Anaplastic transformation of thyroid cancer in mesentery metastases presenting as intestinal perforation: a case report

Background

Anaplastic thyroid carcinoma is a highly aggressive form of thyroid cancer associated with a very poor prognosis. Anaplastic transformation most commonly occurs in the thyroid itself or within regional lymph nodes. Here we report the case of a patient with papillary thyroid cancer, presenting with colon perforation as a result of anaplastic transformation of metastases in the mesentery tissue. There have been no previous reports of this form of anaplastic transformation.

Case presentation

A 74-year-old man was admitted to our hospital, presenting with abdominal pain that he had been experiencing for 1 week prior to admission. The patient had a history of papillary thyroid carcinoma, for which he underwent a total thyroidectomy and mediastinal lymph node dissection 6 years earlier, and subsequently received radioactive iodine therapy for postoperative recurrence in the lung 2 years later. During the present reported admission, a computed tomography scan revealed a large intra-abdominal mass infiltrating into the colon and retroperitoneum and also highlighted the pneumoperitoneum. The patient was diagnosed with generalized peritonitis as a result of colon perforation, as such, we conducted an emergency laparotomy. Intraoperative findings showed a mass affecting the ascending colon and kidney, following which, an ileostomy and biopsy were completed. Poorly differentiated spindle cells were identified in the biopsy specimens, and histopathological and immunohistochemical findings revealed the absence of thyroid carcinoma cells. The tumor was therefore believed to be a primary sarcoma. Following surgery, the patient recovered from sepsis that had arisen as a result of colon perforation, however, rapidly developed systemic metastases and died 1 month post-operation. An autopsy was performed, and the patient was diagnosed with anaplastic papillary thyroid cancer at the mesentery site of metastasis. This conclusion was reached owing to the presence of the squamous differentiation of lymph node cells, and because tumor cells were positive results for paired-box gene 8 expressions.

Conclusions

Anaplastic transformation of papillary thyroid carcinoma should be considered in the diagnosis of a large mesentery mass in patients with a history of papillary carcinoma. An appropriate biopsy and paired-box gene 8 immunostaining can be useful in confirming such a diagnosis.

Pathological complete response by advanced hepatocellular carcinoma with massive macrovascular invasion to hepatic arterial infusion chemotherapy: a case report

Background

Advanced hepatocellular carcinoma (HCC) with macrovascular invasion has an extremely dismal prognosis. We report a rare case of multiple HCC with tumor thrombosis in the portal vein and inferior vena cava that was initially treated with hepatic arterial infusion chemotherapy (HAIC); later resection revealed pathological complete response.

Case presentation

A 75-year-old man presented with HCC in his right liver, with tumor thrombosis growing to the right portal vein and the inferior vena cava, and bilateral intrahepatic liver metastases. He underwent HAIC (5-fluorouracil [170 mg/m²] + cisplatin [7 mg/m²]) via an indwelling port. Although the tumor shrank and tumor marker levels decreased rapidly, we abandoned HAIC after one cycle because of cytopenia. We resumed HAIC 18 months later because of tumor progression, using biweekly 5-fluorouracil only [1000 mg] due to renal dysfunction. However, after 54 months, the HAIC indwelling port was occluded. The patient therefore underwent a right hepatectomy to resect the residual lesion. Histopathological findings showed complete necrosis with no viable tumor cells. The patient has been doing well without postoperative adjuvant therapy for more than 10 years after initially introducing HAIC and 6 years after the resection, without evidence of tumor recurrence.

Conclusions

HAIC can be an effective alternative treatment for advanced HCC with macrovascular invasion.

