[A Case of Malignant Anorectal Melanoma with Laparoscopic Abdominoperineal Resection]

A 69-year-old man with anemia underwent colonoscopy. Colonoscopy showed a black tumor, 2 cm from the anal verge. The biopsy specimen revealed malignant melanoma, which was preoperatively diagnosed as T1(SM), N0, M0, Stage I . We performed laparoscopic abdominoperineal resection. The tissue type and diagnosis were malignant melanoma, pT1b(10 mm), pN0, pM0, ly0, v0, pDM0, pPM0, pRM0, pStage I b, according to the Colon Cancer Handling Terms, 8th edition). The patient did not receive adjuvant chemotherapy. However, he survived postoperatively for 9 months, with no sign of recurrence.

[Multidisciplinary Treatment for High-Risk GIST of the Stomach]

A 59-year-old man underwent total gastrectomy(with D2 dissection)and cholecystectomy for gastric cancer and a submucosal tumor of the stomach. The specimen was immunohistochemically positive for c-kit, the Ki-67 label index was 10%, and the mitotic count was 20/HPF. Finally, the patient was diagnosed with high-risk gastrointestinal stromal cancer with normal type gastric cancer. After discharge from hospital, we started administration of TS-1 as adjuvant therapy for the gastric cancer. As multiple recurrences of the GIST in the abdomen developed, the patient underwent 3 radical local resections. Mutational analysis revealed a PDGFRA mutation in exon 18, which causes resistance to both imatinib and sunitinib. As he was refractory to imatinib, the patient received regorafenib. After a while, it caused liver failure, which required 7 rounds of plasmapheresis. The patient died from multiple organ failure resulting from multiple recurrences 4 years after the first surgery.

[A Case of Advanced Gastric Cancer with Multiple Liver Metastases Successfully Treated with Capecitabine, Cisplatin, and Trastuzumab]

A 70-year-old-man, whose chief complaint was epigastric pain, was referred to our hospital and diagnosed with advanced gastric cancer with multiple liver metastases. Gastrointestinal endoscopy showed a tumor on the anterior wall of the gastric lower body. Histologically, biopsy specimens indicated adenocarcinoma, and immunohistochemistry showed positive expression of HER2(3+). Chest and abdominal computed tomography showed multiple liver metastases and lymph node metastases. We started chemotherapy with capecitabine, cisplatin, and trastuzumab. Abdominal CT showed the primary tumor and metastases to be reduced after 3 courses, but a ringed enhanced space occupying lesion in the liver had appeared, which was diagnosed as a liver abscess. After administering antibiotics and performing percutaneous transhepatic abscess drainage (PTAD), we continued XPT chemotherapy. The patient received 6 courses of XPT, 15 courses of capecitabine and trastuzumab, and 6 courses of trastuzumab alone, and has remained progression free in the 1 year and 5 months after diagnosis. We experienced a case of advanced gastric cancer with multiple liver metastases successfully treated with capecitabine, cisplatin, and trastuzumab.

[A Case of Pure Squamous Cell Carcinoma of the Breast in an Elderly Woman Diagnosed by Cytology]

A n 85-year-old woman presented with a mass in the left breast. A3 7mm lobulated mass including enhancement of a cyst of 37mm was detected by sonography. An axillary lymph node had increased to 16 mm. Atypical cells dyed by light green and orange G were identified by fine needle aspiration and cytology. She was diagnosed with left breast cancer(cT2N1M0, Stage II B), histologically suspected to be squamous cell carcinoma. She underwent a left-breast-conserving surgery and axillary lymph node dissection. On pathology, a cyst of 34×30mm was noted. The tumor grew from inside the cyst to the surround- ing tissue and it had a trend for keratinocytes. Lymph node metastases affected 1/11. By immunostaining, the tumor was found to be ER(+), PgR(-), HER2(-), CK5/6(+), p40(+), mammaglobin(-), and GCDFP15(-). There was no component of ductal carcinoma. She received radiotherapy to the left breast and tamoxifen as an adjuvant therapy. Squamous cell carcinoma of the breast is rare. We encountered a case of pure squamous cell carcinoma of the breast in an elderly woman. We report this case with a discussion of the relevant literature.

