[A Case of Rapidly Progressive Gallbladder Cancer Presented with Gallbladder Hemorrhage]

A 96-year-old woman was brought to our hospital for epigastric pain. Abdominal contrast-enhanced CT and MRCP showed wall thickness of the fundus and extravasation in the gallbladder. With a diagnosis of gallbladder hemorrhage from the tumors, we performed laparoscopic cholecystectomy. The histopathological diagnosis was gallbladder cancer. Herein, we report on this case and also provide a literature review.

[Surgery for Anal Canal Squamous Cell Carcinoma after Prostate Brachytherapy-A Case Report]

Generally, the first treatment plan for anal canal squamous cell carcinoma(SCC)is chemo-radiation therapy(CRT). We experienced an extremely rare surgery case of anal canal SCC after prostate brachytherapy. A man in his 70s who had undergone brachytherapy for prostate cancer 8 years before visited our hospital because of blood in feces. A tumor prolapsed from the anal verge, and biopsy revealed SCC. Contrast-enhanced computed tomography showed front-wall thickness in the lower rectum, but we could not evaluate it in detail because of the halation by brachytherapy seeds. We performed laparoscopic abdominoperineal resection to avoid an overdose of radiation for the rectum. Pathological staging was pT2N1aM0, pStage ⅢA. These findings might suggest radiation-induced cancer after brachytherapy.

[A Case of Neuroendocrine Carcinoma of Ascending Colon with Early Recurrence after Surgery]

A 65-year-old male received the positive result of fecal occult blood. Colonoscopy was performed to reveal a tumor in the ascending colon. The result of biopsy was neuroendocrine carcinoma. Under the preoperative diagnosis of neuroendocrine carcinoma in the ascending colon, cT3N0M0, cStage Ⅱ, laparoscopic ileocecal resection with D3 lymph node dissection was performed. The pathological result was neuroendocrine carcinoma in the ascending colon, pT4aN2M0, pStage Ⅲc. The R0 resection was achieved. As adjuvant chemotherapy, the regimen of cisplatin plus irinotecan was administered for 4 courses. No recurrence was seen until 9 months after the operation, when multiple peritoneal and hepatic metastasis were detected on CT scan. The chemotherapy regimen of etoposide plus carboplatin was started and is now ongoing. The patient is now alive 13 months after the operation.

[Laparoscopic Repair of Incarcerated Diaphragmatic Hernia as a Complication of Left Hepatectomy for Liver Cancer]

We report a case of laparoscopic repair of a diaphragmatic hernia after left hepatectomy for liver cancer. A woman in her 70s had undergone left hepatectomy for liver cancer 9 months earlier, and she was admitted because of epigastric pain after vomiting immediately following contrast-enhanced CT. On the next day, contrast-enhanced CT revealed an incarcerated diaphragmatic hernia, for which laparoscopic diaphragmatic hernia repair was performed. The incarcerated stomach was pushed back into the abdominal cavity, and the diaphragm was closed with 2-0 proline sutures. Gastric resection was not performed because the blood flow gradually improved. The postoperative course was good; the patient was discharged on the 7th postoperative day and is under outpatient follow-up.

[A Case of Early Gastric Cancer in the Remnant Stomach after Successful Treatment with ESD]

We report a case of early gastric cancer in the remnant stomach after successful treatment with endoscopic submucosal dissection(ESD). A 64-year-old woman had undergone distal gastrectomy, D2 dissection, and Billroth Ⅰ reconstruction for advanced gastric cancer 11 years previously. During a routine upper gastrointestinal endoscopy, an elevated lesion was detected at the lesser curvature of the upper gastric body of the remnant stomach, and biopsy indicated a Group 4 tumor. Curative en bloc resection of the lesion was achieved via ESD, although there was severe fibrosis along the suture line. The pathological result was 0-I, pT1a, tub1, 3×3 mm, UL(－), ly(－), v(－), HM0(8 mm), VM0(800 μm), indicating curative resection. Surveillance of the upper gastrointestinal tract 5 years after gastric cancer surgery enabled the early detection of the gastric cancer and curative resection with ESD.

