[Radiofrequency ablation for liver metastases from colorectal cancer after systemic chemotherapy]

PURPOSE

To evaluate the effectiveness and safety of radiofrequency ablation(RFA)for liver metastases from colorectal cancer after chemotherapy.

PATIENTS

From January 2006 to June 2012, 27 tumors in 17 patients with liver metastases from colorectal cancer were treated using RFA after systemic chemotherapy.

RESULTS

The median tumor diameter after chemotherapy was 12(range: 3-35)mm, and the mean number of tumors was 1.6(range: 1-4).The median time without local recurrence was 21.3(range: 2.2-61.9)months, and the median overall survival time was 38.0(range: 5.9-66.3)months. One patient had a complication(liver abscess).Of the 27 tumors, 9 were larger than 20 mm in diameter, and 4 of these 9 tumors showed local recurrence after RFA. In tumors smaller than 20 mm in diameter, only 1 showed local recurrence. The local recurrence rate was significantly higher for tumors larger than 20 mm than for tumors smaller than 20 mm(44.4% vs 5.6%,p=0.030).

CONCLUSION

RFA was an effective and safe method for treating liver metastases from colorectal cancer, especially for tumors smaller than 20 mm and in cases of less than 3 tumors after systemic chemotherapy.

[A case of multiple liver metastases after resection of gastrointestinal stromal tumor of the small intestine that was successfully treated with imatinib mesylate]

A 73-year-old man was found to have an intestinal tumor, approximately 10 cm in diameter, on computed tomography (CT). In September 2001, he underwent partial resection of the jejunum with partial colectomy and left nephrectomy. Pathological examination showed 2 mitoses per 50 high-power fields, and immunohistochemical analysis showed positive staining for c-kit. Based on the above findings, the tumor was diagnosed as a high-risk malignant gastrointestinal stromal tumor( GIST) of the small intestine; the patient was followed up and no adjuvant therapy was administered. In October 2005, an abdominal CT scan revealed 2 tumors with diameters of 21 and 28 mm in the S8 and S7 region of the liver, respectively, and the patient was diagnosed with liver metastases from GIST. After obtaining adequate informed consent, chemotherapy with imatinib (400 mg/day) was initiated. Although the patient experienced partial response (PR) 2 months after the treatment, grade 3 neutropenia and general fatigue were observed. Therefore, the treatment schedule was changed to 1 week of therapy, followed by 1 week of rest. At present, at 91 months after the diagnosis of liver metastases, the patient shows no signs of recurrence. Therefore, it is important that adjuvant chemotherapy should be considered for the treatment of patients with high-risk malignant GIST.

[Two cases of complete response for cStage I( T1bN0M0) esophageal carcinoma treated with chemoradiation therapy]

We report 2 cases of complete response for cStage I(T1bN0M0) esophageal carcinoma treated with chemoradiation therapy. Case 1: A 70-year-old man was diagnosed with cStage I(T1bN0M0) thoracic esophageal carcinoma(Type 0- IIc, squamous cell carcinoma). efinitive chemoradiotherapy (5-FU 250 mg/m2, CDDP 5 mg/m2 days 1-5, 8-12, 15-19, 22-26, 29-33, and 36-40; radiation: 60 Gy/30 Fr) was administrated. After treatment, we confirmed that the esophageal lesion had disappeared by upper endoscopy. Case 2: A 78-year-old man was diagnosed with cStage I(T1bN0M0) thoracic esophageal carcinoma (Type 0-I+IIb, squamous cell carcinoma) and early stage gastric carcinoma. Considering his general condition, radical surgery for esophageal cancer and gastric cancer was difficult; hence, he was treated with definitive chemoradiotherapy. After treatment, the esophageal lesion disappeared and we performed fundusectomy. Chemoradiation therapy appears to be effective for patients with cStage I(T1bN0M0) esophageal carcinoma.

[Treatment of inguinal lymph node recurrence after chemo-radiation for anal canal squamous carcinoma]

Although it is well established that the standard primary treatment for anal canal squamous cell carcinoma is chemoradiation, the strategy varies for recurrence cases.

