Successful conversion surgery for unresectable pancreatic cancer with peritoneal metastases after neoadjuvant albumin-bound paclitaxel and gemcitabine chemotherapy: case report and literature review

We report a case in which combination therapy with albumin-bound paclitaxel (nab-paclitaxel) and gemcitabine converted unresectable pancreatic cancer with peritoneal metastases into resectable disease. The patient was a 71-year-old woman with anorexia. Enhanced abdominal computed tomography (CT) showed an atrophic pancreatic body and tail, dilated main pancreatic duct, peritoneal dissemination, portal vein stricture, bile duct stricture and wall thickening, and blockage of the right ureter. She was diagnosed with pancreatic cancer with peritoneal metastases. Curative resection was initially impossible. Combination therapy consisting of nab-paclitaxel and gemcitabine was initiated. The regimen consisted of 28-day cycles of albumin-bound paclitaxel (nab-paclitaxel) (125 mg/m² intravenously over 30 min on days 1, 8, 15) and gemcitabine (1000 mg/m² intravenously over 30 min on days 1, 8, 15). After 8 cycles of chemotherapy, enhanced CT showed no evidence of the tumor in the pancreatic body and tail or peritoneal metastases. Positron emission tomography with CT (PET-CT) showed no abnormal fluorodeoxyglucose uptake. After pre-operative chemotherapy for 8 months, the patient was underwent distal pancreatectomy with resection of soft tissue that corresponded to the right ureteral tumor seen on enhanced CT. This case showed that chemotherapy consisting of nab-paclitaxel and gemcitabine can be well-tolerated and can convert unresectable pancreatic cancer with peritoneal metastases into resectable disease.

[A Case of Long-Term Survival of Recurrent Bile Duct Cancer with Peritoneal Metastasis Successfully Treated with Surgical Resection]

We report a case of peritoneal metastasis of bile duct cancer that was successfully treated by surgical resection. A 70s man underwent pancreatoduodenectomy(PD)for bile duct cancer, and abdominal CT revealed a tumor in the peritoneum along the right kidney at 55 months after PD. As FDG uptake was seen at the lesion on PET-CT, he was diagnosed as recurrence of bile duct cancer or primary malignant tumor in the retroperitoneum. Because the tumor was solitary on CT and PET-CT, we conducted surgical resection of the tumor. Pathological diagnosis was well differentiated adenocarcinoma that was similar to the primary lesion, and the tumor was confirmed as recurrence of bile duct cancer. He remains alive without 2nd recurrence for 60 months since tumor resection(117 months since PD).

[A Case of Duodenum Neuroendocrine Tumor with Multiple Liver Metastasis Treated with Multimodal Therapy]

The patient is a 65-year-old woman with anemia. The multiple liver tumors detected by ultrasonography, it was diagnosed as neuroendocrine tumor(NET), G2 by biopsy. There was an ulcer at the bulb of the duodenum, so we diagnosed liver metastasis of duodenum NET. Because the liver tumors spreaded to both right and left lobes, we carrying out a transcatheter arterial embolization(TAE)twice to liver metastasis, and chemotherapy by octreotide was performed. 20 months after the beginning of treatment, a 4 cm tumor was remained in the left lobe but others were not detected by computed tomography, so we performed cytoreductive surgery. Duodenum bulb resection and left hepatectomy was performed and the specimens were NET, G2 in the pathological findings. We detected a lot of tumors less than 1 cm in the right lobe during the operation, so TAE was carried out for the right lobe after surgery. The disease showed no progression for 28 months after the first admission(post operation5 months).