Simultaneous triple cancer of the esophagus, pancreas and rectum treated with multimodal strategies: a case report

BACKGROUND

Due to the development of diagnostic imaging technology, we have increased chance of detecting multiple primary cancers. However, simultaneous triple cancer is still a very rare finding whose frequency is not yet known. Treatment of simultaneous triple cancer is a clinical challenge because it requires multimodal strategies including surgery, chemotherapy and radiotherapy.

CASE PRESENTATION

Here, we present the case of a 74-year-old male with triple cancer involving esophageal and pancreatic cancer, and rectal carcinoma. Each cancer was surgically resectable, but simultaneous resection of all cancers seemed to cause too much surgical stress for the patient. First, we performed a laparoscopic Hartmann's operation for rectal cancer to minimize the risk of postoperative complications. Then treatment for pancreatic cancer was initiated by administering neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel. The pancreatic tumor shrank in size, so pancreatoduodenectomy was performed. We chose S-1 as adjuvant chemotherapy. The esophageal cancer showed regression during the treatment of the other two cancers, likely because the chemotherapeutic agents administered for pancreatic cancer had some effect on the esophageal cancer. Definitive chemoradiotherapy was selected instead of esophagectomy because the patient had already undergone two major surgeries. The patient is still alive nine months after the whole course of treatment with no sign of recurrence.

CONCLUSIONS

The treatment of triple cancer requires an elaborate strategy to determine which cancer has to be dealt with first and which can be treated later. An aggressive multimodal treatment strategy may be an important option for a patient with triple cancer.

Long-term treatment outcome of type 1 thyroplasty using novel titanium medialization laryngoplasty implant combined with arytenoid adduction for unilateral vocal cord paralysis: single-arm interventional study at a single institution

OBJECTIVE

To evaluate the long-term treatment outcome of type 1 thyroplasty with novel rearrangeable titanium medialization laryngoplasty implant (TMLI) combined with arytenoid adduction (AA) for unilateral vocal cord paralysis (UVFP) in the authors' institution.

METHODS

A total of 16 Japanese patients with UVFP who received type 1 thyroplasty using TMLI with arytenoid adduction was enrolled in this single-arm, non-randomized interventional study. The results of the auditory perceptual assessment, aerodynamic examination, acoustic measurement, and patient-based survey on these patients were evaluated preoperatively and at 3, 6, and 12 months postoperatively.

RESULTS

Type 1 thyroplasty using TMLI with arytenoid adduction for our patient series presented significant improvements in maximum phonation time, mean flow rates, GRBAS scale, the Voice Handicap Index and the Voice-Related Quality of Life score over the 12-month postoperative period.

CONCLUSION

Type 1 thyroplasty using TMLI with arytenoid adduction was quite effective for obtaining satisfactory postoperative voice improvement without any surgical complication over the long-term period.

[A Case of Late-Onset Recurrent Rectal Cancer Associated with Anal Fistulas]

A 71-year-old man underwent laparoscopic lower anterior resection(D3 dissection)for rectal cancer and bilateral lung metastases. Histopathological findings indicated Ra, type 2, tub2, ly0, v2, pN0, pM1(PUL1), pStage Ⅳ. The lung metastases had disappeared after postoperative chemotherapy and the patient entered cCR. Two years after the surgery, the patient's anal fistulas appeared sclerotic. Biopsy revealed recurrent rectal cancer. We performed an abdominoperineal resection and rectus abdominis muscle flap. Currently, the patient is alive at 9 months after surgery with no re-recurrence.

