[A Case of Lymph Node Metastasis of Intrahepatic Bile Duct Cancer Successfully Treated Using Multidisciplinary Therapy]

We report a case of lymph node metastasis of intrahepatic bile duct cancer that was successfully treated using chemotherapy and radiation therapy.A man in his 70s underwent hepatic resection for intrahepatic bile duct cancer, and abdominal CT 1 year 8 months after surgery revealed lymph node swelling(25mm in diameter)along the common hepatic artery.He was diagnosed with lymph node metastasis and began to receive chemotherapy.We administered gemcitabine(GEM), cisplatin, and S-1 for 6 months, and GEM and S-1 for 1 year 4 further months as combination therapy.One year 10 months after the start of chemotherapy, the size of the lymph node decreased to 13 mm.However, as FDG uptake was seen on FDG-PET, radiation targeted to the lymph node was applied(50 Gy/25 Fr).After completion of radiation therapy, the lymph node has not regrown even in the absence of treatment, and the patient survives 6 years after the primary operation(4 years 4 months since the start of chemotherapy for recurrence).This case suggested that multidisciplinary therapy might be useful for lymph node metastasis of intrahepatic bile duct cancer.

[Effectiveness of Irinotecan, S-1, and Bevacizumab for Rectal Cancer with Lung and Skin Metastases after Adjuvant Chemotherapy]

A 50-year-old woman with a chief complaint of bloody stools was diagnosed with rectal cancer via colonoscopy. Laparoscopic rectal anterior resection with D3 lymph node dissection was performed in June 2014. The pathological diagnosis was pStage III a(Ra, pT3, N1)cancer, and the patient received 8 courses of XELOX as postoperative adjuvant chemotherapy. During follow-up at 12 months after surgery, chest computed tomography revealed a mass in the left lingular segment measuring 25mm in diameter and multiple small nodules in both the lungs, indicating lung metastases. We found several subcutaneous nodules with a maximum diameter of 10mm in her abdomen and the back of head. We removed 3 subcutaneous nodules for the purpose of diagnosis and treatment in June of 2015. The pathological findings were consistent with cutaneous metastases of rectal cancer. The patient received a 1 course of IRIS and 5 courses of IRIS plus bevacizumab. Subsequently, the lung metastases disappeared and no new skin lesions were detected. We suggest that this case could be a good reference in determining the appropriate treatment for rectal cancer having lung or cutaneous metastases.

[A Case of Pulmonary Embolism Developed during Combination Chemotherapy with S-1 and Cisplatin in a Young Female Patient with Type 4Gastric Cancer]

We report a case of a 23-year-old womanwho developed pulmonary embolism(PE)during chemotherapy for advanced gastric cancer following total gastrectomy(R1). She presented with type 4 gastric cancer with peritoneal dissemination and positive washing cytology. Palliative total gastrectomy was performed(R1)and first-line chemotherapy with S-1(80mg/m2, days 1 to 21) plus CDDP(60mg/m2, day 8)(SP; every 35 days)was administered. PE occurred on day 15 of the 3rd courses of SP. Computed tomography(CT)revealed massive PE in both the pulmonary arteries, and ultrasonography indicated an increase in right-sided pressure. Thrombolysis using urokinase and heparin was performed immediately, and she recovered after 10 days in intensive care. Dehydration caused by the adverse event, as well as nausea and the anticancer drug itself, are risk factors for DVT and PE. Risk stratification, prevention, and early treatment are very important for PE.

[A Long-Surviving Patient with Unresectable Gastric Cancer Treated with Multiple Rounds of Chemotherapyafter Gastrojejunostomyand Ileocolonostomy]

We report a long-surviving patient with unresectable gastric cancer treated with multiple rounds of chemotherapy after gastrojejunostomy and ileocolonostomy. The patient was a 79-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the antrum and showed pyloric stenosis. We observed that the gastric tumor had invaded the transverse colon, pancreas, and duodenum, and was associated with peritoneal metastasis on the surface of the hepatoduodenal ligament and the posterior leaf of the transverse mesocolon. We performed gastrojejunostomy and ileocolonostomy to allow oral intake and to prevent ileus. The final diagnosis was fT4b(SI), N2, H0, P1, M0, CY0, Stage IV . The patient's oral intake was not sufficient following the operation, and therefore, he was treated with 8 courses of 5-FU plus PTX intravenously until disease progression was observed. Bi-weekly administration of CPT-11 and CDDP was chosen as the second-line chemotherapy. Grade 2 renal dysfunction was observed after 13 courses of this therapy, and therefore, we changed the regimen to CPT-11 monotherapy, repeating 18 courses until disease progression was observed. The patient was treated with 18 courses of S-1 monotherapy as the fourth-line chemotherapy, and then 2 courses of S-1 plus DTX. The patient died of progressive disease 4 years and 5 months after surgery. During chemotherapy, he maintained a good performance status and could be treated as an outpatient.