[Gastrectomy with Intra-Aortic Balloon Pumping Support for a Hemorrhagic Advanced Gastric Cancer Patient with Severe Coronary Stenosis]

Here we report a case of a hemorrhagic gastric cancer patient with severe coronary artery disease, in whom the cancer was successfully resected with the support of intra-aortic balloon pumping(IABP). An 80-year-old man was referred to our hospital for further examination of his anemia and tumor around the pancreatic head. He was diagnosed with type 3 gastric cancer with multiple bulky lymph node metastases invadingto the pancreas(cT4b[LN-Panc], N3a, M1[LYM No.16a2int], cStage IV ). Tarry stools continued and blood transfusion was repeatedly required. To control tumor bleeding, we considered that gastrectomy should be performed prior to chemotherapy. Since he had a history of acute myocardial infarction, coronary angiography was performed, which showed severe coronary stenosis in 3 vessels. Preoperative percutaneous coronary intervention or coronary artery bypass grafting were inappropriate because of tumor bleeding. We performed palliative distal gastrectomy under the support of IABP. The postoperative course was uneventful and he could initiate subsequent chemotherapy smoothly. IABP may be a useful option for hemorrhagic gastric cancer patients with severe coronary stenosis.

[A Case of Anal Canal Cancer with Skin Invasion to Which Abdominoperineal Resection and Perineum Reconstruction Were Performed after Neoadjuvant Chemoradiotherapy]

A 74-year-old man visited our hospital with an awareness of anal mass and bleeding. He was diagnosed as adenocarcino- ma of anal canal with wide spreading skin invasion. After neoadjuvant chemoradiotherapy(radiationtotal 45 Gy/25 Fr; cape- citabine 825mg/m2)was performed to reduce the mass volume, laparoscopic abdominoperineal resection with large perineum skin resection and lateral lymph node dissection was carried out. The perineal defect was repaired with a rectus abdominis musculocutaneous flap. Six days after surgery, the rectus abdominis musculocutaneous flap necrotized, and second perineum reconstruction by the bilateral gracilis musculocutaneous flaps was performed after debridement of necrotic tissue. We reported a case of radical resection of local advanced anal canal cancer with skin invasion by performing combined modality therapy and perineum reconstruction.

Decalcification of a Heavily Calcified Common Femoral Artery and its Bifurcation with a Cavitron Ultrasonic Surgical Aspirator

Introduction

Surgical endarterectomy is the preferred method for treating occlusive disease of the common femoral artery (CFA). However, endarterectomy is not always straightforward in cases with heavily calcified plaque. To overcome this limitation, a new method for decalcification, which utilizes a Cavitron ultrasonic surgical aspirator (CUSA) has been developed.

Report

The method involves full exposure of the calcified lesion. Following an arteriotomy, protruding calcification is removed using the CUSA, taking care to avoid vessel perforation. Preservation of the medial calcified layer can be accomplished by the accurate control provided by the device, which enables smooth termination in the distal area of the normal wall and does not require a tacking suture. A total of 12 patients underwent decalcification of 13 common femoral artery (CFA) lesions using CUSA with vein patch angioplasty. Concomitant profundaplasty was performed in five cases. The only intra-operative complication was perforation of the arterial wall in one patient, while another had a wound infection that required reintervention.

Discussion

Decalcification of a heavily calcified CFA with CUSA appears to be feasible, although long-term follow-up examinations are warranted.

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Surgical endarterectomy for a heavily calcified common femoral artery and its bifurcation can be challenging.

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The authors have developed a new method for decalcification that utilizes a Cavitron ultrasonic surgical aspirator.

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An important advantage of this procedure is that there is no need for tacking sutures.

Endoscopic Cytology for the Diagnosis of Chronic Enteritis and Intestinal Lymphoma in Dogs