CASE

A 76-year-old woman was diagnosed by biopsy as Stage II (T2N0M0) squamous cell cancer and treated with a total amount of 60 Gy pelvic radiation excluding the groin area, and oral chemotherapy of S-1 (60 mg/m2/day) for 4 weeks. Two years after initial therapy, she had a recurrence at the right inguinal lymph nodes. We resected her right inguinal lymph nodes and added 20 Gy photon radiations to both sides of the inguinal area. She has been recurrence-free for 4 years after the surgery. For recurrent anal canal squamous cell carcinoma, salvage surgery for the original lesion and systemic chemotherapy for distant metastasis are the standard strategy. For inguinal lymph node metastasis such as in this case, unilateral lymph node resection and adjuvant radiation for the bilateral groin area are recommended by the guidelines of National Comprehensive Cancer Network (NCCN).

[Resection of ovarian metastasis of colon cancer to improve quality of life]

A 52-year-old woman with multiple liver metastasis of cecal cancer underwent laparoscopic right hemi-colectomy in September 2010. One year of postoperative chemotherapy for liver metastasis achieved good control, but both ovaries enlarged because of metastasis and caused abdominal distension. In order to improve quality of life, we performed ovarian tumor resection in December 2011. After surgery, she was free from abdominal symptoms and continued to receive chemotherapy. We believe that surgical resection is indicated for ovarian metastasis of colorectal cancer with severe abdominal symptoms, even when metastases are present in other organs.

[A long-term survival case of biliary tract cancer treated with multimodality therapy]

A 64-year-old man with obstructive jaundice underwent percutaneous transhepatic biliary drainage, and bile cytology diagnosed adenocarcinoma. The operation ended with exploratory laparotomy because of severe cirrhosis, and thus, S-1 therapy was started after radiation therapy (50 Gy) with an endoscopic retrograde biliary drainage (ERBD) tube. After 37 months, an abdominal computed tomography(CT) scan detected dilation of the intrahepatic biliary tract without recurrence, and we therefore detained a biliary expandable metallic stent instead of the causal obstruction of the ERBD tube. Subsequent CT scan and upper gastrointestinal endoscopy detected stenosis and a thickened wall of the duodenum because of recurrence, and thus, we detained a duodenal stent and started gemcitabine therapy. The patient is alive 70 months after the initial consultation. We report herein a long-term survival case of biliary tract cancer treated with multimodality therapy.

[A case of diffuse pneumonic type of mucinous adenocarcinoma treated with reduction surgery]

A female never-smoker in her 60s presented with persistent productive cough. Chest radiography and computed tomography revealed widespread consolidation in the basal area of her left lung lower lobe. She received antibiotics and steroid therapy. Nevertheless, consolidation extended over the left lower lobe, and multiple nodular shadows appeared in both the lungs until a histological diagnosis of adenocarcinoma was obtained with lung wedge resection biopsy. Left lower lobectomy was performed as a tumor reduction surgery to palliate dyspnea due to massive sputum. The duration of decreased sputum production was short, and the lesion spread rapidly over the residual lung, resulting in death due to respiratory failure 8 months after her first visit. The histological diagnosis was diffuse pneumonic type of invasive mucinous adenocarcinoma with lepidic, acinar, and solid growth patterns (formerly mucinous bronchioloalveolar cell carcinoma). Mucous sputum containing tumor cells tends to spread aerogenously to other lobes and both lungs, and thus, disease control is difficult. Although there are some case reports of successful treatment with oral epidermal growth factor receptor tyrosine kinase inhibitors or pemetrexed, an effective therapeutic strategy for this type of lung cancer has not been established.