A Longitudinal HbA1c Model Elucidates Genes Linked to Disease Progression on Metformin

One-third of type-2 diabetic patients respond poorly to metformin. Despite extensive research, the impact of genetic and nongenetic factors on long-term outcome is unknown. In this study we combine nonlinear mixed effect modeling with computational genetic methodologies to identify predictors of long-term response. In all, 1,056 patients contributed their genetic, demographic, and long-term HbA1c data. The top nine variants (of 12,000 variants in 267 candidate genes) accounted for approximately one-third of the variability in the disease progression parameter. Average serum creatinine level, age, and weight were determinants of symptomatic response; however, explaining negligible variability. Two single nucleotide polymorphisms (SNPs) in CSMD1 gene (rs2617102, rs2954625) and one SNP in a pharmacologically relevant SLC22A2 gene (rs316009) influenced disease progression, with minor alleles leading to less and more favorable outcomes, respectively. Overall, our study highlights the influence of genetic factors on long-term HbA1c response and provides a computational model, which when validated, may be used to individualize treatment.

Capnography Prevents Hypoxia during Sedation for Dental Treatment: A Randomized Controlled Trial

Intravenous sedation is useful for dental treatment in patients with intellectual disabilities. However, it is often necessary to manage such patients with deep sedation because their cooperation cannot be obtained. During deep sedation, undetected hypoventilation can lead to severe complications, such as hypoxia. Recently, capnographic monitoring has been advocated as a useful technique for preventing hypoxia during sedation. This randomized control trial evaluated whether the use of capnography reduces the incidence of hypoxia during the deep sedation of patients for dental treatment. This study involved patients with intellectual disabilities who underwent dental treatment under sedation. The subjects were randomized to the intervention group (I-group) or control group (C-group). All of the patients underwent routine monitoring, as well as bispectral index (BIS) and capnographic monitoring; however, only an independent observer had access to the patients’ capnographic data during the dental procedures. Sedation was maintained at a BIS of 50 to 70 by administration of propofol. In the I-group, the independent observer signaled to the dental anesthesiologist if the capnogram indicated that the patient had been suffering from alveolar hypoventilation or apnea for >15 s. In the C-group, the observer signaled to the dental anesthesiologist if the capnogram indicated that the patient had been suffering from alveolar hypoventilation or apnea for >60 s. In both groups, the dental anesthesiologists responded to the signals using appropriate airway management strategies. The primary endpoint of this study was the incidence of hypoxia during dental treatment, which was defined as oxygen saturation of <95%. Hypoxemic episodes occurred in 13.4% and 34.8% of cases in the I-group and C-group, respectively. The incidence of hypoxia was significantly lower in the I-group. These results suggest that capnographic monitoring during deep sedation for dental treatment prevents hypoxemic episodes by allowing the early detection of hypoventilation.

Knowledge Transfer Statement: This is the first randomized controlled trial to examine whether the use of capnography reduces the incidence of hypoxia during deep sedation for dental treatment. The findings of this study can be used by clinicians to aid decision-making regarding dental sedation standards at individual clinics. Moreover, they can be used as high-level evidence during the production or updating of clinical guidelines for dental sedation by leading associations.

Age-related changes in cortical and trabecular bone mineral status: A quantitative CT study in lumbar vertebrae

Purpose: To investigate the age and sex dependence of the bone mineral status of human lumbar vertebrae with special regard to differences between cortical and trabecular bone.

Material and Methods: The study group comprised 125 normal Japanese healthy volunteers (54 males and 71 females), and was subdivided into adult male and female groups (subjects younger than 40 years), intermediate male and female groups (ages ranging between 41 and 64 years) and old male and female groups (subjects older than 65 years). The cortical bone mineral status was estimated using a single-energy quantitative CT (SE-QCT) technique, whereas trabecular bone mineral density (BMD) was estimated using a dual-energy (DE-QCT) technique.

