18F-fluorodeoxyglucose positron emission tomography/computed tomography for the prediction of survival in patients with advanced esophageal cancer who have undergone neoadjuvant chemotherapy

Neoadjuvant chemotherapy (NAC) is a promising treatment strategy for advanced esophageal cancer. However, measures of NAC response assessment and prognostic prediction have not yet been established. The aim of this study was to evaluate the usefulness of combined ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT). A total of 77 patients with stage IB-IV esophageal cancer who were treated with NAC followed by curative resection were retrospectively analyzed. PET/CT was performed before and after NAC and 56 patients were clinical responders. The pretreatment maximal standardized uptake value (pre-SUV_max), post-SUV_max and %SUV_max were 11.3±5.8, 5.1±4.8 and 49.0±35.1%, respectively, for the main tumors (T) and 4.3±2.8, 2.5±1.9 and 67.0±39.6%, respectively, for the metastatic nodes (N). Among the preoperatively available factors, clinical response (P=0.018), post-SUV_max-N (P=0.0001) and %SUV_max-T (P=0.0031) were significant prognostic factors by univariate analysis. The multivariate analysis identified post-SUV_max-N as the only significant prognostic predictor (P=0.0254). Patients with a post-SUV_max-N of <3.0 exhibited significantly fewer pathological metastatic nodes and better disease-free survival compared with patients with a post-SUV_max-N >3.0. Therefore, post-SUV_max-N may be a useful prognostic predictor in patients with advanced esophageal cancer who are treated with NAC followed by surgery.

Advantages of 70-kV CT Angiography for the Visualization of the Adamkiewicz Artery: Comparison with 120-kV Imaging

BACKGROUND AND PURPOSE

Preprocedural identification of the Adamkiewicz artery is crucial in patients with aortic diseases. This study aimed to compare 70-kV CTA with conventional 120-kV CTA for the identification of the Adamkiewicz artery, examining differences in radiation dose and image quality.

MATERIALS AND METHODS

We retrospectively analyzed 2 equal groups of 60 patients who had undergone 70-kV or 120-kV CTA to detect the Adamkiewicz artery before aortic repair. Size-specific dose estimate, the CT number of the aorta, and the contrast-to-noise ratio of the anterior spinal artery to the spinal cord were recorded. Furthermore, detectability of the Adamkiewicz artery was evaluated by using a 4-point continuity score (3, definite to 0, undetectable).

RESULTS

There was significantly lower radiation exposure with 70-kV CTA than 120-kV CTA (median size-specific dose estimate, 23.1 versus 61.3 mGy, respectively; P < .001). CT number and contrast-to-noise ratio were both significantly higher in the 70-kV CTA group than the 120-kV group (999.1 HU compared with 508.7 HU, and 5.6 compared with 3.4, respectively; P < .001 for both). Detectability of the Adamkiewicz artery was not impaired in the 70-kV CTA group (90.0% versus 83.3% in the 120-kV group, P = .28). Moreover, the Adamkiewicz artery was detected with greater confidence with 70-kV CTA, reflected by a significantly superior continuity score (median, 3) compared with 120-kV CTA (median, 2; P = .001).

CONCLUSIONS

Seventy-kilovolt CTA has substantial advantages for the identification of the Adamkiewicz artery before aortic repair, with a significantly lower radiation exposure and superior image quality than 120-kV CTA.

[A Case of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis Treated Successfully with Multidisciplinary Therapy Including Preoperative Stereotactic Body Radiotherapy(SBRT)]

A 61-year-old man untreated with hepatitis C virus presented to our hospital.He was diagnosed advanced hepatocellular carcinoma(HCC)with portal vein tumor thrombosis(PVTT).The hazy tumor was located in the left lobe, and the tumor thrombus extended into the left portal vein.The patient received stereotactic body radiotherapy(SBRT, 48 Gy/4 Fr)for PVTT. The extended left lobectomy with thrombectomy was performed 12 days after SBRT.Resected specimen was diagnosed histopathologically as a poorly differentiated HCC, vp1, and no viable tumor cells in the tumor thrombosis.The patient's postoperative course was uneventful, and hepatic arterial infusion chemotherapy was started 1 month after the operation.He remains free of recurrence 5 years after the hepatectomy.Multidisciplinary therapy including preoperative SBRT was feasible and might be a treatment option for HCC with PVTT.