[Advanced Colon Cancer Resected after a Neoadjuvant Chemotherapy of CAPOXIRI-A Case Report]

We report a case ofadvanced colon cancer, stage cT4bN0M0 in the descending colon with formation ofabscesses in the retroperitoneal space ofa 66-year-old woman. After constructing a transverse colostomy and percutaneous abscess drainage, chemotherapy was initiated with CAPOX. After 4 courses of CAPOX, the tumor had significantly regressed; therefore, the regimen was switched to a triplet combination called CAPOXIRI. After 3 courses of CAPOXIRI, the tumor had become smaller and had separated from the iliopsoas muscle, which led us to perform surgical resection. Left hemicolectomy was performed with R0 resection, and the tumor was pathologically diagnosed as ypT3N0M0. The patient is alive 12 months after the surgery, with no signs of recurrence.

[Advanced Gastric Cancer with Liver Metastasis and Para-Aortic Lymph Node Metastases Treated Effectively Using Neoadjuvant CapeOX Therapy]

A 60-year-old man was diagnosed with advanced gastric cancer(cT4a, N1, M1[No. 16LYM], cStage Ⅳ). He was treated with a neoadjuvant chemotherapy of a regimen consisting of capecitabine plus oxaliplatin, followed by distal gastrectomy with D2 and No. 16lymph node dissection and partial hepatectomy of S3 and S6. He had an uncomplicated postoperative course and was discharged early from hospital. Capecitabine was started at POD 40 as an adjuvant chemotherapy. Postoperatively, the histological effect was determined to be Grade 2, and hepatic tumors and lymph nodes showed no residual cancer. He started capecitabine monotherapy as adjuvant chemotherapy. At 10 months postoperatively, the patient was alive and relapse-free.

[A Case of Long-Term Survival of Liver Metastasis from Biliary Carcinoma after Pancreaticoduodenectomy Treated by Multimodal Therapy]

A 73-year-old man underwent a subtotal stomach preserving pancreaticoduodenectomy(SSPPD)for biliary carcinoma without regional lymph node metastasis. Although S-1 was administrated as adjuvant chemotherapy after the operation, the serum CA19-9 level was gradually elevated, and a liver metastasis of 27mm in diameter was detected in Couinaud's segment 8 during chemotherapy. We administrated gemcitabine(GEM)and cisplatin(CDDP)combination therapy(GC therapy). The liver tumor was immediately shrunk to 6mm and kept up the PR state after 15 courses of GC therapy. A stereotactic body radiation therapy(SBRT)was performed 1 year 8 months after the operation. The patient has been alive without recurrence for 4 years since the SBRT. Although systemic chemotherapy is the standard treatment for the recurrence of biliary carcinoma, a loco-regional therapy such as SBRT may be an effective alternative when a patient has a solitary metastasis to the liver with no other evidence of recurrence.

[A Case of Pulmonary Metastases of Colon Cancer with Submucosal Invasion]

In general, distant metastasis is uncommon in colorectal submucosal(SM)invasion without lymph node metastasis. We experienced an extremely rare case of synchronous pulmonary metastases for colon cancer in SM invasion. A man in his 70s was seen at the hospital for a positive fecal occult blood test. Colonoscopy revealed 3 lesions in the sigmoid colon and endoscopic mucosalresection revealed 2,000 mm SM invasion in all 3 lesions. Computed tomography showed no signs of distant lymph node or liver metastasis but showed small nodules in both lungs. Radical treatment included laparoscopic anterior resection with lymph node dissection. Histological examination showed no residual tumor in the colon and no lymph node metastasis. Two years after surgery, the number of lung nodules gradually increased and we performed partial resection of the left lung, which was diagnosed as pulmonary metastasis from colon cancer by histological examination. Therefore, we resected the opposite-side pulmonary metastases. The patient has exhibited no other signs of recurrence in the 2 years since the last operation.

Development of a novel prediction model for recurrent stage II colon cancer

PURPOSE

Adjuvant chemotherapy is recommended for patients with high-risk stage II colon cancer. High-risk stage II is defined by clinicopathological factors in some guidelines. However, there is no unified definition. The aim of this study was to examine the risk factors and develop a novel model to predict the recurrence of stage II colon cancer.