Surgery and imatinib therapy for liver oligometastasis of GIST: a study of Japanese Study Group on GIST

We conducted a multicenter prospective study to clarify the efficacy and safety of surgery and imatinib for liver oligometastasis of gastrointestinal stromal tumors. Eligible gastrointestinal stromal tumor patients were enrolled in the surgery trial or the imatinib trial. Primary endpoints were recurrence-free survival and progression-free survival, respectively. The trials were prematurely terminated due to amendment of guidelines for adjuvant imatinib therapy and low patient accrual. In the surgery trial, all the six patients showed hepatic recurrence: median recurrence-free survival was 145 days (range: 62-1366 days). Of the five patients receiving salvage imatinib therapy, two showed progressive disease although no death was observed. Of the five patients enrolled in the imatinib trial, one died of pneumonia after progressive disease, and four had not shown progressive disease as of last visit. The results suggest that liver oligometastasis of gastrointestinal stromal tumor may not be controllable by surgery alone and require concomitant imatinib therapy.

Familial gastrointestinal stromal tumor with hyperpigmentation: association with a germline mutation of the c-kit gene

We describe 2 siblings with multiple gastrointestinal stromal tumors (GISTs) and cutaneous hyperpigmentation. Both had a point mutation of the c-kit gene. The patients were sisters who had exhibited cutaneous hyperpigmentation since their late teens, but the diagnosis of multiple gastrointestinal submucosal tumors was not made until they were 41 and 45 years old. Histologic examination showed that these tumors were GISTs expressing CD34 and Kit protein. Both patients died of GISTs. Single-strand conformation polymorphism analysis showed a mutation of c-kit in tumor DNA extracted from paraffin-embedded specimens. Direct sequencing analysis showed that the point mutation occurred at codon 559 of exon 11 (Val-->Ala). The same single-point mutation was detected in DNA extracted from peripheral leukocytes obtained from the younger sister and her 2 children (who had similar general hyperpigmentation) as well as in DNA from a skin biopsy specimen taken from the older sister. The germline mutation at codon 559 of the c-kit gene found in the present familial GISTs differed from that in a previously reported case of familial GISTs. We propose that GISTs caused by a germline mutation of the c-kit gene should be referred to as GIST-cutaneous hyperpigmentation disease.

Palliative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

Although palliative gastrectomy for advanced gastric cancer may be favorable in selected patients presenting with bleeding and obstruction, little has been reported about the clinical significance of palliative gastrectomy, including prognosis.

METHODOLOGY

A retrospective comparison between 84 patients with palliative gastrectomy (PG group) and 100 patients with unresectable operation (UO group) for advanced gastric cancer was carried out.

RESULTS

The incidence of serosal invasion, peritoneal dissemination, hepatic and lymph node metastases, and undifferentiated tissue type in the UO group were significantly higher than in the PG group. Median survival after operation in the PG group (20.6 months) was significantly longer than in the UO group (5.7 months). Also, in stage IVb patients, median survival time in the PG group (10.2 months) was significantly longer than in the UO group (5.0 months). However, median survival in the patients with synchronous liver metastasis between PG (8.4 months) and UO (4.6 months) groups was not significantly different. Survival rates after operation of 6 months, 1 year and 2 years in all patients between the palliative gastrectomy group versus UO group were 83.6% versus 38.3% (P < 0.01), 63.0% versus 9.3% (P < 0.01) and 35.2% versus 0% (P < 0.01), respectively.

CONCLUSIONS

Palliative gastrectomy compared to unresectable operation may be effective for improvement of prognosis even if stage IVb patients with peritoneal dissemination and/or distant lymph node metastasis. However, it may be unfavorable on survival of patients with synchronous liver metastasis.

Postoperative chemotherapy in elderly patients with advanced gastric cancer

BACKGROUND/AIMS

The definitive efficacy of postoperative chemotherapy in elderly patients with advanced gastric cancer has not been established. The aim of this study is to evaluate prognosis in elderly patients with advanced gastric cancer and the effect of postoperative chemotherapy on prognosis.

METHODOLOGY

Fifty-three patients, 75 years of age or older who underwent curative surgery for advanced gastric cancer were divided into 14 patients with postoperative chemotherapy (chemotherapy group) and 39 patients without postoperative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-FU alone (n = 11), intravenous mitomycin plus 5-FU: MF (n = 2), and MF plus oral 5-FU (n = 1). No prior chemotherapy or radiation was given.