[Surgical Resection of Peritoneal Recurrence of Hepatocellular Carcinoma with Endoscopic Fluorescence Imaging System]

A 66-year-old man presented with recurrences in the peritoneum 3 years after heavy particle beam therapy with hepatocellular carcinoma(HCC)and underwent laparoscopic surgery.Five months after surgery, a new peritoneal dissemination found in the vicinity of the colon hepatic flexure area by CT examination, and laparoscopic resection was planned again.Indocyanine green(ICG)0.5 mg/kg was administered on the day before surgery.ICG imaging by the PINPOINT®system revealed 2 small ICG accumulation sites in the diaphragm, as well as the main lesion, and each lesion was excised laparoscopically.All lesions were diagnosed as peritoneal dissemination of HCC, and the postoperative course was uneventful.Although new dissemination nodules were appeared 6 months after surgery, he underwent laparoscopic surgery again and survives.In PINPOINT fluorescence mode, high-definition white-light image and fluorescence image was combined, and it was easy to determine the cut line but also to visualize the small lesion difficult to identify in the visible light mode.It was suggested that the PINPOINT®system might be useful in cases of HCC peritoneal dissemination.

[A Case of Laparoscopic Low Anterior Dissection for Rectal Carcinoma with Left-Sided Inferior Vena Cava]

A 43-year old-male was admitted to the hospital for the treatment of rectal carcinoma. Preoperative abdominal computed tomography(CT)revealed a left inferior vena cava. There is no report of the patient with left inferior vena cava which focused on an anatomical feature of autonomic nerves. We report a case of rectal cancer patient with left inferior vena cava who underwent autonomic nerve-sparing laparoscopic low anterior resection, and review the relevant literature here.

Clinical Assessment of Sarcopenia and Changes in Body Composition During Neoadjuvant Chemotherapy for Esophageal Cancer

AIM

The aim of this study was to assess changes in body composition during neoadjuvant chemotherapy (NAC) and investigate whether chemotherapy-related toxicities affect body composition in patients with esophageal cancer.

PATIENTS AND METHODS

In ninety-four patients who underwent NAC for esophageal cancer, body composition was assessed before and after NAC. Associations between the incidence of toxicities and change in body composition during NAC were investigated.

RESULTS

Forty-four (46.8%) and 50 (53.2%) out of 94 patients were defined as having sarcopenia before and after NAC, respectively. There was no significant difference in the incidence of any toxicity pre-treatment between patients with sarcopenia and those without sarcopenia. No significant reduction in skeletal muscle mass or fat mass was observed in the patients during NAC (p=0.501 and p=0.072). However, patients who experienced grade 4 neutropenia or febrile neutropenia during NAC showed a significantly larger decrease in change of skeletal muscle mass compared to patients who did not experience those toxicities (p=0.013 and 0.036, respectively).

CONCLUSION

The incidence of serious adverse events such as febrile neutropenia and grade 4 neutropenia is associated with a significant reduction of skeletal muscle mass during NAC. We should make an effort to reduce the incidence of adverse events in order to maintain an appropriate body composition during NAC.

Prediction model and treatment of high-output ileostomy in colorectal cancer surgery

The aim of the present study was to examine the risk factors of high-output ileostomy (HOI), which is associated with electrolyte abnormalities and/or stoma complications, and to create a prediction model. The medical records of 68 patients who underwent colorectal cancer surgery with ileostomy between 2011 and 2016 were retrospectively investigated. All the patients underwent surgical resection for colorectal cancer at the Osaka Medical Center for Cancer and Cardiovascular Diseases (Osaka, Japan). A total of 7 patients with inadequate data on ileostomy output were excluded. Using a group of 50 patients who underwent surgery between 2011 and 2013, the risk of HOI was classified by a decision tree model using a partition platform. The HOI prediction model was validated in an additional group of 11 patients who underwent surgery between 2014 and 2016. Univariate analysis of clinical factors demonstrated that young age (P=0.003) and high white blood cell (WBC) count (P<0.001) after surgery were significantly correlated with HOI. Operative factors, such as surgical procedure, approach, operative time and blood loss, were not significantly correlated with HOI. Using these clinical factors, the risk of HOI was classified by statistical partition. In this model, three factors (gender, age and WBC on postoperative day 1) were generated for the prediction of HOI. The patients were classified into five groups, and HOI was observed in 0-88% of patients in each group. The area under the curve (AUC) was 0.838. The model was validated by an external dataset in an independent patient group, for which the AUC was 0.792. In conclusion, HOI patients were classified and an HOI prediction model was developed that may help clinicians in postoperative care.