[Multiple Metachronal Liver Metastases from a Rectal Neuroendocrine Tumor Controlled by Repeated Transcatheter Arterial Chemoembolization]

A 60-year-old woman was diagnosed with a rectal neuroendocrine tumor(NET)with SM invasion.We performed laparoscopic low anterior resection with D3 lymph node dissection.Pathological findings were rectal NET, G1, pSM(9,000 mm), ly0, v0, pN0, PM0, DM0, pR0, pStage I .Four years and 6 months later, contrast enhanced abdominal computed tomography (CECT)and contrast enhanced magnetic resonance imaging revealed multiple liver metastases.The tumors were unresectable because they were bilobar; therefore, we performed transcatheter arterial chemoembolizaion(TACE).One month later, CECT showed the lesions had shrunk.The metastases were well controlled via repeated TACE.For unresectable liver metastases from rectal NET, TACE can be an effective treatment.

[A Case of Successful Multidisciplinary Therapy for Advanced Esophagogastric Junction Cancer with Multiple Lymph Node Metastase]

A 64-year-old man reporting dysphagia was examined. Upper gastrointestinal endoscopy showed a type 3 cancer at the esophagogastric junction. Enhanced CT scan showed several swollen mediastinal and abdominal lymph nodes. We diagnosed the patient with advanced adenocarcinoma of the esophagogastric junction with multiple lymph node metastases(Siewert type II , cT3N2M1[LYM], Stage IV ). After 5 courses of chemotherapy(S-1 plus cisplatin), a significant reduction was observed in the size of the tumor and lymph nodes. Therefore, we performed conversion surgery. The patient underwent esophagectomy and mediastinal lymph node dissection using a right thoracotomy approach. He has survived without recurrence in the 10 months since this radical surgery.

[A Case of a Patient with Metastatic Rectal-Uterine Cancer from the Ascending Colon Who Underwent NOSE]

An 80-year-old woman had undergone a right hemicolectomy for ascending colon cancer 9 months prior to the current presentation. CT and PET-CT showed a solitary tumor measuring 55mm in diameter at the uterus and rectum. Three 5mm ports and two 12mm two ports were placed. The sigmoid colon was mobilized using a medial approach as usual in laparoscopic surgery. The rectum and uterus were mobilized and were resected. We inserted the End-catchTM in from the vagina and removed the specimen. The patient had no abdominal pain and was discharged from the hospital 9 days after the operation.

[A Case of Schwannoma Originating from the Sciatic Nerve]

A 75-year-old man was admitted with abdominal pain and taken to our hospital. CT and MRI showed a tumor measuring 60mm in diameter in the pelvic cavity. Based on the imaging findings, we suspected a schwannoma and decided to perform surgery. As the tumor was found to be benign in intraoperative frozen section diagnosis, the tumor was enucleated. Histopathological findings showed no nuclear atypia, and the patient was diagnosed with a schwannoma. He complained of paresthesia in his right leg after surgery, and underwent walking training. Six months after surgery, no recurrence was found.

Single-site laparoscopic right hemicolectomy for acute cecal volvulus: a case report

BACKGROUND

Cecal volvulus is an uncommon cause of acute abdomen in patients. Cecal volvulus is currently treated mostly with right hemicolectomy with laparotomy, which is an invasive surgical procedure. Less invasive techniques, such as endoscopic decompression, have a poor success rate.

CASE PRESENTATION

We report a case of cecal volvulus in a 35-year-old male patient. He was successfully treated with single-site laparoscopic decompression by inserting a catheter through the amputated appendix, detorsion, and hemicolectomy. This approach was less invasive than the traditional approach and resulted in satisfactory outcomes and cosmesis.