[A case of rapidly progressing retroperitoneal differentiation type liposarcoma]

A 75-year-old man visited our hospital in August 2011 due to general malaise and loss of appetite. Abdominal computed tomography scan showed a retroperitoneal tumor. Therefore, we performed resection of the retroperitoneal tumor, pancreas tail, and spleen. The pathological diagnosis was dedifferentiation-type liposarcoma with invasion of pancreas. Abdominal computed tomography scan 2 months after the operation showed peritoneal dissemination and multiple liver metastasis. The patient selected the best supportive care. An effective cure for dedifferentiation-type liposarcoma, besides surgical resection, is not yet established. Therefore, complete resection is important. Moreover, since the rate of recurrence is high, the development of an effective systemic chemotherapy is desired.

[A case of primary splenic malignant lymphoma associated with gastric cancer]

The patient was an 85-year-old woman with a chief complaint of anemia and epigastralgia. She was diagnosed with type 4 gastric cancer(por) located in the upper-third of the stomach by gastrointestinal endoscopy in April 2011. Computed tomography scan revealed no distant metastases, but a tumor measuring about 4 cm in diameter was detected in the spleen. We performed total gastrectomy with D2 lymph node dissection and splenectomy in June 2011. The postoperative pathological finding of the gastric cancer was pT4aN3aM1P0CY1H0, p-Stage IV(Japanese Classification of Gastric Carcinoma, 14th Edition). Histological examination of the splenic tumor revealed a follicular-type malignant lymphoma. At present, our patient is being treated with S-1 monotherapy in the outpatient clinic and shows no signs of recurrence. However, it is important that the patient is followed-up carefully because peritoneal lavage cytology was positive and the relapse rate of follicular lymphoma is comparatively high.

[A case of peritoneal dissemination that exhibited a complete response to systemic chemotherapy following the resection of primary colon cancer]

In June 2010, a 62-year-old man underwent right hemicolectomy with transverse colostomy for advanced ascending colon cancer with peritoneal dissemination(pSE, pN3H0P3M0, fStage IV, R2). One month after surgery, systemic chemotherapy (combination regimen of oxaliplatin injection and S-1 per os; SOX regimen) was introduced for the residual lesion. After completing 4 courses of the SOX regimen, peritoneal dissemination was not detected by abdominal computed tomography. In the same month, laparotomy was performed to close the temporary stoma, in which the lack of peritoneal dissemination was confirmed. After the stoma was closed, although no chemotherapy was administered because of patient preference, he has been free from relapse of the peritoneal dissemination, according to his latest follow-up examinations in June 2012. In this case, resection of the primary lesion immediately followed by a short period of systemic chemotherapy resulted in good control of peritoneal dissemination. Because the effect of these therapies allowed him to undergo stoma closure and to refuse further chemotherapy, he has been able to maintain his quality of life. In cases of reduction surgery for advanced colorectal cancer with unresectable peritoneal dissemination, a minimal resection including the primary lesion to avoid perioperative complications, which could permit the immediate start of systemic chemotherapy, could result in good control of peritoneal dissemination.

[Liver damage detected after a hepatectomy for liver metastasis after 12 courses of mFOLFOX6 therapy as an adjuvant chemotherapy for colorectal cancer]

The FOLFOX regimen is approved as an adjuvant therapy for colon cancer in Japan. We report a case of pathological damage in the resected non-cancerous liver after 12 courses of mFOLFOX6 therapy as an adjuvant therapy for stage IIIb colon cancer. A 45-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer. After completing 12 courses of adjuvant mFOLFOX6 therapy, this patient exhibited liver metastasis. Lateral segment resection was performed, and pathological examination of the resected specimen revealed irregular sinusoidal dilatation and cell apoptosis in the non-tumorous part of the liver. This was probably due to the effects of mFOLFOX6. We stress that when resectable liver metastasis is found after 12 courses of FOLFOX as an adjuvant therapy for colon cancer, careful attention should be paid during surgery and during postsurgical management because there may be damage in the remnant liver.