Although cytology is a rapid diagnostic procedure in dogs, the cytologic criteria of endoscopic biopsies for chronic enteritis and intestinal lymphoma are not well defined. An immediate diagnosis using cytology would benefit patients by enabling prompt initiation of therapy. The objective of this study was to investigate the correlation between the results of endoscopic cytology and histopathology. In this study, 167 dogs with clinical signs of chronic gastrointestinal disease were included. On the basis of histopathology, the following diagnoses were determined: lymphocytic-plasmacytic enteritis in 93 dogs; eosinophilic enteritis in 5 dogs; small cell intestinal lymphoma in 45 dogs; and large cell intestinal lymphoma in 24 dogs. Two clinical pathologists retrospectively evaluated the endoscopic cytology of squash-smear preparations. The cytologic diagnoses of inflammation, small cell lymphoma, and large cell lymphoma were based on the severity of lymphocyte infiltration, the size of infiltrated lymphocytes, and eosinophil/mast cell infiltration. The clinical severity score was significantly increased along with the degree of lymphocyte infiltration evaluated by cytology. The cytologic diagnosis was in complete agreement with the histopathologic diagnosis in 136 of 167 (81.4%) cases. For the differentiation between enteritis and lymphoma, endoscopic cytology had a sensitivity of 98.6%, a specificity of 73.5%, a positive predictive value of 72.3%, and a negative predictive value of 98.6%. The log-rank test and Cox regression analysis showed that the results of cytology predicted the prognosis. These results suggest that endoscopic cytology is a useful technique to aid diagnosis of intestinal inflammation and lymphoma in dogs.

Prognostic impact of nodal statuses in patients with pancreatic ductal adenocarcinoma

BACKGROUND

The present study aimed to clarify the prognostic impact of nodal statuses in pancreatic ductal adenocarcinoma (PDAC) after potentially curative pancreatectomy.

METHODS

In 110 patients with >10 examined lymph nodes (ELNs), we investigated how nodal statuses were associated with postoperative survival. Nodal statuses included the number of positive LNs (PLNs); the ratio of PLNs to ELNs (lymph node ratio; LNR); and the location of regional LN metastases, classified as group one (peripancreatic area) and group 2 (outside the peripancreatic area). The maximum χ² value, provided by a Cox proportional hazards model, was used to determine the optimal cutoff value for the number of PLNs and the LNR.

RESULTS

The median numbers of ELNs and metastatic LNs were 33 and 2, respectively. Median survival was longer in patients with ≤3 PLNs (37.5 months), LNR <0.11 (36.1 months), and group 1 LN metastases (37.5 months) compared to in patients with ≥4 PLNs (23.7 months), LNR ≥0.11 (23.9 months), and group 2 LN metastases (22.8 months), respectively. Multivariate analyses revealed that all three investigated nodal statuses were independent factors associated with survival: HR of 2.38 and p = 0.0006 for the location of LN metastases, HR of 1.92 and p = 0.0071 for the number of PLNs, and HR of 1.89 and p = 0.010 for the LNR.

CONCLUSIONS

Three nodal statuses-the number of PLNs, the LNR, and the location of LN metastases-could stratify postoperative survival among PDAC patients with an adequate number of examined LNs after pancreatectomy.

Effects of Aerobic and Resistance Training Combined with Fortified Milk on Muscle Mass, Muscle Strength, and Physical Performance in Older Adults: A Randomized Controlled Trial

OBJECTIVES

Fortified milk and resistance training (RT) increase muscle mass, muscle strength, and physical performance in older adults, but it remains unclear whether RT combined with aerobic training (AT) would have stronger effects on these outcomes. The purpose of this study was to examine the effects of aerobic and resistance training (ART) combined with fortified milk consumption on muscle mass, muscle strength, and physical performance in older adults.

DESIGN

Open-labeled randomized controlled trial.

SETTING

University of Tsukuba.

PARTICIPANTS

Fifty-six older adults aged 65-79.

INTERVENTION

Participants were randomly allocated into resistance training (RT + fortified milk, n = 28) and aerobic and resistance training (ART + fortified milk, n = 28) groups. All participants attended supervised exercise programs twice a week at University of Tsukuba and ingested fortified milk every day for 12 weeks. Skeletal muscle index ([SMI]: appendicular lean mass/height2) was assessed using dual-energy X-ray absorptiometry as a muscle mass measure. One-repetition maximum strength was measured using four kinds of resistance training machines (chest press, leg extension, leg curl, and leg press) as muscle strength measures. Sit-to-stand and arm curl tests were also assessed as physical performance measures.