CONCLUSIONS

Application of single-site laparoscopic colectomy to acute cecal volvulus is feasible using decompression of the dilated colon by inserting a catheter through the amputated appendix. To the best of our knowledge, this is the first report of this treatment.

[A Case of Neuroendocrine Carcinoma of the Gallbladder]

A 58-year-old woman presented to our hospital with a huge hepatic mass. A CT scan showed an enhanced mass lesion on the fundus of the gallbladder and an enhanced mass ring on the gallbladder bed. Since FDG-PET showed no evidence of metastasis, we performed cholecystectomy, hepatectomy of S4a/5, and regional lymph node dissection. The immunohistochemical study of the specimen was positive for CK7, CK20, chromogranin A, and synaptophysin. The Ki-67 labeling index was 50%, and the SSTR2 score was 2+. The patient was diagnosed with neuroendocrine carcinoma. Since she was in poor condition and on hemodialysis, we started administration of somatostatin analog at the time of recurrence, and soon her diarrhea improved but the tumor increased in size.

[FOLFIRINOX Combination Chemotherapy in Patients with Metastatic or Recurrent Pancreatic Cancer--A Single Institution Experience]

Pancreatic adenocarcinoma is one of the leading causes of cancer-related deaths in Japan. oxaliplatin: L-OHP, irinotecan: CPT-11, fluorouracil: 5-FU, and Leucovorin: l-LV (FOLFIRINOX) combination chemotherapy provided significant improvements in overall and progression-free survival in a phase Ⅲ trial in France and in a phase Ⅱ trial in Japan. As a result, this combination therapy was approved for use in Japan. We evaluated the efficacy of FOLFIRINOX in metastatic or recurrent pancreatic cancer. Between October 2014 and July 2015, 10 patients received mFOLFIRINOX as follows: 2-hour infusion of LOHP at 85 mg/m2, 2-hour infusion of l-LV at 200 mg/m2 and infusion of CPT-11 over 90 min at 150 mg/m2, followed by continuous infusion of 5-FU over 46 hours at 2,400mg/m2. Prior to the treatment, a 5-hydroxytryptamine receptor antagonist, aprepitant, and dexamethasone were given. The treatment was repeated every 2 weeks until disease progression, unacceptable toxicity, discontinuation as decided by the investigators, or patient refusal. The mean age of the patients was 65.0 years (range, 59-75 years), and 4 out of 10 patients were men. Only 2 patients had no prior therapy. Nine patients had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 0. Eight patients had metastasis and 2 had locally recurrent disease. The median number of treatment cycles was 5 (range, 1-14). The relative dose intensities of 5-FU, L-OHP and CPT-11 were 93.3% (range, 58.3-100%), 84.0% (range, 63.2-100%), and 76.0% (range, 44.4-83.3%), respectively. The major Grade 3 and 4 hematological toxicities were neutropenia (40%), leucopenia (30%), and thrombocytopenia(10%). The major Grade 2 and 3 non-hematological toxicities were diarrhea (30%), nausea (60%), and vomiting (10%). Serious adverse events occurred in 2 patients. Severe biliary tract infection causing sepsis was observed in 1 patient with a biliary stent. Overwhelming post-splenectomy infection was observed in 1 patient after distal pancreatectomy. No cases of interstitial lung disease were observed. The 6-month progression-free and overall survival rates were 59.3% and 61.7%, respectively. The overall response rate was 10%, and the disease control rate was 90%(complete response [CR], n=0; partial response [PR], n=1; stable disease [SD], n=8; progressive disease [PD], n=1). Although FOLFIRINOX is associated with increased treatment efficacy and survival outcomes, because of its severe toxicity it cannot be administered to all patients. FOLFIRINOX can be used as the standard treatment for patients with a good performance status.