RESULTS

There were no significant differences of clinical and pathological backgrounds between the two groups. The rate of death due to recurrent carcinoma was 50.0% in the chemotherapy group and 43.6% in the control group, the difference being insignificant. Although the median survival time of the chemotherapy group (40.4 months) was longer than in the control group (31.7 months), a significant difference did not exist between the groups. The 1-, 3-, and 5-year survival rates did not significantly differ between the chemotherapy group versus the control group, 85.7% versus 82.1%, 42.9% versus 51.3%, and 35.7% versus 46.2%, respectively.

CONCLUSIONS

Postoperative chemotherapy did not contribute to prolong survival in elderly patients with advanced gastric cancer mainly because the incidence of recurrent carcinoma was not reduced.

Hepatectomy of cavernous hemangioma with constitutional indocyanine green excretory defect

The constitutional ICG excretory defect with marked ICG retention in spite of other normal hepatic functions has not been so rare in Japan. However, there is no previous report of hepatectomy in a patient with this disease. We describe a successful case of hepatectomy for cavernous hemangioma with this disease and use of technetium-99m diethylenetriaminepentaacetic acidgalactosyl-human serum albumin (99mTC-GSA) liver scintigraphy as the preoperative assessment of the liver functional reserve. In our case, ICGR15 was more than 55%, however, a modified receptor index obtained from 99mTC-GSA liver scintigraphy was normal. Left lateral segmentectomy of the liver was performed without any perioperative complications. Hepatectomy of patients with the constitutional ICG excretory defect is possible if modified receptor index value obtained from 99mTC-GSA scintigraphy is within the normal range.

Surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma

BACKGROUND/AIMS

The aim of this study was to clarify the surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma (HCC).

METHODOLOGY

The surgical outcome of 26 HCVAb-positive cirrhotic patients with hepatitis C antibody (the C-related HCC group) and 18 HCVAb-negative cirrhotic patients with (the non-C-related HCC group) undergoing hepatectomy for HCC were compared. The C-related HCC group was HCVAb[+], HBsAg[-] for hepatitis B surface antigen in 25 patients and HCVAb[+], HBsAg[+] in 1, and the non C-related HCC group was HCVAb[-], HBsAg[+] in 15 and HCVAb[-], HBsAg[-] in 3.

RESULTS

Preoperative aspartate and alanine aminotransferase in the C-related HCC group were significantly (P < 0.01) higher than in the non-C-related HCC group. There were no significant differences in the operative method, intraoperative blood loss and weight of resected liver or pathological data between the 2 groups. In the recurrence pattern, the incidence of multicentric occurrence in the C-related HCC group (53.3%) was significantly (P < 0.05) higher than in the non-C-related HCC group (7.7%). The mortality rate in both groups was 0% and no operative death was encountered. The crude survival and disease-free survival rates at 3 years were similar: 80.8% and 57.7% in the C-related HCC group and 77.8% and 55.6% in the non-C-related HCC group, respectively.

CONCLUSIONS

Although surgically treated cirrhotic patients with C-related HCC showed worse preoperative hepatitis status and a higher incidence of recurrence due to multicentricity compared with non-C-related HCC, the mortality and prognosis of patients with C-related HCC did not differ from that of non-C-related HCC. The indication of hepatic resection and consideration for the high incidence of postoperative multicentric occurrence in the patients with C-related HCC should therefore be more careful than in patients with non-C-related HCC.

Hepatic function immediately after hepatectomy as a significant risk factor for early recurrence in hepatocellular carcinoma

BACKGROUND/AIMS

The aim of this study was to clarify the significant risk factors as they relate to early recurrence after hepatectomy in cirrhotic patients with hepatocellular carcinoma (HCC).

METHODOLOGY

We retrospectively investigated 42 cirrhotic patients undergoing hepatectomy for a single HCC. We compared the clinicopathologic features of 14 patients with early intrahepatic recurrence (recurrence was detected within 1 year after hepatic resection; Group 1) with 28 patients without recurrence or with late intrahepatic recurrence (recurrence was confirmed more than 1 year after hepatic resection; Group 2).