MEASUREMENTS

The primary measurements were muscle mass and strength. The secondary outcomes were physical performance, blood samples, habitual diet, habitual physical activity, and medication use.

RESULTS

Although the muscle strength and physical performance measures significantly improved in both groups, SMI significantly improved in only the RT group. There was no significant difference in the change in SMI and muscle strength measures between the two groups. However, the change in sit-to-stand and arm curl measures in the ART group were significantly higher than those in the RT group.

CONCLUSIONS

These results suggest that AT before RT combined with fortified milk consumption has similar effects on skeletal muscle mass and strength compared with RT alone, but it may be a more useful strategy to improve physical performance in older adults. Although the mechanism of our intervention is uncertain, our program would be an effective prevention for sarcopenia in older adults.

[A Case of Recurrent Esophagogastric Junction Cancer Responding to Trastuzumab]

We report a case of recurrent esophagogastric junction cancer successfully treated with chemotherapy including trastuzumab. A 66-year-old man reporting black stool was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Video-assisted thoracoscopic surgery of the esophagus with 3-field lymph node dissection was performed. The final diagnosis was adenocarcinoma(tub1-pap-muc), pT3N3M0, pStage III C. The tumor was at the squamo-columnar junction and classified as Siewert type II . Following surgery, 6 months of adjuvant therapy with S-1 was administered. Computed tomography(CT)confirmed metastases in the lung, liver, and recurrence in the reconstructed stomach. In spite of chemoradiotherapy(FP plus RT)and weekly PTX, these metastases had grown. Pathological examinationshowed overexpressionof humanepidermal growth factor receptor 2(HER2), and treatment with CPT- 11 plus trastuzumab was initiated at postoperative 15 months. A partial response was achieved 3 months later. The lesions in the lung, liver, and reconstructed stomach were controlled with this therapy, but he died from meningeal seeding at postoperative 20 months. These findings suggest that inclusion of trastuzumab in chemotherapy regimens is effective for recurrent HER2-positive esophagogastric junction cancers.

[A Case of Rectal Metastasis of Gastric Cancer Associated with Dermatomyositis]

We report a case of rectal metastasis of gastric cancer associated with dermatomyositis showing paraneoplastic syndrome. The patient was a 70-year-old man who had undergone curative total gastrectomy for Stage III Agastric cancer in March 2005. He was diagnosed with dermatomyositis and treated with prednisolone after gastrectomy. In April 2006, erythema of his face relapsed, and his serum CPK level was abnormally elevated. He experienced muscle weakness and dysphagia, and was treated with increased doses of prednisolone and gamma-globulin. At this time, endoscopic examination and computed tomography(CT)revealed a rectal tumor with hepatic metastasis. We performed Hartmann's operation in July 2006. The rectal tumor was predominantly submucosal, was 7 cm in diameter, involved #251 lymph node, and had positive peritoneal lavage cytology. The histopathological findings of the rectal tumor were comparable with those of gastric cancer, and we therefore diagnosed metastatic adenocarcinoma of gastric cancer. After surgery, we could control the patient's dermatomyositis with prednisolone at a reduced dose. However, chemotherapy with S-1 was ineffective and the patient died 8 months postoperatively.

[A Case of Duodenal Papilla Cancer 22 Years after Total Proctocolectomy for Familial Adenomatous Polyposis]

Familial adenomatous polyposis has an autosomal dominant pattern of inheritance. Colon cancer occurs frequently as a result of colorectal adenoma. The standard treatment is total proctocolectomy. However, it is reported that duodenal papilla cancer and desmoid tumors can also occur alongside colon cancer. We report a patient with duodenal papilla cancer who underwent total proctocolectomy 22 years previously. The patient was a 47-year-old man who had undergone a total proctocolectomy at the age of 25 years for familial adenomatous polyposis. On abdominal CT, duodenal papilla cancer that was suspected to be malignant was found. Using single-balloon enteroscopy, duodenal papilla cancer was diagnosed and pancreatoduodenectomy was performed. Seventeen months after surgery, liver and lung metastases were diagnosed. We began to provide palliative treatment, but the patient died 7 years 10 months after surgery.

