A case of incarcerated femoral hernia with intestinal blood flow assessment by brightfield full-color near-infrared fluorescence camera: Report of a case

•

We report the case of a patient with incarcerated obturator femoral hernia.

•

The intestinal blood flow was evaluated by Indocyanine green (ICG) fluorescence.

•

The bowel could be preserved after intraoperative evaluation of intestinal blood flow.

•

PINPOINT, a brightfield color fluorescence camera was used for ICG fluorescence.

Introduction

Indocyanine green (ICG) fluorescence has been reported for examining intestinal blood flow (IBF), but not in the case of bowel released from entrapment in a femoral hernia. We report the case of a patient with incarcerated obturator femoral hernia in whom the bowel was preserved after evaluation of IBF with ICG fluorescence using a brightfield full-color near-infrared fluorescence camera.

Presentation of case

A woman in her 60s was diagnosed with incarcerated femoral hernia and underwent surgery. Laparotomy was performed to reduce bowel incarceration via an anterior approach. The small bowel showed deep-red discoloration on gross evaluation, but intravenous injection of ICG revealed uniform fluorescence of the mesentery and bowel wall. This indicated an absence of irreversible ischemic changes to the bowel, so resection was not performed and a modified Kugel herniorrhaphy was performed. The patient showed a good postoperative course.

Conclusion

In herniorrhaphy with mesh, minimization of bowel resection is important for preventing postoperative infection of the mesh. In this case, ICG fluorescence with a near-infrared fluorescence camera was central to reducing bowel resection.

ICG fluorescence may be useful for evaluating IBF in surgery for incarcerated femoral hernias.

An in vivo screening system to identify tumorigenic genes

Screening for oncogenes has mostly been performed by in vitro transformation assays. However, some oncogenes might not exhibit their transforming activities in vitro unless putative essential factors from in vivo microenvironments are adequately supplied. Here, we have developed an in vivo screening system that evaluates the tumorigenicity of target genes. This system uses a retroviral high-efficiency gene transfer technique, a large collection of human cDNA clones corresponding to ~70% of human genes and a luciferase-expressing immortalized mouse mammary epithelial cell line (NMuMG-luc). From 845 genes that were highly expressed in human breast cancer cell lines, we focused on 205 genes encoding membrane proteins and/or kinases as that had the greater possibility of being oncogenes or drug targets. The 205 genes were divided into five subgroups, each containing 34-43 genes, and then introduced them into NMuMG-luc cells. These cells were subcutaneously injected into nude mice and monitored for tumor development by in vivo imaging. Tumors were observed in three subgroups. Using DNA microarray analyses and individual tumorigenic assays, we found that three genes, ADORA2B, PRKACB and LPAR3, were tumorigenic. ADORA2B and LPAR3 encode G-protein-coupled receptors and PRKACB encodes a protein kinase A catalytic subunit. Cells overexpressing ADORA2B, LPAR3 or PRKACB did not show transforming phenotypes in vitro, suggesting that transformation by these genes requires in vivo microenvironments. In addition, several clinical data sets, including one for breast cancer, showed that the expression of these genes correlated with lower overall survival rate.

Stomaplasty with pannicuectomy in an obese patient with stomal retraction: A case report

INTRODUCTION

Stomal retraction is a common complication following stoma formation. A repeat surgical procedure for stomal revision is an invasive treatment that is often required as a result.

CASE PRESENTATION

An 81-year-old woman with obstructive rectal carcinoma and perforative peritonitis underwent an emergent anterior resection and colostomy (Hartmann's operation). After the operation, the patient changed the stoma pouch every day because of stomal retraction and leakage. Thirty-eight days after the operation, we performed a stomaplasty with pannicuectomy. Following this procedure, the patient changed the stoma pouch twice weekly.

DISCUSSION

Stomal retraction is caused by the thick subcutaneous fat and abnormal skin folds in obese patients, as well as the excess tension that is the result of inadequate mobilization. Treatment of stomal retraction typically requires an intraperitoneal stoma revision. Our method of panniculectomy with skin excision but without stomal revision does not involve an incision around the stoma and there is no risk of fecal contamination.