Results: A considerable gender difference in the age-related cortical bone status was found. There was a significant reduction of the mean values of the cortical volume and BMD in the old female group compared with those obtained in the old male group.

Conclusion: The results suggest that in men, cortical and trabecular bone volume decrease very little with age. In women, cortical volume and BMD and trabecular BMD decrease with age while trabecular bone volume does not. The study showed that all variables had higher values in men than in women and that the difference increased with age.

The first report of the thyroid function of haemophilic patients with HIV/HCV co-infection in Japan

INTRODUCTION

A high incidence of thyroid dysfunction is reported in patients with HIV or HCV mono-infection. We have conducted a periodic medical examination including the thyroid function for haemophilic patients with HIV/HCV co-infection due to contaminated blood products.

METHODS

We examined the thyroid function (as assessed by the FT3, FT4 and TSH levels) in 45 haemophilic patients, including thyroglobulin and auto-antibody, antithyroglobulin antibody, antithyroid peroxidase antibody and anti-TSH receptor antibody in 28 patients.

RESULTS

All the patients were males (median age: 42 years; range: 29-66). The median values of thyroid function were FT3 3.36 pg mL(-1) , FT4 1.125 ng mL(-1) and TSH 1.65 μIU mL(-1) . Five patients (11.1%) had high TSH levels. In 28 patients in whom the presence of auto-antibodies was examined, the median age was 47 years of age. The median value of thyroglobulin was 16 ng mL(-1) and two patients showed high levels of thyroglobulin. The presence of anti-TSH receptor antibody of all the patients was negative, but one patient (3.5%) was positive of antithyroid peroxidase antibody and antithyroglobulin antibody.

CONCLUSIONS

Since 0.68-3.6% of the general healthy population is reported to show hypothyroidism, our data showed that the proportion of hypothyroidism in haemophilic patients with HIV/HCV co-infection was more frequent than that of the normal population.

Neuroprotective impact of prothymosin alpha-derived hexapeptide against retinal ischemia-reperfusion

Prothymosin alpha (ProTα) has robustness roles against brain and retinal ischemia or serum-starvation stress. In the ProTα sequence, the active core 30-amino acid peptide/P30 (a.a.49-78) is necessary for the original neuroprotective actions against ischemia. Moreover, the 9-amino acid peptide sequence/P9 (a.a.52-60) in P30 still shows neuroprotective activity against brain and retinal ischemia, though P9 is less potent than P30. As the previous structure-activity relationship study for ProTα may not be enough, the possibility still exists that any sequence smaller than P9 retains potent neuroprotective activity. When different P9- and P30-related peptides were intravitreally injected 24h after retinal ischemia in mice, the 6-amino acid peptide/P6 (NEVDEE, a.a.51-56) showed potent protective effects against ischemia-induced retinal functional deficits, which are equipotent to the level of P30 peptide in electroretinography (ERG) and histological damage in Hematoxylin and Eosin (HE) staining. Further studies using ERG and HE staining suggested that intravitreal or intravenous (i.v.) injection with modified P6 peptide/P6Q (NEVDQE) potently inhibited retinal ischemia-induced functional and histological damage. In an immunohistochemical analysis, the ischemia-induced loss of retinal ganglion, bipolar, amacrine and photoreceptor cells were inhibited by a systemic administration with P6Q peptide 24h after the ischemic stress. In addition, systemic post-treatment with P6Q peptide significantly inhibited retinal ischemia-induced microglia and astrocyte activation in terms of increased ionized calcium-binding adaptor molecule 1 (Iba-1) and glial fibrillary acidic protein (GFAP) intensity, respectively, as well as their morphological changes, increased number and migration. Thus, this study demonstrates the therapeutic significance of modified P6 peptide P6Q (NEVDQE) derived from 6-amino acid peptide (P6) in ProTα against ischemic damage.

Prognostic impact of preoperative NLR and CA19-9 in pancreatic cancer

BACKGROUND

Recently, several preoperative proinflammatory markers and nutritional factors such as neutrophil-to-lymphocyte ratio (NLR) and prognostic nutrition index (PNI) have been reported as significant predictor for poor prognosis of various malignant tumors. In this study, we evaluated the prognostic values of these preoperative parameters in patients with resectable pancreatic head cancer.