[A Long-Term Survival Case of Hepatocellular Carcinoma with Lymph Node Metastasis Treated by Multidisciplinary Therapy]

We report a long-term survival case of hepatocellular carcinoma with lymph node metastasis that was successfully treated with multidisciplinary therapy. The patient was a 52-year-old man. He underwent right lobe liver resection with lymph node sampling at the hepatic portal section for hepatocellular carcinoma. Histopathological examination revealed hepatocellular carcinoma with lymph node metastasis. Residual liver recurrences were treated by transcatheter arterial chemoembolization and percutaneous ethanol injection therapy, and lymph node recurrences were treated by radiation therapy and lymph node dissection combined with systemic chemotherapy. The patient has been in good health without recurrence for 10 years and 9 months after the first surgery.

[A Patient with HER2-Positive Stage IV Advanced Gastric Cancer Who Received Chemotherapy with Trastuzumab plus XP Followed by Conversion Surgery]

A 68-year-old man presented with type 3 advanced gastric cancer(Circ, tub2>por, HER2 score 3)in the antrum, with skip lesions in the duodenum. The tumor was cT4aN2M1(DUO)CY0, cStage IV . An XP plus trastuzumab regimen(1,000mg/m2 capecitabine[Xeloda®]twice a day on days 1-14, 80mg/m2 CDDP on day 1, 8 mg/m2 trastuzumab on day 1[second course- 6mg/m2])was administered every 3 weeks and repeated for 6 courses without severe adverse events. After 6 courses, the primary tumor and metastatic lymph nodes shrank by 31.7%(a PR according to the RECISTcriteria ), and open distal gastrectomy, D3 lymphadenectomy, and Roux-en-Y reconstruction(ante colic)were performed as conversion surgery(R0). During the administration of adjuvant chemotherapy with S-1, para-aortic, mediastinum, left supraclavicular fossa, and cervical lymph node recurrence developed. Four courses of weekly PTX plus trastuzumab as first-line chemotherapy and 11 courses of biweekly CPT-11 plus CDDP as second-line chemotherapy were administered. Because of prolonged adverse events such as Grade 3 diarrhea, the patient refused continuation of chemotherapy. The patient died 24 months after the start of preoperative chemotherapy.

[A Case of GIST of the Stomach with Long-Term Survival after Multidisciplinary Treatment, Including Four Surgical Resections of Liver Metastases]

The most frequent relapse site of gastrointestinal stromal tumors(GIST)is the liver. We encountered a patient with longterm survival treated with multidisciplinary treatment, including4 hepatectomies for liver metastases. The patient was a woman aged 69 years at the time of the first medical treatment. She underwent total gastrectomy and S6 segmental hepatec- tomy for a stomach GIST with a hepatic metastasis. The tumor diameter was 24 cm and the mitotic figure was 65/50 HPF. According to the guidelines, it was diagnosed as a high risk GIST based on strong positive immunostaining for CD34 and c-kit. The tumor had metastasized to the liver and greater omentum. She took imatinib in the year following surgery. Because the GIST had spread to the lung1 8 months after the operation, she took imatinib again. Two years after the operation the pulmonary metastasis showed a clinical complete response(cCR)and the CR lasted for 4 years. Six years after the surgery she had a hepatic recurrence in S5, and she underwent an S5/4 partial hepatic resection. Seven years after the first operation, a liver S7 metastasis developed and she underwent S7 partial hepatectomy. Ten years after the first surgery, the GIST relapsed in liver S6 with right adrenal gland permeation. She underwent partial S6/7 liver resection and a right adrenal gland resection. She resumed takingimatinib after this surgical resection. Now, 11 years after the first operation, she is alive with an S1 hepatic recurrence taking sunitinib. Therefore, multidisciplinary treatment with surgical resection prolongs the survival of patients with resectable liver metastases of GIST.