.014) were independent risk factors for PSDs. A separate multivariable logistic regression analysis of risk factors for severe PSDs, found that the only independent risk factor was the CONUT score (OR 10.040, 95% CI 1.191–84.651, p = 0.034). Severe PSDs are associated with preoperative nutritional disorders, as determined by the CONUT score. Furthermore, nutritional disorders may increase the severity of PSDs, regardless of the stoma type.

Fibrin/fibrinogen Degradation Products Are Associated With Tumor Stage and Prognosis in Patients Undergoing Resection of Esophageal Cancer

BACKGROUND/AIM

To investigate the significance of preoperative fibrin/fibrinogen degradation products (FDP) in patients with esophageal cancer (EC), we examined the association between the preoperative FDP level and clinicopathological features in patients with EC who underwent McKeown esophagectomy with gastric tube reconstruction without neoadjuvant therapy.

PATIENTS AND METHODS

Ninety patients with EC who underwent surgery between 2006 and 2014 were included in this study. We investigated the association of FDP levels with clinicopathological features and prognosis.

RESULTS

Multivariate analysis revealed increased FDP level and pathological tumor depth to be independent prognostic factors for overall survival (OS) (p=0.008 and p=0.002, respectively). In addition, FDP levels were significantly positively associated with more advanced pathological TNM stage as a continuous variable (p for trend=0.002).

CONCLUSION

The preoperative FDP level was associated with a poor prognosis and was an independent prognostic factor for the OS of EC patients who underwent esophagectomy. Furthermore, the tumor stage-related increase in FDP indicated that a high FDP level is associated with tumor progression in patients with EC.