METHODS

We retrospectively reviewed consecutive patients who underwent PD for pancreatic head cancer between 2007 and 2012. A total of 46 patients were enrolled in this analysis. Preoperative parameters such as CRP, CA19-9, NLR and PNI at the time of presentation were recorded as well as overall survival. Cancer specific survival was assessed using Kaplan-Meier method. Univariate and multivariate Cox regression models were applied to evaluate the prognostic relevance of preoperative parameters. The correlations between CA19-9 values, NLR and pathological findings, first recurrence site were respectively reviewed.

RESULTS

In multivariable analysis preoperative high NLR (≧2.7) and high CA19-9 (≧230) were independent prognostic factors for poor survival (P value: 0.03 and 0.025, respectively). Kaplan-Meier survival analysis demonstrated the overall 2-year survival rate in patients with high NLR or high CA19-9 were 37.5% compared with 89.9% in patients with low NLR and low CA19-9.

CONCLUSION

Preoperative NLR and serum CA19-9 offer significant prognostic information associated with overall survival following PD in the patients with pancreatic head cancer.

[A Case of Recurrent Gastric Cancer with Left Cervical Lymph Node and Para-Aortic Lymph Node Successfully Treated with TS-1 Chemotherapy]

We report a case of recurrent gastric cancer with left cervical and para-aortic lymph node close to the hilum of the right kidney that was successfully treated with TS-1 monotherapy and surgical resection. The patient was a 55-year-old woman. She underwent total gastrectomy with D2 lymphadenectomy for gastric cancer in June 2002. Histopathological examination revealed type 4, por1, pT3 (SE), pN1 (#4d: 1/5), H0, P0, M0, CY0, pStageⅢA. She refused to receive adjuvant chemotherapy. At 1 year 7 months after gastrectomy, she noticed cervical lymph node swelling. Computed tomography (CT) revealed a 2.5 cm diameter lymph node. Histopathological examination of an aspiration needle biopsy specimen from the left cervical lymph node confirmed that the tumors had metastasized from gastric cancer. Treatment with TS-1 (120 mg/day) was initiated in January 2004 and continued for 2 years 5 months. A complete response was achieved 5 months after treatment initiation and continued until the present. Abdominal CT revealed a para-aortic lymph node that tended to increase in size. Positron emission tomography revealed accumulation with a standardized uptake value in the lymph node. Because it was a solitary tumor, we performed tumor resection in October 2009, histopathologically confirming the lymph node metastasis. Subsequently, the patient was again treated with TS-1 monotherapy again until the present. She is currently alive 5 years 9 months after the surgery, without any signs of disease recurrence.

[Optimal Target Population for Adjuvant Chemotherapy for Pathological T1 Gastric Cancer]

The ACTS-GC trial showed the efficacy of adjuvant treatment with S-1 in patients who had undergone D2 gastrectomy for Stage Ⅱ or Ⅲ(excluding pT1) gastric cancer, classified according to the 13th Japanese Classification of Gastric Carcinoma. We retrospectively analyzed the treatment outcomes of pT1 gastric cancer patients who underwent gastrectomy at our institute to determine the optimal target population for adjuvant treatment among these particular patients. Patients with pT1 gastric cancer who underwent gastrectomy for primary gastric cancer at our institute between 2000 and 2008 without perioperative chemotherapy and mortality were included in the current analysis (n=461). The incidence of lymph node metastasis in M and SM patients were 1.7% (4/240) and 16.7% (37/221), respectively. The 5-year relapse-free survival in M and SM patients was 100% and 96.2%, respectively. On multivariate analysis, the most important risk factor for recurrence in SM patients was 3 or more involved nodes (HR: 6.53, [95%CI: 1.10-31.29], p=0.040). The 5-year relapse-free survival in SM patients with involvement of 3 or more nodes was 66.7% and was comparable with that in stage Ⅱ surgery-only patients in the ACTS-GC trial. Hence, SM patients with 3 or more involved nodes are candidates for effective adjuvant treatment after curative gastrectomy.

[A Case of Lateral Lymph Node Recurrence Five-Years after Curative Surgery for Rectal Cancer]

A 62-year-old woman had undergone laparoscopic abdominoperineal resection for rectal cancer in February 2008. The pathological diagnosis was pT2, pN0, M0, pStageⅠ. At her request, she took UFT for 5 years as adjuvant chemotherapy. A CT examination revealed lateral lymph node swelling in January 2014. She was referred to our hospital after a diagnosis of lateral lymph node recurrence. She was administered 6 courses of FOLFIRI plus Cmab as neoadjuvant chemotherapy, after which the tumor size reduced by 62%. The treatment effect was rated as a PR. Laparoscopic right intrapelvic lymph node dissection was performed in July 2014, and the pathological diagnosis was recurrence of rectal cancer in the lateral lymph nodes. We report a case of dissection of lymph node recurrence 5 years after curative surgery for rectal cancer, along with a literature review.