CONCLUSION

We report a case of an obese patient who underwent stomaplasty with pannicuectomy for stomal retraction. We believe that stomaplasty with pannicuectomy is a feasible option in obese patients with stomal retraction.

Spontaneous breast cancer remission: A case report

•

Spontaneous cancer remission without treatment is a known phenomenon with various types of cancer.

•

Although spontaneous breast cancer remission has been thought to be a rare, this may occurs at a certain rate(not rare phenomenon).

•

When cancer was not detected in the pathological specimen and there were no known biological markers to provide information for the decision regarding adjuvant therapy, observation without further treatment can be option.

Introduction

Spontaneous breast cancer remission is a rare phenomenon. We report the disappearance from the remaining breast of a new primary carcinoma that had been confirmed through cytology of a pathological specimen, in a case that is strongly suspected to be spontaneous remission.

Presentation of case

A 44-year-old woman underwent breast-conserving surgery for a tumor located on the border between the upper-outer and lower-outer quadrants of the left breast (T2, N1, M0; Stage IIB). Eleven years after surgery, computed tomography indicated a mass in the upper-inner quadrant of the left breast. Excisional biopsy was initially planned for treatment following the definitive diagnosis because cytology revealed malignancy. The patient had noticed tumor regression one month after fine-needle aspiration and repeat ultrasonography performed the day before excisional biopsy confirmed the tumor reduction. On pathological examination, no tumor cells were observed in the mass.

Discussion

There was a discrepancy between FNA cytology and pathological diagnosis in our patient. The cytological findings indicated malignancy, but the pathological findings did not. When a tumor’s pathological diagnosis is not malignant even though its FNA cytology diagnosis was malignant, sampling error, cytological over-diagnosis or some other error may have occurred. In this case, however, these were not detected. Because fibrosis was visible on pathological examination, we believe that these events corresponded to spontaneous remission.

Conclusion

We report a rare case of spontaneous remission in which the cancer disappeared on pathological examination although the cytological diagnosis had been malignant.

Development of myelofibrosis during eltrombopag treatment in a patient with immune thrombocytopenia

Eltrombopag, a thrombopoietin (TPO) receptor agonist, is effective for treating refractory immune thrombocytopenia (ITP). However, the development of bone marrow fibrosis is a concern. A 78-year-old man was diagnosed with ITP in 2004. His platelet count did not increase after eltrombopag treatment initiation in 2014. However, anemia progressed, along with the presence of immature myelocytes, erythroblasts, and tear drop cells. At 8 months after initiating eltrombopag treatment, the patient underwent a bone marrow biopsy that showed grade 2 myelofibrosis. Hence, eltrombopag was discontinued. In our experience with this case indicates that careful observation is required while using TPO receptor agonists.

Impact of body mass index on postoperative complications and long-term survival in patients with esophageal squamous cell cancer

Undernutrition and cachexia have been suggested to be risk factors for postoperative complications and survival in cancer patients. The aim of this study was to investigate whether body mass index (BMI) is related to the short-term and long-term outcomes in patients who undergo an esophagectomy for the resection of esophageal squamous cell cancer (ESCC). Three hundred forty patients who underwent an esophagectomy for the resection of ESCC between 2003 and 2008 were retrospectively reviewed. The patients were divided into two groups: an L-BMI group characterized by a BMI < 18.5 kg/m(2) and an N-BMI group characterized by a BMI ≥ 18.5 kg/m(2). Clinical and pathological outcome were compared between groups. The study included 40 patients in the L-BMI group and 300 patients in the N-BMI group. A clinicopathological assessment showed that nodal involvement was seen more frequently in the L-BMI group (P = 0.016). Pulmonary complications seemed to occur more frequently in the L-BMI group (P = 0.006). The 5-year overall survival rate was higher in the N-BMI group (63.6%) than in the L-BMI group (32.3%) (P < 0.001). The 5-year disease-free survival rate was also higher in the N-BMI group (58.0%) than in the L-BMI group (33.6%) (P = 0.001). In multivariate analysis, the BMI (hazard ratio, 2.154; 95% CI, 1.349-3.440, P = 0.001) was found to be an independent prognostic factor for overall survival. Our data suggested that a lower BMI not only increased pulmonary complications but also impaired overall and disease-free survival after an esophagectomy for the resection of ESCC.