RESULTS

There were no significant differences in the pre-operative and intra-operative clinical background data or pathological data between the 2 groups. Regarding recurrence pattern, although not significant, the incidence of intrahepatic metastasis in Group 1 (85.7%) was higher than in Group 2 (50.0%). Maximum values of total bilirubin and albumin within 7 days after hepatectomy for patients in Group 2 were significantly better than those in Group 1. Aspatate aminotransferase (AST) and alanine aminotransferase (ALT) immediately after hepatectomy in Group 1 were also higher than in Group 2, although statistically insignificant. The overall 1-year and 3-year survival rates between Group 1 versus Group 2 were 85.7% versus 100% (p < 0.01) and 57.2% versus 90.0% (p < 0.01), respectively.

CONCLUSIONS

Hepatic functional damage immediately after hepatectomy is as significant risk factor for early intrahepatic recurrence in cirrhotic HCC. Careful perioperative management of hepatic function may therefore be important in preventing early recurrence and prolonging survival.

Efficacy of extended lymphadenectomy in the noncurative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

We retrospectively analyzed clinicopathologic data on 83 patients with advanced gastric cancer who underwent noncurative gastrectomy, with respect to the relation between the extent of lymphadenectomy and survival benefit.

METHODOLOGY

These 83 patients were divided into 44 patients with limited or simple lymph node dissection (D0 in 14 and D1 in 30: Group A) and 39 patients with extended lymph node dissection (D2: Group B).

RESULTS

The 1-year survival rate in Group B (82.1%) was significantly higher than in Group A (49.0%). However, the 3-year and 5-year survival rates did not significantly differ between Group A versus Group B, 39.7% versus 25.7% and 39.7% versus 20.5%, respectively. Median survival time after surgery with and without distant metastasis in Group B (21.5 months) was longer than in Group A (16.4 months), although not significant.

CONCLUSIONS

While gastrectomy with extended lymphadenectomy did not contribute to improve long-term survival in patients with noncurable advanced gastric cancer, the utility of extended lymph node dissections may be relevant to improved locoregional control, at least in the prognosis within 1 year after surgery. Not only extended lymphadenectomy but also aggressive chemotherapy may be needed to improve the long-term survival for such patients.

Post-operative chemotherapy in non-curative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

The definitive effects of post-operative chemotherapy for prolonging survival in patients with non-curative gastrectomy for advanced gastric cancer have not been established.

METHODOLOGY

Eighty-three patients with advanced gastric cancer who underwent non-curative gastrectomy were divided into 49 patients with post-operative chemotherapy (chemotherapy group) and 34 patients without post-operative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-fluorouracil (5-FU) alone (n = 22), intravenous mitomycin (MMC) plus 5-FU (n = 20), intravenous methotrexate (MTX) plus 5-FU (n = 3), intravenous cisplatin plus 5-FU (n = 2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n = 2). No prior chemotherapy or radiation therapy was given.

RESULTS

Although the age in the control group (mean: 71.9 years) was significantly older than in the chemotherapy group (mean: 66.1 years), there were no significant differences in the other clinical and pathological background data between the two groups. The 1-year survival rate in the chemotherapy group (71.4%) was significantly higher than in the control group (50.0%). However, the 3-year and 5-year survival rates did not significantly differ in the chemotherapy group versus the control group, 30.6% vs. 32.4% and 24.5% vs. 32.4%, respectively. Although a significant difference did not exist between the two groups, median survival after operation in the chemotherapy group (20.5 months) was longer than that in the control group (16.2 months). Furthermore, median survival of patients with peritoneal dissemination in the chemotherapy group (16.4 months) was significantly longer than that in the control group (7.7 months).

CONCLUSIONS

Post-operative chemotherapy may contribute to prolonged survival in patients with non-curable advanced gastric cancer, even when patients had peritoneal dissemination. However, the long-term survival rate was not improved by post-operative chemotherapy. More aggressive chemotherapy may be needed to improve the long-term prognosis for such patients.