[Laparoscopic Liver Resection for HCC Recurrence]

Laparoscopic surgery is less invasive and provides better cosmetic outcomes than conventional surgery. Laparoscopic liver resection has been covered by insurance since April 2010 and is increasingly performed in many hospitals. However, laparoscopic hepatectomy is sometimes difficult to perform safely in the case of HCC recurrence because adhesions restrict vision and manipulation of forceps. We report the results of laparoscopic hepatectomy for cases of HCC recurrence. From June 2010 through December 2014, 180 laparoscopic hepatectomy procedures for HCC were performed in our hospital; 33 were in patients with HCC recurrence. Of the 33 patients, 26 underwent pure laparoscopic partial hepatectomy. The median operative time was 242 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 12.0 days. In the group that underwent laparoscopic hepatectomy after open liver resection (12 patients), the median operative time was 303.5 min, the median bleeding amount was less than 5 g, and the median hospital stay after surgery was 9.0 days. Among the 21 patients that underwent laparoscopic hepatectomy after laparoscopic liver resection, the median operative time was 248 min (p=0.382), the median bleeding amount was less than 5 g (p=0.112), and the median hospital stay after surgery was 11.0 days (p=0.236). We could perform laparoscopic hepatectomy for cases of HCC recurrence. This procedure can be suitable for HCC recurrence, which sometimes requires poly-surgery.

Initial experience of reduced port surgery using a two-surgeon technique for colorectal cancer

BACKGROUND

With the decreasing number of surgeons on surgical teams, reduced port surgery (RPS) operations have become popular. We herein present our initial experience with RPS, which was successfully performed using a two-surgeon technique. A retrospective analysis was performed to compare the two-surgeon technique with conventional laparoscopic colectomy and evaluate its efficacy.

METHODS

A total of 535 patients were eligible among 749 registered patients. Conventional multiport laparoscopic colectomy with three surgeons and RPS using the two-surgeon technique with a surgeon and surgeon's assistant were performed in 429 and 106 cases, respectively. The patient characteristics, short-term outcomes (including intraoperative and postoperative findings) and pathological results were recorded and analyzed.

RESULTS

The two groups were similar with respect to age, gender, BMI, history of abdominal surgery, depth of tumor invasion and TNM classification. Reconstruction via extracorporeal functional end-to-end anastomosis was performed in a significantly higher number of patients in the two-surgeon technique group (74 %) than in the conventional laparoscopic colectomy group (57 %). Furthermore, the mean operative time in the two-surgeon technique group (117.9 min) was significantly shorter than that observed in the conventional laparoscopic colectomy group (170 min), and the median postoperative hospital stay was significantly shorter in the two-surgeon technique group (6 days) than in the conventional laparoscopic colectomy group (7 days). There were no major postoperative complications. The final TNM stage was similar in both procedures.

CONCLUSION

RPS using the two-surgeon technique compares favorably with conventional laparoscopic colectomy and is considered to be a safe and successful procedure.

Dextromethorphan for neuropathic pain with Churg-Strauss syndrome

Abstract A 48-year old man who had been treated with prednisolone, aminophylline, and pranlukast, a leukotriene-receptor antagonist, was diagnosed with Churg-Strauss syndrome based on the findings of asthma, eosinophilia, mononeuropathy, and extravascular eosinophils. Intractable neuropathic pain of the legs was successfully controlled with an N-methyl-d-aspartate receptor antagonist, dextromethorphan. We suggest that dextromethorphan receptor antagonists may be a useful treatment for the pain of neuropathy caused by vasculitis syndrome.

Rapid detection of blaIMP-6 by amplification refractory mutation system

Klebsiella pneumoniae resistant to almost all ß-lactams except imipenem designated as ISMRK (imipenem-susceptible meropenem-resistant Klebsiella) is emerging in Japan. All ISMRK carries bla(IMP-6) which differs from bla(IMP-1) by only a single nucleotide at position 640. We devised a rapid detection system of bla(IMP-6) by using ARMS PCR.