[A Case of Combined Modality Therapy for a Cervical Lymph Node Recurrence after Surgery for Esophageal Cancer]

In the present report, we describe a man with type 2 progressive squamous cell carcinoma (cT3N1M0, cStage Ⅲ) that was detected in the esophago-gastric junction during follow-up after ESD for early gastric cancer. We performed a middle inferior part esophagectomy, a 2-region dissection, and a posterior mediastinum gastric tube reconstruction after preoperative chemotherapy (docetaxel plus cisplatin plus 5-FU). The patient only received 1 course of preoperative chemotherapy because of neutropenia. The pathology results were pT3N2M0, pStage Ⅲ. Six months later, we started chemotherapy (nedaplatin plus adriamycin plus 5-FU) owing to an abdominal lymph node recurrence. We administered 3 courses, but then switched to radiotherapy because of AEs. After receiving a radiation dose of 50.4 Gy, the patient experienced a para-aortic lymph node recurrence and was administered 50.4 Gy for the new lesion, resulting in a CR. Six months later, we identified lymph node recurrences under the left superficialis neck muscle and performed left cervical lymph node resection. All 3 of the enlarged lymph nodes that we resected were found to contain a metastasis of esophageal cancer. Currently (after 6 months), there are no signs of recurrence.

[A Case of Rectal Cancer Completely Resected after Successful Treatment with Irinotecan plus Cetuximab-Induced Interstitial Pneumonia with Steroid Pulse Therapy]

We report of a 74-year-old man with advanced rectal cancer invading the small intestine and bladder. Initially, 3 courses of neoadjuvant chemotherapy with FOLFIRI and cetuximab were administered. At the beginning of the 4 course, the patient experienced fever and dyspnea. Chest radiography and computed tomography showed ground-grass opacities in both lungs. He was diagnosed with interstitial pneumonia induced by irinotecan or cetuximab. Steroid pulse therapy consisting of methyl-prednisolone (1,000 mg/day; 3 days) with respiratory assist resulted in significant improvement, and prednisolone was continued while reducing the dose gradually. He stopped the medicine on the 106th day from the first treatment, and underwent the R0 operation on the 113th day. We report for the first time a case of interstitial pneumonia occurring after neoadjuvant chemotherapy for advanced rectal cancer that was successfully resected after treatment.

[A Case of Cholangiocarcinoma with Intestinal Malrotation Treated with Pancreaticoduodenectomy]

We report a case of cholangiocarcinoma with intestinal malrotation that was treated with pancreaticoduodenectomy. The patient was a 74-year-old man, who underwent laboratory screening and was subsequently found to have elevated γglutamyl transpeptidase levels. Preoperative ultrasonography revealed intrahepatic bile duct dilatation. Endoscopic retrograde cholangiopancreatography demonstrated a filling defect in the common bile duct and cytology of the bile demonstrated the presence of an adenocarcinoma. On preoperative computed tomography (CT), the SMV was located on the left side of the SMA, which showed the SMV rotation sign. Additionally, the small intestine and the colon were deviated to the right and left side of abdominal cavity, respectively. We diagnosed the patient with cholangiocarcinoma with intestinal malrotation and preduodenal portal vein involvement using the CT scan, and performed pancreaticoduodenectomy. Since the ligament of Treitz was absent during surgery, we diagnosed this as a case of the nonrotation type of malrotation. The postoperative course was uneventful and the patient was discharged from the hospital 42 days after the surgery. Anomalies of the portal venous system are so rare that recognition of its variation is important in order to avoid accidental injuries during the operation.