Is 18F-FDG-PET useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma?

OBJECTIVE

Induction therapy followed by surgery is a promising strategy for esophageal cancer patients with invasion of the trachea/bronchus or aorta. However, no diagnostic criteria have been established to diagnose whether R0 resection can be performed. We investigated whether ¹⁸F-2-deoxy-D-glucose positron emission tomography (¹⁸F-FDG-PET) and other modalities are useful for predicting R0 resection.

METHODS

Fifty-seven patients with esophageal cancer invading the trachea/bronchus or aorta who underwent induction therapy followed by surgery were enrolled. We divided the participants into two groups, an R0 resection group (n = 43) and a non-R0 resection group (n = 14), and then compared the between-group results of three modalities, including computed tomography (CT), endoscopy and ¹⁸F-FDG-PET, before and after induction therapy.

RESULTS

The post-maximal standardized uptake value (SUV_max) after induction therapy in the R0 resection group was significantly lower than that in the non-R0 resection group (4.4 vs. 6.6, p = 0.005). The receiver operating characteristic curve analysis showed that the cut-off value for the post-SUV_max based on ¹⁸F-FDG-PET prediction of R0 resection was 4.7. Furthermore, a tumor reduction rate of ≥44% on CT, no residual stenosis, and no deep ulcer on endoscopy were associated with R0 resection after induction therapy (p = 0.002, p = 0.091, and p = 0.059, respectively). Multivariate logistic analyses revealed that the tumor reduction rate on CT and post-SUV_max <4.7 in ¹⁸F-FDG-PET were independent factors for R0 resection.

CONCLUSIONS

The post-SUV_max determined by ¹⁸F-FDG-PET and the volume reduction rate based on CT scans were useful for predicting R0 resection after induction therapy for initially unresectable locally advanced esophageal carcinoma.

A Pilot Study of Post-Operative Adjuvant Vaccine for Advanced Gastric Cancer

BACKGROUND

Previously, we had performed a clinical study using human leukocyte antigen (HLA)-A24-binding peptide vaccines containing a combination of novel cancer-testis antigens and anti-angiogenic peptides derived from DEPDC1, URLC10, FOXM1, KIF20A and VEGFR1 for advanced gastric cancer (AGC) patients who were refractory to chemotherapy. We applied the cocktail vaccine to the combination therapy with S-1 for patients with AGC as a post-operative adjuvant therapy and performed this clinical pilot study.

METHODS

AGC patients who had curative surgery and were classified as pathologically stage III were enrolled. At each 6-week treatment cycle, patients received weekly subcutaneous administration of the cocktail vaccine with 5 continuous injections and one break for the first 4 cycles and with bi-weekly injections for the following 4 cycles. S-1 (80 mg/m²) was administered orally for 4 weeks with 2-week rest for all 8 cycles. The primary endpoint was the safety of the combination therapy and the secondary was the relative dose intensity for S-1.

RESULTS

Fourteen patients were enrolled. Six patients with HLA-A*2402 had received S-1 plus the cocktail vaccine as an adjuvant therapy and the remaining 8 had S-1 monotherapy for eight cycles. Five out of 6 patients subjected to the combination group completed the therapy and one patient discontinued because of Grade 3 injection-site reaction. No adverse events of grade 3 or higher were observed except injection-site reactions shown in 5 out of 6 patients who had vaccine therapy. The mean and median relative dose intensities for S-1 were 75.5% and 88% in the combination group and 67% and 80.5% in S-1.