METHODS

Three hundred fifty patients who underwent curative resection for stage II colon cancer at Osaka International Cancer Institute and Yao Municipal Hospital from 2004 to 2012 were included. Clinicopathological factors were assessed in a subgroup of 298 patients (Learning Set), and the relapse-free survival (RFS) rate was evaluated as the main outcome. A statistical analysis was performed using a proportional hazards model to determine the factors associated with RFS and a nomogram was developed to predict recurrence. A second subgroup of 52 independent patients who underwent curative resection in 2012 (Validation Set) was used to validate the nomogram.

RESULTS

The median RFS time was 4.96 years, and recurrence was observed in 35 patients. A univariate analysis revealed that a high serum CEA level, preoperative occlusion, tumor location (left-side colon), lymphatic invasion, and vascular invasion were significantly correlated with RFS. These variables were used to develop the nomogram. The C-index was 0.701 in the learning set and 0.585 in the validation set. Using nomogram points, the patients were classified into low-risk, middle-risk, and high-risk categories.

CONCLUSION

A recurrence prediction model was developed that integrated multiple risk factors in stage II colon cancer patients. High-risk patients were identified by the nomogram.

[A Case of Early Gastric Cancer That Coexisted with Multiple Submucosal Heterotopic Gastric Glands]

We report a case of surgical resection of an early gastric cancer that coexisted with multiple submucosal heterotopic gastric glands.A man in the 80's referred to our department because of an increased level of CEA.He had undergone hepatectomy for heterochronous liver metastasis of colon cancer.Gastrointestinal endoscopy revealed an early gastric cancer that coexisted with multiple submucosal gastric glands.He underwent segmental gastrectomy for gastric cancer.He exhibited no symptoms at the time of discharge.He has had no recurrence of gastric cancer 6 months after the surgery.We should appropriately care for synchronous or heterochronous gastric cancer in the remnant stomach if total gastrectomy is not performed in cases of therapy for gastric cancer with multiple submucosal heterotopic gastric glands.

[A Case of Recurrence in the Lateral Pelvic Lymph Node after Local Excision of Lower Rectal pT1a Cancer]

The patient was a man in his 70s who visited our hospital to undergo an examination for fecal occult blood, which detected a 20 mm, Ⅱa lesion in the lower rectum on colonoscopy. He was diagnosed with SM-invasive cancer and was planned to undergo trans-anal local excision. After the surgery, he had a good postoperative course without complications. The pathological findings were Ⅱa, tub1, 22×16 mm, pT1a(950 mm), int, INF a, ly0, v0, pHM0, pVM0(300 mm). He was followed up after the surgery, but was diagnosed with lateral lymph node recurrence 4 years after a local surgery. The surgery involved right-sided lateral lymphadenectomy with resection of the ureter, spermatic duct, seminal vesicle, and piriformis muscle. He was diagnosed with lymph node metastasis with invasion of the spermatic duct based on pathology. Eight courses of adjuvant chemotherapy containing CapeOX was administered. Unfortunately, primary squamous cell lung cancer was detected, and he died after surgery for recurrence in the second year. It is suggested that it is necessary to note lateral lymph node recurrence on postoperative follow-up for lower rectal cancer at any stage.

[A Case of Anastomotic Recurrence of Rectal Cancer 22 Years after Surgery]

In general, anastomotic recurrence of colorectal cancer occurs within 3 years after surgery. We encountered an extremely rare case of anastomotic recurrence over 20 years after surgery. A 70-year-old woman who had undergone low anterior resection for rectal cancer 22 years previously was admitted to the hospital because of anal bleeding. Colonoscopy revealed a 1.5 cm sized, elevated lesion on the anastomotic site, and a biopsy revealed an adenocarcinoma(tub2). EUS demonstrated that the tumor was located on the staples, and the depth of the tumor was expected to be within the muscle layer of the rectum. Computed tomography showed no signs of distant metastasis. Given the diagnosis of anastomotic recurrence of rectalcancer 22 years after surgery, laparoscopic abdominoperinealresection was performed. Histologicalassessment showed that the tumor was on the staples, and did not exhibit vascular and lymphatic invasion. Finally, she was diagnosed with anastomotic recurrence due to implantation. The patient has exhibited no other signs of recurrence in the 3 years since the last surgery.