New technique for treating abdominal surgical site infection using CT woundgraphy and NPWT: A case report

•

Negative pressure wound therapy for abdominal surgical site infection is effective, but we should take steps to avoid enterocutaneous fistula.

•

Separation of the wound from the intestine is important in preventing enterocutaneous fistula.

•

CT woundgraphy can be used to evaluate the distance by which the wound and intestine are separated.

Introduction

Negative pressure wound therapy (NPWT) for abdominal surgical site infection (SSI) is becoming increasingly common, although enterocutaneous fistula (ECF) has been reported as a complication. To avoid ECF, we used computed tomography (CT) woundgraphy to evaluate the relationship between the wound and the intestine, and then safely treated the abdominal SSI with NPWT.

Case presentation

Following a laparoscopic intersphincteric resection for low rectal neuroendocrine tumor and covering ileostomy, a 59-year-old woman underwent stoma closure. Six days after surgery, we diagnosed SSI. We suspected ECF, because the wound was deep and the pus resembled enteric fluid. However, CT woundgraphy showed that the wound was separated from the abdominal cavity and the intestine by the abdominal rectus muscle. Accordingly, we performed NPWT. SSI was cured and the wound was well granulated. Twenty-three days after surgery, the patient was discharged. Eventually, the wound was completely epithelialized.

Discussion

Although successful NPWT has been reported for open abdominal wounds, ECF is a common complication. ECF can be prevented by separating the wound from the intestine by the omentum or muscle fascia, protecting the intestinal serosa during surgery, and applying low vacuum pressure. The relationships among the wound, the fascia, and the intestine must be evaluated before abdominal SSI treatment. One good method is CT woundgraphy, which evaluates wound extent and depth, closure of muscle fascia, and the relationship between the wound and the intestine.

Conclusion

We report a case of CT woundgraphy before NPWT for abdominal SSI. CT woundgraphy is a good candidate for evaluating wound condition.

Percutaneous endoscopic sigmoidopexy for sigmoid volvulus: A case report

INTRODUCTION

Sigmoid volvulus often recurs and it is controversial whether preventive surgery should be performed in recurrent cases, especially in elderly and high-risk cases. Herein, we report a case of successful endoscopic sigmoidopexy using fixation to the abdominal wall.

CASE PRESENTATION

The patient was an 86-year-old woman with multiple system atrophy, cerebral infarction, and disuse syndrome. She was admitted to our hospital with a recurrent sigmoid volvulus. Since surgery was considered high-risk, percutaneous endoscopic sigmoidopexy with fixation to the abdominal wall was indicated.

DISCUSSION

Percutaneous endoscopic sigmoidopexy was performed for this high-risk case with recurrent sigmoid volvulus. This procedure is advantageous in that suture removal is not necessary because the fixation sutures are buried subcutaneously. Reviewing the relevant literature, we believe that this is the first case of percutaneous endoscopic sigmoidopexy using abdominal wall fixation with buried sutures.

CONCLUSION

Although further experience is necessary, percutaneous endoscopic sigmoidopexy may be an acceptable treatment for recurrent sigmoid volvulus in high-risk patients.

A case of mediastinal goiter treated surgically using a clavicle-lifting technique

•

A thyroidectomy is indicated in all cases of mediastinal goiter because of the risks of airway obstruction, potential malignancy, tracheomalacia and invasion into the adjacent structures.

•

The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan).

•

The clavicle-lifting technique is a good surgical option for upper-mediastinal lesions such as mediastinal goiters and it obviates the need for a sternotomy.

Introduction

Mediastinal goiter is a benign disease, which is defined as a goiter with the greater portion of its mass lying below the thoracic inlet. It is controversial whether the cervical approach is the best approach for all mediastinal goiter surgeries.