CONCLUSION

The vaccine therapy combined with S-1 was manageable and safe adjuvant therapy for stage III gastric cancer. Furthermore, the optimal relative dose intensity of S-1 was achieved in combination group, although the injection-site reaction should be considered.

Metastatic mixed acinar-endocrine carcinoma of the pancreas treated with a multidisciplinary approach: a case report

Background

Pancreatic neoplasms are usually characterized by ductal, acinar, or endocrine differentiation. Mixed exocrine and endocrine pancreatic tumours are extremely rare. Here, we report a case of pancreatic mixed acinar-endocrine carcinoma (MAEC) with multiple synchronous liver metastases that were treated with surgery and transcatheter arterial chemoembolization (TACE) that later recurred in the stomach.

Case presentation

A 45-year-old female with severe anaemia was referred to our hospital. Computed tomography (CT) demonstrated a hypervascular tumour, 17 cm in diameter, that was in the tail of the pancreas. In addition, there were multiple hypervascular tumours in the liver. She underwent a distal pancreatectomy with splenectomy after the liver metastases were treated with TACE. Pathology confirmed that the pancreatic tumour was MAEC. After 4.5 years, a follow-up CT showed a hypervascular tumour at the upper part of the stomach. Gastric endoscopy showed a big tumefactive lesion with surface irregularities, gastric erosion, and multiple dilated vessels in the fornix and greater curvature of the stomach. She underwent a proximal gastrectomy and survived 7 years and 2 months after the start of the treatment.

Conclusions

This is the first report of a metastatic stomach tumour from pancreatic MAEC, which was successfully treated with a multidisciplinary approach. Additionally, we review the literature and discuss the treatment of MAEC.

The Clinical Significance of Alpha-Fetoprotein mRNAs in Patients with Hepatocellular Carcinoma

BACKGROUND/AIMS

Alpha-fetoprotein (AFP) mRNA-expressing cells are candidates for circulating tumor cells in hepatocellular carcinoma. We analyzed portal vein blood, peripheral blood, and peritoneal lavage samples to detect the presence of AFP mRNA-expressing cells, and explored their relationship with metastasis.

METHODS

We measured the AFP mRNA expression in 112 sets of portal vein and peripheral blood samples and 61 peritoneal lavage samples that had been obtained during surgery. We estimated the change in the positive ratio of patients with AFP mRNA, the associated background factors, and the rate of recurrence.

RESULTS

The change in AFP mRNA positivity in the peripheral blood specimens was remarkable, while that in the portal vein blood and peritoneal lavage samples was similar during hepatectomy. Tumor location was the only factor associated with AFP mRNA positivity. The rate of recurrence was higher in the patients who were positive for AFP mRNA than in those who were negative 9-24 months after hepatectomy. During this limited period, the recurrence rate in the AFP mRNA-positive cases was significantly higher than that in the AFP mRNA-negative cases (p = 0.0472). Postoperative AFP mRNA positivity was not related to very early recurrence (0-9 months) or multicentric liver carcinogenesis (>24 months).

CONCLUSION

AFP mRNA positivity in the peripheral blood was elevated after hepatectomy, and the elevation depended on the tumor location. AFP mRNA positivity might contribute to recurrence-free survival 9-24 months after hepatectomy.

Using spatial metrics and surveys for the assessment of trans-boundary deforestation in protected areas of the Maya Mountain Massif: Belize-Guatemala border

Understanding the trans-boundary deforestation history and patterns in protected areas along the Belize-Guatemala border is of regional and global importance. To assess deforestation history and patterns in our study area along a section of the Belize-Guatemala border, we incorporated multi-temporal deforestation rate analysis and spatial metrics with survey results. This multi-faceted approach provides spatial analysis with relevant insights from local stakeholders to better understand historic deforestation dynamics, spatial characteristics and human perspectives regarding the underlying causes thereof. During the study period 1991-2014, forest cover declined in Belize's protected areas: Vaca Forest Reserve 97.88%-87.62%, Chiquibul National Park 99.36%-92.12%, Caracol Archeological Reserve 99.47%-78.10% and Colombia River Forest Reserve 89.22%-78.38% respectively. A comparison of deforestation rates and spatial metrics indices indicated that between time periods 1991-1995 and 2012-2014 deforestation and fragmentation increased in protected areas. The major underlying causes, drivers, impacts, and barriers to bi-national collaboration and solutions of deforestation along the Belize-Guatemala border were identified by community leaders and stakeholders. The Mann-Whitney U test identified significant differences between leaders and stakeholders regarding the ranking of challenges faced by management organizations in the Maya Mountain Massif, except for the lack of assessment and quantification of deforestation (LD, SH: 18.67, 23.25, U = 148, p > 0.05). The survey results indicated that failure to integrate buffer communities, coordinate among managing organizations and establish strong bi-national collaboration has resulted in continued ecological and environmental degradation. The information provided by this research should aid managing organizations in their continued aim to implement effective deforestation mitigation strategies.