[A case of adenocarcinoma of the esophagogastric junction successfully treated with chemoradiation therapy]

The patient was an 80-year-old female with chief complaint of anemia. She was diagnosed as a type 3 gastric cancer (por/tub2) of the esophagogastric junction by gastrointestinal endoscopy in November 2010. CT scan revealed no distant metastasis and we diagnosed as c-stage II B (T4aN0M0). However, severe COPD was detected by the respiratory function test. Considering her age and respiratory function, we decided that total gastrectomy under general anesthesia was difficult. She was treated with radiation( 50.4 Gy/28 Fr) and the combination chemotherapy of S-1( 80 mg/m², day 1-21) plus low-dose CDDP (6 mg/m², day 1-5, 8-12, 15-19) during her hospitalization, and treated with S-1 mono-therapy as an outpatient. The tumor was reduced and the hemorrhage was not seen though the response was SD. Moreover, she did not experience any adverse event of grade 3 or more. The chemoradiation therapy appears to be effective for patients of adenocarcinoma of the esophagogastric junction.

[A case of laparoscopic radiofrequency ablation for liver metastatic tumor from colorectal carcinoma]

Hepatic resection is a first choice for resectable liver metastatic tumor from colorectal carcinoma. In the case of unresectable tumor or a refusal to operation, laparoscopic radiofrequency ablation (RFA) becomes an option to treat. We report a case of laparoscopic RFA for liver metastatic tumor from colorectal carcinoma. A 74-year-old woman had a laparoscopic transverse colectomy for transverse colon cancer with multiple liver metastases in February 2009. She received UFT/LV and liver metastases were reduced. After the second course, the patient desired to stop chemotherapy. But the liver metastases had grown again. We recommended a hepatic resection. Since she didn't want to have the operation, we performed RFA. After the RFA, a liver metastasis was detected twice. After tumors were located near other organs, we performed a laparoscopic RFA. At 9 months after undergoing last RFA, she had no recurrence in the liver. We thought laparoscopic RFA was safe and effective for the lesion, which was difficult to treat with percutaneous approach RFA.

[A case of unresectable mediastinal carcinoma obtaining clinical complete response after sequential chemoradiotherapy]

A man in his sixties was pointed out a solitary anterior mediastinal tumor 3 cm in diameter by CT scan with a complaint of chest compression, which grew 7 cm in diameter involving right subclavian and common carotic arteries and left innominate vein and superior vena cava 2 months later. FDG-PET/CT showed a high abnormal uptake only in the mediastinal tumor. A histological diagnosis of mediastinal poorly differentiated carcinoma or mediastinal lymph node metastasis of unknown origin was made by medistinoscopic biopsy. After 4 courses of chemotherapy with carboplatin and paclitaxel, the tumor was markedly decreased but was judged as unresectable because of residual involvement of great vessels. Addition of 60 Gy of radiotherapy targeted for the tumor resulted in further decrease in diameter of the tumor in CT scan and disappearance of abnormal uptake of the tumor in FDG-PET/CT thus regarded as clinical complete response. Since then, a disease free status has been maintained for 16 months.

[A case of liver tumor diagnosed 5 years after gastrectomy against gastric cancer]

A-62-year-old man with gastric cancer underwent gastrectomy 5 years ago, and an abdominal computed tomography scan detected a 15 mm early enhanced lesion located liver (S8) in 2008. Although primary or metastatic were unclear, we underwent partial hepatectomy( S8) as it was an isolated liver tumor. Pathological finding showed adenocarcinoma, and immunostaining was negative for cytokeratin (CK) 7 and positive for CK20 which was the same in primary gastric cancer, so it was diagnosed liver metastasis of gastric cancer. The patient was living at the time, but he passed away 24 months after hepatectomy. We report herein the case of resectable case of liver tumor 5 years after gastrectomy against gastric cancer.

[A case report of stage IV inoperable gastric cancer demonstrating a cCR treated with S-1/Paclitaxe (l PTX) therapy]

We report a case of Stage IV inoperable gastric cancer demonstrating a cCR treated with S-1/PTX. The patient was a 65-year-old female with advanced gastric cancer. CT scan suggested an invasion of tumor into a pancreatic body, jejunum and transverse colon. Staging laparoscopy showed it to be positive with peritoneal washing cytology and peritoneal dissemination. The surgical findings were T4a (SE) N2M1H0P1CY1, Stage IV. Chemotherapy was conducted with a combination of S-1/CDDP. After 2 courses of this regimen, the endoscopy findings did not show an improvement, so we decided to change the chemotherapy to S-1/PTX as second-line treatment. After 2 courses of this regimen, the endoscopy findings revealed a reduction of the primary tumor. After 19 courses, histopathological examination of biopsy specimen showed Group 1. Second-line chemotherapy was continued for 28 courses. The patient has had no recurrence without chemotherapy and been alive for 91 months after diagnosis.