DISC1 regulates cell-cell adhesion, cell-matrix adhesion and neurite outgrowth

Disrupted-in-schizophrenia 1 (DISC1) is a promising susceptibility gene for major mental illness. Recent studies have implicated DISC1 in key neurodevelopmental processes, including neurite outgrowth, neuronal migration and proliferation. Here, we report that DISC1 regulates cell-cell and cell-matrix adhesion and neurite outgrowth. DISC1 overexpression increased expression of the adherence junction protein N-cadherin and enhanced cell-cell adhesion. The increased N-cadherin accumulated in the areas of cell-cell contact. DISC1 overexpression also enhanced cell-matrix adhesion by inducing expression of beta1-integrin protein. In the presence of nerve growth factor (NGF), DISC1 overexpression increased beta1-integrin expression at the cell membrane and growth cone. NGF-induced neurite extension was enhanced by DISC1, and anti-beta1-integrin antibody reduced the neurite outgrowth of DISC1-overexpressing cells to the control level. Furthermore, DISC1 also regulated N-cadherin and beta1-integrin expression at the cell membrane in primary neurons. We conclude that DISC1 regulates cell-cell adhesion and cell-matrix adhesion by regulating the expression of adhesion molecules.

First isolation of blaIMP-7 in a Pseudomonas aeruginosa in Japan

We report here the first isolation in Japan of a carbapenem-resistant Pseudomonas aeruginosa strain that carries the metallo-beta-lactamase gene bla(IMP-7). This isolate revealed high-level resistance to all of the tested antibiotics except for piperacillin, showing a multidrug-resistant phenotype.

Transfer of spermatogenesis-related cDNAs into eel testis germ-somatic cell coculture pellets by electroporation: Methods for analysis of gene function

Genes encoding spermatogenesis-related substance (eSRSs) show unique expression patterns during spermatogenesis. To analyze their function, we developed a new assay system using gene transfer techniques combined with coculture of the eel germ-somatic cells. First, we investigated the efficacy of in vitro electroporation transfer of gene into germ-somatic cell pellets using green fluorescent protein (GFP) gene. Second, in order to define the function of the eSRSs, we electrophoretically transferred eel spermatogonial stem cell renewal factor (eSRS34) and eel spermatogenesis-preventing substance (eSRS21) genes into germ-somatic cell pellets. Presence of the transferred cDNA was examined by reverse transcription-polymerase chain reaction (RT-PCR). Furthermore, proliferating cells were detected histologically, after labeling with BrdU. Transfer of the eSRS34 gene induced spermatogonial stem cell renewal in the pellets. Moreover, 11-ketotestosterone (11-KT) treatment stimulated the proliferation of spermatogonia, which resulted in the appearance of late type B spermatogonia in the pellets. The proliferation of spermatogonia by 11-KT stimulation was suppressed by transfer of the eSRS21 gene. These results indicate that the transferred eSRS34 and 21genes were functional in the pellets. Thus, an efficient in vitro gene transfer technique for coculture system of germ and somatic cell of Japanese eel was established.

Treatment of lentigo maligna with topical imiquimod

A published case report and anecdotal experience suggested that topical imiquimod is an effective treatment for stage 0 melanoma (lentigo maligna). To gauge the efficacy of this therapy, we undertook a trial of topical imiquimod in 30 subjects with histologically confirmed lentigo maligna. Thirty subjects with lentigo maligna were recruited for an open-labelled efficacy trial with daily topical application of imiquimod 5% cream for 3 months. Study subjects were enrolled from the Dermatology service of the University of Oklahoma, the Oklahoma City Veteran's Administration Hospital Dermatology service and from referrals for the study from other practitioners. In order to determine an initial response rate, a four-quadrant biopsy was carried out on all patients 1 month after cessation of treatment, targeting the most clinically and dermatoscopically suspicious areas. Of 28 evaluable subjects who have completed the 3-month treatment phase, 26 (93%) were complete responders and two were treatment failures at the time of the 4-quadrant biopsy. Over 80% of the 28 subjects that completed treatment have been followed for more than 1 year with no relapses. The results of this study demonstrate that topical imiquimod produces a high complete response rate in lentigo maligna when applied daily for 3 months.