[Prognostic Prediction Models for Liver Metastasis of Colorectal Cancer]

We developed a reliable prediction model for colorectal cancer(CRC)patients after surgically curative resection. Using clinicopathological factors, prediction models were constructed for liver metastasis-free survival(LMFS). Between January 2004 and December 2010, 528 CRC patients were investigated. On univariate analysis of clinicopathological factors, the following factors associated with LMFS: pathological tumor invasion, lymph node metastasis, lymphatic invasion, venous invasion, and preoperative serum CEA. Using these factors, a prediction model was constructed using a Cox regression model with a concordance index of 0.824 for LMFS. These individualized prediction models could help clinicians in the treatment of postoperative CRC patients.

Comparison of Single-Incision and Conventional Multi-Port Laparoscopic Distal Gastrectomy with D2 Lymph Node Dissection for Gastric Cancer: A Propensity Score-Matched Analysis

BACKGROUND

Single-incision laparoscopic surgery maximizes the advantages of laparoscopic surgery by reducing abdominal trauma; however, few comparative studies have addressed its role in gastric cancer.

PURPOSE

This study sought to demonstrate the safety and feasibility of single-incision laparoscopic distal gastrectomy (SLDG) with radical D2 lymphadenectomy by comparing its short- and long-term outcomes with those of conventional multi-port laparoscopic surgery (MLDG).

METHODS

From October 2007 to December 2011, we identified 175 patients with clinical stage I-III gastric cancer who underwent SLDG with D2 lymphadenectomy (n = 90) and MLDG (n = 85) according to a review of our prospective gastric cancer database in our institute. One-to-one propensity score matching was performed to compare short-term outcomes and long-term survival between the two groups.

RESULTS

Mean operative time was similar between the two groups, while blood loss was significantly lower in the SLDG group than in the MLDG group. Postoperative recovery was faster in the SLDG group in terms of earlier initiation of oral intake, less use of analgesics, and shorter hospital stay. Serum C-reactive protein levels were significantly lower in the SLDG group than in the MLDG group on postoperative days 1, 3, and 7, and the 5-year overall survival rate was not significantly different between the two groups (93.7 vs. 87.6 %; p = 0.689).

CONCLUSIONS

This study shows that SLDG with D2 lymphadenectomy is safe and feasible for gastric cancer, with better short-term outcomes than MLDG and acceptable oncologic outcomes. Thus, SLDG may be an attractive surgical alternative in minimally invasive surgery.

Standardized technique for single-incision laparoscopic-assisted stoma creation

To describe the procedure, efficacy, and utility of single-incision laparoscopic-assisted stoma creation (SILStoma) for transverse colostomy. Using single-incision laparoscopic surgery, we developed a standardized technique for SILStoma. Twelve consecutive patients underwent SILStoma for transverse colostomy at Osaka Medical Center for Cancer and Cardiovascular Diseases from April 2013 to March 2016. A single, intended stoma site was created with a 2.5-3.5 cm skin incision for primary access to the intra-abdominal space, and it functioned as the main port through which multi-trocars were placed. Clinical and operative factors and postoperative outcomes were evaluated. Patient demographics, including age, gender, body mass index, and surgical indications for intestinal diversion were evaluated. SILStoma was performed in nine cases without the requirement of additional ports. In the remaining three cases, 1-2 additional 5-mm ports were required for mobilization of the transverse colon and safe dissection of abdominal adhesions. No cases required conversion to open surgery. In all cases, SILStoma was completed at the initial stoma site marked preoperatively. No intraoperative or postoperative complications greater than Grade II (the Clavien-Dindo classification) were reported in the complication survey. Surgical site infection at stoma sites was observed in four cases; however, surgical interventions were not required and all infections were cured completely. In all cases, the resumption of bowel movements was observed between postoperative days 1 and 2. SILStoma for transverse loop colostomy represents a feasible surgical procedure that allows the creation of a stoma at the preoperatively marked site without any additional large skin incisions.