[Hepatic resection after systemic chemotherapy for liver metastasis of colorectal cancer]

We report 8 cases of hepatic resection after systemic chemotherapy for metastatic colorectal cancer. Three patients had unresectable hepatic lesions, and 5 patients were given neoadjuvant chemotherapy. The mean age was 69 (range: 55-81). Five patients received an oxaliplatin based regimen, 4 patients received irinotecan based regimen and 1 patient received UFT/LV. Four patients were treated with bevacizumab, and 2 patients with cetuximab. Duration of chemotherapy was 12 weeks (the mid range of 7-90 weeks). Six patients were PR, and 2 were SD. Although 1 patient had a minor biliary fistula, no major complications were observed. The duration of postoperative hospital stay was 17 (the average range of 13-22). Our results suggest that preoperative chemotherapy for hepatic resection of metastatic colorectal cancer is safe and has no adverse effect on surgery.

[Idiopathic thrombocytopenic purpura during chemotherapy for liver metastasis of rectal cancer]

Neoadjuavnt chemotherapy for liver metastasis of colorectal cancer implies issues about timing for resection and management for adverse events due to chemotherapy.

CASE

A 50-year-old male patient with synchronous liver metastasis from rectal cancer had a surgery for primary lesion followed by neo-adjuvant chemotherapy for liver resection. Chemotherapy of bevacizumab + mFOLFOX6 achieved a partial response for liver metastasis. When we planned a liver resection, platelet count decreased to 1.4 × 10(4)/µL. The patient was diagnosed as idiopathic thrombocytopenic purpura (ITP) by several examinations but medical control including steroids failed. Partial splenic artery embolization could recover platelet count successfully. However, during the period of therapy for ITP, liver metastasis became unresectable. The patient is currently treated by FOLFIRI and with stable disease for three months.

CONCLUSION

NeoPyloriadjuvant chemotherapy for respectable liver metastasis should be considered carefully in terms of timing for resection and prompt management for adverse events.

Ion channels in sperm motility and capacitation

Spermatozoa depend upon ion channels to rapidly exchange information with the outside world and to fertilise the egg. These efficient ion transporters participate in many of the most important sperm processes, such as motility and capacitation. It is well known that sperm swimming is regulated by [Ca2+]i. In the sea urchin sperm speract, a decapeptide isolated from egg outer envelope, induces changes in intracellular Ca2+ ([Ca2+]i), Na+, cAMP and cGMP, membrane potential (Em) and pH (pHi). Photoactivation of a speract analogue induces Ca2+ fluctuations that generate turns that are followed by straighter swimming paths. A fast component of the [Ca2+], increase that most likely occurs through voltage dependent Ca2+ channels (Ca(v)s) is essential for these turns. The Ca(v)s involved are modulated by the Em changes triggered by speract. On the other hand, mammalian sperm gain the ability to fertilise the egg after undergoing a series of physiological changes in the female tract. This maturational process, known as capacitation, encompasses increases in [Ca2+]i and pHi, as well as an Em hyperpolarization in mouse sperm. Our electrophysiological, immunological and molecular-biological experiments indicate that inwardly rectifying K+ channels regulated by ATP (KATP channels) and epithelial Na+ channels (ENaCs) are functionally present in mouse spermatogenic cells and sperm. Notably, pharmacological experiments indicate that the opening of KATP channels and closure of ENaCs may contribute to the hyperpolarization that accompanies mouse sperm capacitation. Remarkably, both in the sea urchin sperm speract response and in the mouse sperm capacitation, Em hyperpolarization seems necessary to remove inactivation from Ca(v) channels so they can then open.