[A Long Surviving Case of Resected Advanced Gastric Cancer with a Synchronous Adrenal Metastasis]

We report a long surviving case of gastric cancer with a synchronous adrenal metastasis in a patient who underwent curative resection. The patient was a 74-year-old man. Endoscopic examination revealed a type 3 gastric cancer in the proximal stomach. Abdominal computed tomography (CT) revealed a soft tissue density mass in the right adrenal gland and a high-density mass suspected as hemangioma in the left adrenal gland. The CT scan indicated no other distant metastasis. The patient had no endocrine abnormalities according to blood test results. Total gastrectomy with D2 lymphadenectomy and right adrenalectomy were performed in August 2003. On histopathological examination, the gastric tumor was diagnosed as a poorly differentiated adenocarcinoma. The histopathological findings of the right adrenal tumor were compatible with those of gastric cancer. The final diagnosis was por1, 105×65 mm, pT2 (SS), pN1 (#1: 2/8, #3: 1/11), P0, H0, CY0, pM1 (ADR), pStage Ⅳ. Two months after the surgery, the patient was treated with adjuvant TS-1 monotherapy (80 mg/m2 day 1-28/q6w) for 1 year 9 months. The patient had been in good health without a recurrence for more than 9 years 3 months after the operation.

[XELOX plus Bevacizumab Chemotherapy for a Patient with Postoperative Recurrence of Colorectal Cancer Under Hemodialysis for Chronic Renal Failure]

We report the case of a patient with a postoperative recurrence of colon cancer who received XELOX plus bevacizumab chemotherapy whilst undergoing hemodialysis. A 73-year-old man had been receiving maintenance hemodialysis for 9 years due to chronic renal failure. At 64 years old, a Hartmann's operation and a posterior segment and segment 3 partial liver resection were performed for sigmoid colon cancer and metastatic liver cancer. Three years 1 months after surgery, local recurrence at the liver invading into the right lung was detected. XELOX plus bevacizumab chemotherapy was administered. After 16 courses of treatment, tumor control was achieved. Chemotherapy with molecular target drugs is currently recommended for advanced/metastatic colorectal cancer; however, a standardized strategy for hemodialysis patients is not established. As the number of hemodialysis patients receiving chemotherapy for some cancers is likely to increase in the future, it will be necessary to consider chemotherapy strategies for hemodialysis patients.

[An Evaluation of Outcome of Surgical Treatment for Recurrence after Curative Pancreatectomy for Pancreatic Ductal Cancer]

The aim of this study was to evaluate the outcome of surgical treatment for recurrence after curative pancreatectomy for pancreatic ductal cancer. Ten cases were enrolled, and the time from initial pancreatectomy to recurrence, location of recurrence, and outcome after surgical treatment for recurrence was evaluated. The time to recurrence was more than 1 year in 4 cases, and the locations of recurrence in these cases were the remnant pancreas and lung in 3 and 1 patients, respectively. Among these 4 cases, a second recurrence was observed in only 1 case, and survival after surgical treatment of the first recurrent site was more than 3 years in the other 3 cases. For the remaining 6 cases, the time to recurrence was less than 1 year and the recurrences were located in the abdomen but not in the remnant pancreas. A second recurrence was observed in all cases, and the survival time was less than 2 years in 4 out of 6 cases. Based on the results of this study, recurrence in the remnant pancreas and lung after curative resection for pancreatic ductal cancer could be a potential indication for surgical treatment.

[A Case of Esophageal Cancer with Paraaortic Lymph Node Metastasis Treated with Lymphadenectomy after Esophagectomy]

A 70-year-old woman underwent subtotal esophagectomy with two-field lymph node dissection for squamous cell carcinoma of the middle thoracic esophagus (type 0- /Ⅱa+Ⅱc, pT1bN1 [2/25] M0, pStage Ⅱ). Approximately 1 year and 2 months after surgery, abdominal CT showed a swollen paraaorticlymph node. PET-CT also indicated lymph node metastasis. The lymph node was diagnosed to have metastasis from the esophageal cancer, and the patient began treatment with chemotherapy. However, the treatment plan was changed to lymphadenectomy because of neutropenia. She underwent paraaortic lymph node dissection and right partial adrenalectomy. The lymph node was confirmed to have metastasis from the esophageal cancer. The neutropenia persisted after surgery, so she did not receive adjuvant chemotherapy. The patient remained alive for more than 5 years after surgery without any evidence of recurrence. Isolated paraaortic lymph node metastasis after esophagectomy is rare, and there have been only 2 cases, including our own, of long-term survival after paraaortic lymph node dissection. Lymphadenectomy for isolated lymph node metastasis can improve long-term prognosis but it cannot sufficiently predicate it. Therefore, accumulation of more cases is required.

Survival Impact of Pulmonary Metastasis as Recurrence of Pancreatic Ductal Adenocarcinoma

AIM

This study aimed at investigating the survival impact of pancreatic ductal adenocarcinoma (PDAC) recurrence as pulmonary metastasis.