Bile leakage resulting from clip displacement of the cystic duct stump: a potential pitfall of laparoscopic cholecystectomy

We present the case of a patient who underwent successful endoscopic nasobiliary drainage (ENBD) for bile leakage resulting from clip displacement of the cystic duct stump sustained during a laparoscopic cholecystectomy (LC). This 69-year-old man was admitted with symptomatic cholecystolithiasis. After LC was performed, intraoperative cholangiography (IOC) revealed no abnormal findings. However, postoperatively, bilious material began to appear from the intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage from the end of the cystic duct stump. ENBD was performed. Cholangiography using the ENBD tube 14 days later failed to show a bile leak. The ENBD was subsequently removed. The patient improved rapidly with no complaints. Bile leakage due to clip displacement from the cystic duct stump is a potential pitfall of LC, especially if IOC is normal. We recommend careful cystic duct ligation, combined with the use of superior quality ligation clips, to prevent this complication. ENBD is a useful technique to prevent bile leakage after this complication.

Arterial ketone body ratio and adenosine triphosphate concentration in hepatic ischemia and reperfusion

BACKGROUND/AIMS

The arterial ketone body ratio (AKBR) and the cellular adenosine triphosphate (ATP) concentration have been proposed as indicators of liver function. However, recent studies of the utility of the AKBR as a biochemical marker have been called into question. Furthermore, there is no practical data defining the relationship between ATP concentration and ischemia-reperfusion (IR) changes during liver surgery.

METHODOLOGY

The relationship of the AKBR and arterial ATP concentration to IR during hepatectomy was investigated. In 20 patients who underwent hepatectomy, arterial acetoacetate, beta-hydroxybutyrate, and ATP concentrations were measured. The ratio of acetoacetate to beta-hydroxybutyrate (AKBR) was calculated before and after vascular occlusion.

RESULTS

The AKBR 15 minutes after clamping was lower than the preclamping values in all of the patients. It increased after unclamping, returning toward the preclamping levels. An AKBR of less than 0.5 prior to clamping did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 throughout IR was not a consistent risk factor for postoperative complications and liver dysfunction. The arterial ATP concentration did not correlate with the changes during IR or with preoperative hepatocellular function.

CONCLUSIONS

Although the AKBR changed during IR as a general indicator of cellular activity, the absolute value of the AKBR was not an accurate predictor of liver function. The arterial ATP concentration also was not a suitable clinical biochemical marker of hepatic function.

Significant risk factors of recurrence in muscularis proprial carcinoma of the stomach

BACKGROUND/AIMS

The aim of this study is to elucidate significant risk factors of recurrence in muscularis proprial gastric cancer (MPGC).

METHODOLOGY

Seventy-three patients who underwent curative gastrectomy for MPGC were divided into 14 patients with postoperative recurrence (Group 1) and 59 patients without recurrence (Group 2). A retrospective study of Group 1 compared the clinicopathological features with Group 2.

RESULTS

There were no significant differences of age, gender and operative method including frequency of lymph node dissection between Group 1 and Group 2. Although tumor size, gastric location and histological type did not significantly differ between the two groups, the rate of Borrman type in Group 1 (71.4%) was significantly higher than in Group 2 (42.4%). Significant risk factors of recurrence in pathological findings were the presence of secondary lymph node metastasis or more, lymphatic and venous involvement. Median survival in Group 1 (28.8 months) was significantly worse than in Group 2 (59.0 months). The 1-year, 3-year, and 5-year survival rates between Group 1 versus Group 2 were 71.4% versus 98.3% (p<0.01), 28.6% versus 96.7% (p<0.01), and 7. 1% versus 95.0 (p<0.01), respectively.

CONCLUSIONS

Prognosis of the postoperative recurrence in MPGC was very poor. More careful prophylactic treatment against recurrence of MPGC should therefore, be prescribed in patients with the aforementioned risk factors of recurrence.