Case presentation

A 71-year-old woman presented with respiratory discomfort during exertion. Computed tomography (CT) revealed a mediastinal goiter extending to the arch of the aorta. Surgical resection was performed using a clavicle-lifting technique. The excised specimen was 13 × 10 × 5 cm in size and weighed 220 g. The pathological diagnosis was nodular goiter.

Discussion

The clavicle-lifting technique is a simple and safe technique that involves lifting the clavicles with a pediatric extension retractor (Kent Retractor Set, Takasago Medical Industry, Tokyo, Japan). This is a good choice for surgery on upper mediastinal lesions such as mediastinal goiters as it obviates the need for a median sternotomy.

Conclusion

Although further study is necessary, it appears that a transcervical approach using the clavicle-lifting technique may be an acceptable treatment for mediastinal goiters that extend to the aortic arch.

Deployment Accuracy of the Conformable GORE(®) TAG(®) Thoracic Endoprosthesis in the Treatment of Zones 2 and 3 Aortic Arch Aneurysms Compared with the Previous TAG(®)

PURPOSES

When placing stent grafts, deployment accuracy and birdbeaking due to inadequate conformability and device apposition along the inner curvature of the arch have been encountered. The new Conformable GORE® TAG® Thoracic Endoprosthesis (CTAG) is designed to have enhanced compression resistance and improved conformability in difficult anatomy. The present study compared the deployment accuracy and conformability of the CTAG Device with TAG Device.

METHOD

Deployment accuracy and birdbeaking was compared of CTAG Device and TAG Device implantation for initial treatment of thoracic aortic aneurysm conducted by our department between March 2010 and March 2012. Deployment accuracy was defined as the distance between the actual and intended device implantation locations measured from DSA images.

RESULTS

Deployment accuracy at the time of implantation (mean ± SD) was significantly better for the CTAG Device compared to the TAG Device (2.2 ± 1.7 mm vs. 4.4 ± 3.0 mm, P <0.05). Also, while birdbeaking was seen in 8 of 20 cases (40%) for the TAG Device, it was only seen in 1 of 12 cases (8%) for the CTAG Device.

CONCLUSION

The present study found enhanced deployment accuracy and conformability along the aortic arch using the CTAG Device compared to the previous-generation TAG Device.

Gastric Carcinoma: Ex Vivo MR Imaging at 7.0 T-Correlation with Histopathologic Findings

PURPOSE

To determine the imaging detail and diagnostic information that can be obtained at 7.0-T magnetic resonance (MR) imaging with a voxel volume of 9.5-14.0 nL as a means of evaluating the depth of mural invasion by gastric carcinomas ex vivo.

MATERIALS AND METHODS

This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty gastric specimens containing 20 carcinomas were studied with a 7.0-T MR imaging system equipped with a four-channel surface coil. MR images were obtained with a 50-60 × 25-30 mm field of view, a 512 × 256 matrix, and a 1.0-mm section thickness, resulting in a voxel volume of 0.0095-0.0140 mm(3) (9.5-14.0 nL). The signal intensity of the gastric wall layers, tumor tissue, and fibrosis was described as low, intermediate, or high by comparing it with the signal intensity of the muscularis propria. Depth of invasion initially was assessed by two reviewers independently and then by the two reviewers in consensus. MR images were compared with histopathologic findings.

RESULTS

The 7.0-T T2-weighted MR images clearly depicted the normal gastric wall in all 20 specimens (100%) as consisting of seven layers, which clearly corresponded to the tissue layers of the gastric wall. These MR images enabled clear differentiation between tumor tissue and fibrosis. Reviewers disagreed on the depth of invasion at the initial reading in three (15%) of 20 specimens (between mucosa and submucosa in two specimens and between muscularis propria and subserosa and serosa in one specimen); however, in all 20 gastric carcinomas, the depth of invasion could be accurately determined on T2-weighted images after consensus interpretation.