Randomized study of the clinical effects of ω-3 fatty acid-containing enteral nutrition support during neoadjuvant chemotherapy on chemotherapy-related toxicity in patients with esophageal cancer

OBJECTIVES

Omega-3 (ω-3) fatty acids have potential positive effects during chemotherapy, such as body weight maintenance and muscle mass preservation. However, little is known about the effect this supplement might have on reducing chemotherapy-induced toxicities. The aim of this study was to determine the usefulness of ω-3 fatty acid supplementation in the reduction of chemotherapy-related toxicities.

METHODS

Sixty-one patients undergoing neoadjuvant chemotherapy for esophageal cancer randomly received ω-3-rich enteral nutrition (EN; n = 31) or ω-3-poor EN support (n = 30) for 15 d during chemotherapy. The daily dosage of ω-3 fatty acids was 900 mg in the ω-3-rich group and 250 mg in the ω-3-poor group. The primary endpoint was the frequency of grade 3/4 neutropenia, and secondary endpoints included other chemotherapy-related adverse events, body weight, and inflammatory markers.

RESULTS

The total and dietary intake calories during chemotherapy were equal in both groups. There was no significant difference in the body weight change after chemotherapy between the two groups. There was no significant difference in the incidence of grade 3/4 leukopenia and neutropenia (P > 0.05). However, stomatitis was significantly less frequent in the ω-3-rich group, than in the ω-3-poor group (P = 0.018). Grade 3/4 diarrhea occurred relatively less frequently in the ω-3-rich group than in the ω-3-poor group; however, this difference was not significant (16.1% versus 36.7%, respectively, P = 0.068). Increases in the aspartate aminotransferase and alanine aminotransferase levels were seen significantly less frequently in the ω-3-rich group than in the ω-3-poor group (P = 0.012 and P = 0.015, respectively).

CONCLUSIONS

ω-3-rich EN support decreased the frequency of chemotherapy-induced mucosal toxicities, such as stomatitis and diarrhea, and exhibited a hepatoprotective effect during chemotherapy, compared with the ω-3-poor EN support.

Novel prognostic prediction models for patients with stage IV colorectal cancer after concurrent curative resection

BACKGROUND

We developed a prediction tool for recurrence and survival in patients with stage IV colorectal cancer (CRC) following surgically curative resection.

PATIENTS AND METHODS

From January 1983 to December 2012, 113 patients with CRC and synchronous liver and/or lung metastatic CRC were investigated at the Osaka Medical Center for Cancer and Cardiovascular Diseases. All patients underwent curative resection of primary and metastatic lesions. In the group of patients who underwent surgery from 1983 to 2008, a Cox regression model was used to develop prediction models for 1-year, 3-year and 5-year cancer-specific survival (CSS) and relapse-free survival (RFS). In the other group of patients who underwent surgery from 2009 to 2012, the developed prediction model was validated.

RESULTS

Univariate analysis of clinicopathological factors showed that the following factors were significantly correlated with CSS and RFS: preoperative serum carcinoembryonic antigen level, tumour location, pathologically defined tumour invasion and lymph node metastasis, and synchronous metastatic lesions. Using these variables, novel prediction models predicting CSS and RFS were constructed using the Cox regression model with concordance indexes of 0.802 for CSS and 0.631 for RFS. The prediction models were validated by external data sets in an independent patient group.

CONCLUSIONS

We developed novel and reliable personalised prognostic models, integrating tumour, node, metastasis (TNM) factors as well as the preoperative serum carcinoembryonic antigen level, tumour location and metastatic lesions, to predict patients' prognosis following surgically curative resection. This individualised prediction model may help clinicians in the treatment of postoperative stage IV CRC following surgically curative resection.