Treatment of Retinal Detachment with Giant Tear by Pneumatic Retinopexy

Nine eyes suffering from retinal detachment with giant tear were treated successfully by pneumatic retinopexy, followed by conventional buckling procedures and cryopexy. The retina in six of the nine eyes reattached after initial operation, whereas two required additional injection of SF6 gas. The remaining eye, having developed low-grade proliferative vitreoretinopathy (PVR C1), was treated successfully with vitrectomy. Visual outcome was rather poor immediately after the procedures due to vitreous opacity caused by gas injection. However, all cases showed excellent visual acuity five months after surgery. Visual field examined in six cases after surgery showed no significant constriction. If the retinal flap is mobile, pneumatic retinopexy may be effective in treating retinal detachment with giant tear.

[Gallbladder Carcinoma That Occurred 50 Years after Cholecystojejunostomy]

Creation of a cholecystojejunostomy has been recommended as one option in the palliation of biliary obstruction due to pancreatic carcinoma.However, it was a technique used for biliary drainage for acute cholecystitis a long time ago.We describe a patient who underwent a cholecystojejunostomy for acute cholecystitis 50 years prior to presentation, and then revealed a gallbladder carcinoma.

[Hepatocellular Carcinoma with Bile Duct Thrombosis - A Case Report]

Hepatocellular carcinoma(HCC)is not commonly observed with bile duct thrombosis.Here, we report a case of HCC with bile thrombi that extended to the liver hilum.The patient was a 61-year-old man who visited us due to untreated type B hepatitis.He underwent screening with a CT scan that revealed LDA on the right posterior lobe of his liver with infiltration of the bile duct.Generally, bile resection and reconstruction should be considered for curative resection for bile thrombi; however, we attempted to conserve the common bile duct to preserve the options of percutaneous therapy in case of tumor recurrence.We performed right lobectomy of the liver.The bile duct thrombus was extracted without bile duct resection or reconstruction.The patient is alive 6 months after the surgery without any development.

[A Case of Malignant Transformation of Intraductal Papillary Mucinous Neoplasm of the Pancreas Accompanied by Metachronous Triple Primary Cancer]

A 70's woman with a history of abdominal surgery for gastric cancer visited our hospital for the evaluation of bleeding during defecation.We diagnosed her with advanced rectal cancer and performed laparoscopic low anterior resection.As postoperative pathological staging was pT3N2M0, pStage III b, we included CapeOx therapy as adjuvant chemotherapy.One year and 4 months after the surgery, lung and liver metastases were revealed by CT and PET-CT scans.At the same time, dilatation of the main pancreatic duct(intraductal papillary mucinous neoplasm: IPMN)was detected.Thus, we first performed liver resection and then lung resection.After the surgery, new lung nodules and a mass lesion with IPMN with superior mesenteric venous invasion was found on CT scans.We then administered chemo-radiation therapy(CRT).After CRT, the lung and pancreatic lesions seemed to decrease slightly.Accidentally, a nodule on the cystic bladder was found, resected by transurethral resection of the bladder tumor(TUR-Bt), and diagnosed as a bladder cancer.Thirty months after the rectal surgery, she is continuing the S-1 chemotherapy with stable disease.