Postoperative chemotherapy may improve prognosis in unresectable gastric cancer

We have retrospectively evaluated to prognosis of patients with unresectable gastric cancer (UGC) and the effect of postoperative chemotherapy on that prognosis. One hundred patients who died of UGC included 37 patients who received postoperative chemotherapy (chemotherapy group) and 63 patients who did not receive postoperative chemotherapy (control group). Chemotherapy regimens were as follows: intravenous mitomycin (MMC) plus 5-fluorouracil (5-FU) (n=15), oral 5-FU alone (n=10), intravenous methotrexate (MTX) plus 5-FU (n=8), intravenous cisplatin plus 5-FU (n=2), and hepatic arterial infusion of 5-FU plus oral 5-FU (n=2). No prior chemotherapy or radiation therapy was given. All patients' cancers were stage IV. Median survival of the chemotherapy group (238 days) was significantly longer than the control group (137 days). The 1-year survival rate in the treated group was 19.0% but only 2.4% in the control group (p < 0.01). Patients with palliative gastrojejunostomy did not survive significantly longer than those having laparotomy alone or ileal tube insertion. We conclude that the prognosis for patients with UGC remains very poor, but postoperative chemotherapy may contribute to prolonged survival in patients with UGC.

Long-term survivor with liver metastases from rectal cancer treated by hepatectomy after hepatic arterial infusion chemotherapy

A 58-year-old man who had rectal cancer with synchronous hepatic metastases of bilateral lobe is described in this case report. Anterior resection for rectal cancer was performed, and subsequent hepatic arterial infusion (HAI) chemotherapy for liver metastases was continued. Nine months later, although right hepatic metastases showed complete remission after chemotherapy, metastases of the left lateral segment were still remained. Left lateral segmentectomy of the liver was performed. HAI chemotherapy has continued for 17 months after hepatectomy to prevent intrahepatic recurrence of the tumor. The patient has been no evidence of recurrence including hepatic metastasis, and he is still doing well 8 years after initial HAI chemotherapy. A review of the literature reveals that this patient has survived longer than any other patient has with hepatic metastases from colorectal cancer treated by this approach. We suggest that this form of therapy should be considered for future patients.

Carcinoembryonic antigen and intra-arterial chemotherapy response of liver metastases

BACKGROUND/AIMS

We investigated the relationship between serum carcinoembryonic antigen and response to hepatic artery chemotherapy for unresectable colorectal liver metastases.

METHODOLOGY

The study included 14 patients with unresectable colorectal liver metastases receiving hepatic arterial chemotherapy weekly. Patients were evaluated monthly including liver function tests and carcinoembryonic antigen. Ten patients received high dose 5-fluorouracil (1000 mg/m2) and 4 patients received other regimens. One patient underwent hepatectomy for cure after 5-fluorouracil.

RESULTS

Thirteen patients (93%) had normal quality of life without toxicity during hepatic artery infusion. Response rate in the high dose 5-fluorouracil group was 50%, while the response rate of other regimens was 25%. Mean survival time differed between responding (n = 6) and non-responding patients (n = 8) (527 vs 289 days), and the high dose 5-fluorouracil (n = 10) and other regimens (n = 4) (462 vs 213 days). In responding patients, peak serum carcinoembryonic antigen levels before hepatic artery infusion decreased within 6 months. In the non-responding patients, serum carcinoembryonic antigen levels increased rapidly despite hepatic artery infusion.

CONCLUSIONS

Serum carcinoembryonic antigen levels correlated well with response. Hepatic artery infusional chemotherapy with high dose 5-fluorouracil may be recommended as effective treatment for unresectable liver metastasis from colorectal cancer if serum carcinoembryonic antigen levels decrease within 6 months.

Arterial ketone body ratio does not correlate with ischemic changes during major hepatectomy

BACKGROUND/AIMS

The arterial ketone body ratio (AKBR) has been proposed as an accurate indicator of hepatic mitochondrial redox potential. However, recent studies of the utility of the AKBR as a biochemical marker have been called into question. It is not clear whether the AKBR is closely related to ischemic changes during major hepatectomy.