CONCLUSION

Ex vivo 7.0-T MR imaging enables clear delineation of the gastric wall layers and clear differentiation of tumor tissue from fibrosis and allows one to assess the depth of mural invasion by gastric carcinomas.

Apparent diffusion coefficient value as a biomarker reflecting morphological and biological features of prostate cancer

PURPOSE

To assess whether there is an association between the apparent diffusion coefficient (ADC) value and the pathological characteristics of prostate cancer.

METHODS

The study cohort consisted of 29 consecutive patients with prostate cancer treated with radical prostatectomy. All patients underwent diffusion-weighted MRI before the prostate biopsy. In 42 tumor foci, the associations of the ADC values with the clinicopathological characteristics and Ki-67 labeling index (LI) were analyzed.

RESULTS

High-grade cancers (Gleason score [GS] ≥ 4 + 3), larger cancers (maximum diameter (MD) ≥ 16 mm), and highly proliferating cancers (Ki-67 LI ≥ 4.43 %) had significantly lower ADC values, respectively (P < .001, P = .008, and P = .044, respectively). There was no significant difference in ADC value according to age, prostate-specific antigen, presence of extra-prostatic extension, and intra-tumoral stroma proportion. Multivariate analysis showed that GS, Ki-67 LI, and MD had independent and significant correlations with ADC value (P < .001, P = .006, and P = .002, respectively). Low ADC tumors (<0.52 × 10(-3) mm(2)/s) are likely to be high-grade cancer foci compared with high ADC tumors (relative risk: 65.2). The sensitivity and specificity of the ADC value to predict high-grade cancer foci are 81.8 and 93.5 %, respectively.

CONCLUSIONS

A low ADC value reflects the morphological and biological features of prostate cancer. Analyzing the ADC value may make it possible to more precisely predict the cancer aggressiveness of each focus before treatment.

[A case of long-term survival without recurrence from an unknown primary carcinoma after resection of lymph node metastases]

A 76-year-old woman was diagnosed with intraabdominal tumors at a regular medical check-up. The tumors were resected and were identified as number 8a and 3 lymph nodes with adenocarcinoma. No primary was identified despite various studies; the final diagnosis was of adenocarcinoma of unknown primary. No recurrence developed; the patient has survived for 5 years without postoperative chemotherapy. The patient was disease-free 5 years after diagnosis. To the best of our knowledge, this is the first report of long-term survival of number 8a and 3 lymph node metastasis from an unknown primary carcinoma.

Clinicopathological significance of laminin-5γ2 chain expression in superficial esophageal cancer

The glycoprotein laminin 5γ2 chain (LN-5γ2) has recently become a focus of increased interest and investigation as a marker of invasion in gastrointestinal malignancies. We investigated the significance of LN-5γ2 expression as a prognostic factor in superficial esophageal cancer. The study population consisted of 87 patients who had undergone a transthoracic esophagectomy and three-field lymphadenectomy for the treatment of superficial esophageal cancer at Tokai University Hospital. Formalin-fixed, paraffin-embedded sections of the resected specimens were examined using immunohistochemical staining and hematoxylin and eosin staining to assess the correlations between the LN-5γ2 expression pattern and the clinicopathological factors (age, sex, T-factor, N-factor, ly-factor, v-factor, degree of differentiation, infiltrative growth pattern, tumor node metastasis classification of malignant tumors [TNM] stage, etc.) and the patient outcome. The expression pattern of LN-5γ2 was classified into an extracellular type (E type), characterized by the staining of extracellular matrix such as the basement membrane and the stroma (31 cases, 35.6%), and a cytoplasmic type (C type), characterized by the staining of the cytoplasm in the cancer cells (56 cases, 64.6%). The expression pattern was not correlated with any of the clinicopathological factors that were assessed. However, univariate analyses of the survival analysis data showed that the N-factor (P = 0.011), TNM stage (P = 0.011), and LN-5γ2 C type (P = 0.017) were prognostic factors. A multivariate analysis revealed that the N-factor (P = 0.049) and LN-5γ2 C type (P = 0.048) were prognostic factors. In the survival analysis, a univariate analysis of the 75 T1b cases also showed that the N-factor (P = 0.048), TNM stage (P = 0.048), and LN-5γ2 C type (P = 0.029) were prognostic factors, while a multivariate analysis showed that the LN-5γ2 C type (P = 0.035) was a prognostic factor. The C type expression of LN-5γ2, i.e. confined to the cytoplasm, was correlated with an unfavorable outcome among the patients with superficial esophageal cancer in the present series. Observation of the LN-5γ2 expression pattern may be useful for the diagnosis of highly malignant tumors.