P-REX1 amplification promotes progression of cutaneous melanoma via the PAK1/P38/MMP-2 pathway

P-REX1 (PIP3-dependent Rac exchange factor-1) is a guanine nucleotide exchange factor that activates Rac by catalyzing exchange of GDP for GTP bound to Rac. Aberrant up-regulation of P-REX1 expression has a role in metastasis however, copy number (CN) and function of P-REX1 in cutaneous melanoma are unclear. To explore the role of P-REX1 in melanoma, SNP 6.0 and Exon 1.0 ST microarrays were assessed. There was a higher CN (2.82-fold change) of P-REX1 in melanoma cells than in melanocytes, and P-REX1 expression was significantly correlated with P-REX1 CN. When P-REX1 was knocked down in cells by P-REX1 shRNA, proliferation, colony formation, 3D matrigel growth, and migration/invasiveness were inhibited. Loss of P-REX1 inhibited cell proliferation by inhibiting cyclin D1, blocking cell cycle, and increased cell apoptosis by reducing expression of the protein survivin. Knockdown of P-REX1 expression inhibited cell migration/invasiveness by disrupting P-REX1/RAC1/PAK1/p38/MMP-2 pathway. Assessment of patient tumors and disease outcome demonstrated lower distant metastasis-free survival among AJCC stage I/II/III patients with high P-REX1 expression compared to patients with low P-REX1 expression. These results suggest P-REX1 plays an important role in tumor progression and a potential theranostic target.

Short-term outcomes following single-port laparoscopic surgery in elderly patients with colon cancer compared with younger patients

Surgeons are increasingly being faced with the challenge of treating elderly patients with colon cancer. The present study therefore aimed to compare the short-term outcomes of single-port laparoscopic surgery (SILS) for elderly patients with colon cancer (≥70 years) with those in younger patients (41-69 years; control group). Among 100 patients with colorectal cancer who had been treated with single-port laparoscopic surgery between January 2011 and December 2014, 56 (56.0%) were ≥70 years of age. The results of treatment and short-term outcomes in the elderly group (n=56) were retrospectively compared with the younger patients in the control group (n=44). The sex distribution, body mass index, history of prior surgery and the American Society of Anesthesiologists physical status classification were similar between the groups. Onodera's prognostic nutritional index demonstrated significant differences between the elderly and control groups (38.3 vs. 49.8; P<0.05). No significant differences were observed in the mean length of surgery (219.5±73.5 vs. 201.4±76.5 min; P=0.43), estimated blood loss (32.2±74.5 vs. 36.1±90.2 ml; P=0.10), postoperative complications (10.9 vs. 7.1%; P=0.78), length of postoperative hospital stay (9.6±12.5 vs. 7.3±3.0 days; P=0.23) or number of harvested lymph nodes (21.8±24.3 vs. 22.5±11.3; P=0.87) between the elderly and control groups. In conclusion, the results of the present study demonstrate that SILS may be carried out feasibly in elderly patients with colon cancer.

[A Case of Synchronous Double Cancers of the Liver and Pancreas Treated Using Pancreaticoduodenectomy and Liver Resection]

A 50-year-old woman had a 12mm liver tumor at segment 4 and was diagnosed with hemangioma. Two years later, the liver tumor had grown to 27mm in diameter, and a new pancreatic tumor was detected using CT examination. The pancreatic tumor was suspected of being pancreatic carcinoma, based on the results of endoscopic-ultrasound-guided fine-needlebiopsy( EUS-FNA)of the pancreas. The liver tumor was diagnosed as adenocarcinoma using liver biopsy. Because of its slow growth and the solitary liver tumor, synchronous pancreatic cancer and intrahepatic cancer were suspected. We therefore performed pancreaticoduodenectomy with portal vein resection and partial liver resection of segment 4. Upon histological analysis, carcinoma in situ was detected in the liver tumor and the patient was diagnosed with synchronous double cancers of the liver(cholangiocellular carcinoma)and pancreas(invasive ductal carcinoma). Our case indicated that it is very difficult to distinguish cholangiocellular carcinoma from metastatic liver tumor using diagnostic images. We should therefore consider the possibility of cholangiocellular carcinoma when a solitary tumor in the liver is detected at the same time as pancreatic cancer.