METHODS

We performed a retrospective case-control study of 142 patients who underwent curative resection for PDAC at our institution between 2003 and 2012. Clinicopathological features were compared among patients stratified according to the recurrence pattern and pulmonary metastasis treatment strategy.

RESULTS

Patients underwent pancreaticoduodenectomy (n = 96), distal (n = 42), or total pancreatectomy (n = 4). At the last follow-up, 99 patients had developed recurrent post-resection PDAC, including 14 cases of isolated pulmonary recurrence. The median overall survival was significantly longer for patients with isolated pulmonary recurrence (40.3 months) than with other metastases (20.9 months; HR 5.85; p = 0.0156). Two patients underwent resection for isolated pulmonary recurrence, and both survived for ∼70 months after primary resection.

CONCLUSION

Patients with first recurrence of PDAC as pulmonary metastasis had a better prognosis than patients with other types of metastases. Moreover, when isolated pulmonary metastasis is controlled for a certain period, pulmonary resection is likely to improve patient survival.

Elevated pentraxin 3 level at the early stage of exercise training is associated with reduction of arterial stiffness in middle-aged and older adults

Regular exercise improves aging-induced deterioration of arterial stiffness, and is associated with elevated production of pentraxin 3 (PTX3) and anti-inflammatory as well as anti-atherosclerotic effects. However, the time-dependent effect of exercise training on arterial stiffness and PTX3 production remains unclear. The purpose of this study was to investigate the time course of the association between the effects of training on the circulating PTX3 level and arterial stiffness in middle-aged and older adults. Thirty-two healthy Japanese subjects (66.2±1.3 year) were randomly divided into two groups: training (exercise intervention) and sedentary controls. Subjects in the training group completed 8 weeks of aerobic exercise training (60-70% peak oxygen uptake (VO2peak) for 45 min, 3 days per week); during the training period, we evaluated plasma PTX3 concentration and carotid-femoral pulse wave velocity (cfPWV) every 2 wk. cfPWV gradually declined over the 8-week training period, and was significantly reduced after 6 and 8 week of exercise intervention (P<0.05). Plasma PTX3 level was significantly increased after 4 weeks of the intervention (P<0.05). In addition, the exercise training-induced reduction in cfPWV was negatively correlated with the percent change in plasma PTX3 level after 6 week (r=-0.54, P<0.05) and 8 weeks (r=-0.51, P<0.05) of the intervention, but not correlated at 4 weeks. Plasma PTX3 level was elevated at the early stage of the exercise training intervention, and was subsequently associated with training-induced alteration of arterial stiffness in middle-aged and older adults.

Prevalence of Malnutrition Among Gastric Cancer Patients Undergoing Gastrectomy and Optimal Preoperative Nutritional Support for Preventing Surgical Site Infections

BACKGROUND

Malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. The aim of this study was to investigate the prevalence of malnutrition and identify the optimal preoperative nutritional support for preventing postoperative surgical site infections (SSIs) in malnourished gastric cancer patients undergoing gastrectomy.

METHODS

We analyzed 800 patients with gastric cancer who underwent gastrectomy. Nutritional risk factors included weight loss >10 % within 6 months, body mass index <18.5 kg/m(2), Subjective Global Assessment Grade C, and serum albumin <3.0 g/dl. Adequate energy intake was defined as receiving ≥25 kcal/kg ideal body weight per day. Optimal nutritional support was examined in terms of both duration and calorie intake.

RESULTS

Overall, 152 patients (19.0 %) were classified as malnourished. The incidence of SSIs was significantly higher in malnourished patients than in well-nourished patients (35.5 vs. 14.0 %; p < 0.0001). The incidence of SSIs in malnourished patients was significantly lower in the well-supported group receiving adequate energy support for at least 10 days than in the poorly-supported group, which received inadequate or no energy support or adequate energy support for <10 days (17.0 vs. 45.4 %; p = 0.0006). In multivariate analysis, well-managed nutritional support was identified as an independent factor associated with fewer SSIs (odds ratio 0.14; 95 % confidence interval 0.05-0.37; p = 0.0002).

CONCLUSIONS

Malnutrition, a risk factor for SSI, was prevalent in gastric cancer patients preoperatively. Well-managed preoperative nutritional support decreased the incidence of postoperative SSIs in malnourished patients.