Effect of eculizumab and recombinant human soluble thrombomodulin combination therapy in a 7-year-old girl with atypical hemolytic uremic syndrome due to anti-factor H autoantibodies

Atypical hemolytic uremic syndrome (aHUS), which is defined as non-Shiga toxin-associated hemolytic uremic syndrome, is a type of thrombotic microangiopathy. This syndrome presents with hemolytic anemia, thrombocytopenia, and acute kidney injury. Excessive complement activation due to genetic disorders of the complement system or production of autoantibodies to factor H (FH) causes the disease. We report a successful treatment course using eculizumab and recombinant human soluble thrombomodulin (rTMD) for a 7-year-old girl with aHUS due to anti-FH autoantibodies. Although her chief complaints were abdominal pain and loose stools, we were finally able to diagnose her with aHUS because Shiga toxin-producing Escherichia coli was not detected in her feces and a hemolytic assay analyzing FH function was positive. We administrated rTMD to our patient because of signs of disseminated intravascular coagulation. Soon after the therapeutic intervention, the platelet count began to increase and abdominal pain was moderately improved. Plasma exchange limited the efficacy of her disease. Therefore, we administered eculizumab, monoclonal humanized antibody against C5, 3 weeks after admission. Platelet counts immediately increased and kidney function gradually recovered. Genetic disorders were not detected. However, anti-FH autoantibody was observed. There were no symptoms for recurrence of aHUS or kidney dysfunction for 15 months, as a result of the administration of eculizumab every other week. In conclusion, combination therapy of eculizumab and rTMD was effective for an aHUS patient. This therapy may be helpful for improving the prognosis and long-term kidney function of aHUS patients.

Esophageal carcinoma: ex vivo evaluation with diffusion-tensor MR imaging and tractography at 7 T

PURPOSE

To determine the feasibility of diffusion-tensor magnetic resonance (MR) imaging and tractography as a means of evaluating the depth of mural invasion by esophageal carcinomas.

MATERIALS AND METHODS

This study was approved by the institutional review board, and written informed consent was obtained from each patient. Twenty esophageal specimens, each containing a carcinoma, were studied with a 7.0-T MR imaging system equipped with a four-channel phased-array surface coil. Diffusion-tensor MR images were obtained with a field of view of 50-60 mm × 25-30 mm, matrix of 256 × 128, section thickness of 1 mm, b value of 1000 sec/mm(2), and motion-probing gradient in seven noncollinear directions. The MR images were compared with the histopathologic findings as the reference standard. The differences in diffusion-tensor MR imaging parameters between the carcinoma and the layers of the esophageal wall were statistically analyzed by using the Dunnett test.

RESULTS

In all 20 carcinomas (100%), the diffusion-weighted images, apparent diffusion coefficient (ADC) maps, fractional anisotropy (FA) maps, λ1 maps, and direction-encoded color FA maps made it possible to determine the depth of tumor invasion of the esophageal wall that was observed during histopathologic examination. The λ1 maps showed the best contrast between the carcinomas and the layers of the esophageal wall. The carcinomas had both lower ADC values and lower FA values than the normal esophageal wall; thus, the carcinomas were clearly demarcated from the normal esophageal wall. Diffusion-tensor tractography images were also useful for determining the depth of tumor invasion of the esophageal wall.

CONCLUSION

Diffusion-tensor MR imaging and tractography are feasible in esophageal specimens and provide excellent morphologic data for the evaluation of mural invasion by esophageal carcinomas.