Mutation analysis of the acid ceramidase gene in Japanese patients with Farber disease

Farber disease is a rare lysosomal storage disease, characterized by the accumulation of ceramide in tissues due to acid ceramidase deficiency. Here we report the identification of three novel mutations in the acid ceramidase gene from two Japanese patients. Patient 1 showed joint problems at around 10 months of age and the patient is now emaciated, with multiple nodules and mild neurological problems at 10 years of age. Patient 2 had consanguineous parents and showed joint contractures at around 8 months of age. He showed neurological symptoms around 2 years of age and died at 6 years owing to respiratory failure. The diagnosis was made clinically and was confirmed by enzymatic assay of acid ceramidase. Molecular analysis of cultured skin fibroblasts showed normal mRNA levels expressed in both patients. By direct sequencing of cDNA, missense mutations of V97E in exon 4 and G235R in exon 9 were detected in patient 1 and 96delV in exon 4 was homozygously identified in patient 2. These mutations were also confirmed in genomic DNA. Expression of mutated acid ceramidase cDNA in COS-1 cells showed acid ceramidase activity decreased to 35%, 2% and 37% of control value, respectively. We also found a new polymorphism V3691 in exon 14 in the allele from the mother of patient 1. To date, 13 mutations, including our newly identified mutations, have been reported. All these mutations were genetically private and genotype-phenotype correlations could not be made.

Ion transport in sperm signaling

Ion channels and transporters, key elements in sperm-egg signaling and environmental sensing, are essential for fertilization. External cues and components from the outer envelopes of the egg influence sperm ion permeability and behavior. Combining in vivo measurements of membrane potential, intracellular ions, and second messengers with new molecular approaches and reconstitution strategies are revealing how sperm ion channels participate in motility, sperm maturation, and the acrosome reaction. Sperm are tiny differentiated terminal cells unable to synthesize proteins and difficult to characterize electrophysiologically. Spermatogenic cells, the progenitors of sperm, have become useful tools for probing sperm ion channels since they are larger and molecular biology techniques can be applied. These complementary strategies are opening new avenues to determine how sperm ion channels function in gamete signaling.

Time-resolved sperm responses to an egg peptide measured by stopped-flow fluorometry

Speract, a decapeptide from sea urchin egg jelly, induces various sperm responses. Stopped-flow fluorometry was used to examine the binding of labeled speract and the intracellular changes in pH (pH(i)) and Ca2+ ([Ca2+]i) it induces in sperm. We observed significant time delays for the increase in pH(i) and [Ca2+]i induced by 200 nM speract (69 and 190 ms, respectively). Also, we found that the receptor undergoes a pH(i)-dependent affinity change at around 129 ms. These time delays probably reflect biochemical processes underlying each sperm response to speract that circumscribe the time sequence of the signaling events.

SSCP analysis by RT-PCR for the prenatal diagnosis of Niemann-Pick disease type C

The molecular prenatal diagnosis of Niemann-Pick disease type C (NPC) is presented. The proband with a late infantile type of NPC was a compound heterozygote of a paternal missense mutation, T529G, and a maternal 2 bp deletion at nt 350 of the NPC1 gene. These mutations were detected by single-strand conformation polymorphism (SSCP) analysis of RT-PCR products. When the proband was aged 4 years 3 months, prenatal diagnosis for the second child was performed using both biochemical and molecular methods. SSCP analysis for the parental mutations using cDNA from cultured amniotic fluid cells revealed the absence of both mutations and the fetus was diagnosed as being unaffected. This diagnosis was supported by a normal level of cholesterol esterification using cultured amniotic fluid cells. After the child's birth, when he was 21 months old, the diagnosis was confirmed by SSCP analysis of genomic DNAs of his family. This analysis also revealed a unique variation of intron 13, IVS13+753-758 del TTTTTT, that was shared only by the proband and the father, and was suspected as being linked to the T529G missense mutation. A combination of both biochemical and molecular analyses is very useful and reliable for prenatal diagnosis of Niemann-Pick disease type C.