METHODOLOGY

Arterial acetoacetate and beta-hydroxybutyrate concentrations were measured in eleven patients who underwent major hepatectomy. The ratio between them (AKBR) was calculated before and after vascular occlusion during the hepatectomy procedure.

RESULTS

The AKBR increased following normothermic arterial or portal venous ischemia as compared to the levels prior to vascular occlusion in 36.4% of the patients who underwent major hepatectomy. An AKBR of less than 0.5 prior to vascular occlusion did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 throughout surgery was not a consistent risk factor for postoperative complications or liver dysfunction.

CONCLUSIONS

The AKBR does not correlate with ischemic changes or postoperative complications after major hepatectomy.

Hepatic metastasis from esophageal cancer treated by surgical resection and hepatic arterial infusion chemotherapy

We herein describe a successful surgical resection of esophageal cancer with syncronous liver metastasis and report the first case of a partial response to hepatic arterial infusion chemotherapy for recurrence of esophageal hepatic metastasis after hepatectomy. Hepatectomy and subsequent hepatic arterial infusion chemotherapy with cisplatin and 5-fluorouracil is thus recommended as an effective treatment for liver metastasis from esophageal cancer.

Surgery for gastric cancer in patients older than 80 years of age

BACKGROUND/AIMS

Although the number of elderly patients who undergo surgery for gastric cancer has increased in recent years, the clinical features associated with this group of patients, including their postoperative survival rate, remain unclear.

METHODOLOGY

The cases of 50 patients > or = 80 years of age (the older group) with gastric cancer who underwent surgical treatment in our Department from January 1988 to December 1995 were reviewed and compared to the records of 239 patients < or = 60 years of age (the younger group) who had surgery during the same time period.

RESULTS

The incidence of advanced gastric cancer in the older versus younger groups was 59.6% versus 27.9%, respectively (p < 0.01). The tumor size was significantly larger in the older group. The tumor location in the older group predominantly involved the upper third of the stomach, while in the younger group, the middle third of the stomach was primarily involved. Histologically, the incidence of differentiated tumor types was 65.1% versus 50.5% (p < 0.05), and undifferentiated types, 34.9% versus 49.5% (p < 0.05), in the older and younger groups, respectively. Retrospective comparisons conducted between the older and younger groups revealed the following: curative resectability rate: 52.0% versus 74.5% (p < 0.01); hospital mortality rate: 2% versus 0%; overall 5-year survival rate: 46.1% versus 71.1% (p < 0.01); and a 5-year survival rate in patients who underwent curative resection of 65.0% versus 88.8% in the older versus younger age groups, respectively.

CONCLUSIONS

These results suggest that the survival of elderly patients with gastric cancer is worse than that of younger patients because of a lower curative resection rate of the advanced cancer. However, the survival rate in elderly patients is identical to that in younger patients if a curative resection is performed.

Hemorrhage into a simple liver cyst: diagnostic implications of a recent case

Hemorrhage complicating simple liver cyst is rare. On imaging studies, the differential diagnosis between intracystic hemorrhage and cystadenocarcinoma of the liver is unreliable, and hepatectomy has been performed for benign liver cyst in this situation. We describe the characteristics of hemorrhage into a liver cyst in a patient who underwent dome resection of the cyst. In our patient, important diagnostic findings included benign cytologic features in a cyst fluid specimen aspirated with ultrasonographic guidance and a fall in hemoglobin and hematocrit, suggestive of hemorrhage. Other informative features were absence of communication between the intrahepatic bile ducts and the cystic liver lesion upon endoscopic retrograde cholangiopancreatography, as well as benign intraoperative frozen-section histology.

[Anesthesia for a patient with macrothrombocytopenia]

A 56-year-old female with macrothrombocytopenia was scheduled for colectomy and hepatectomy. She had not shown significant bleeding tendency. Her preoperative platelet counts were 0.5-1.6 x 10(4) microliters-1 with the use of an automated cell counter. However, microscopic examination showed platelet number ranging 0.9-3.4 x 10(4) microliters-1 and many macrothrombocytes. Therefore, platelet biomass (platelet number x platelet volume) seemed almost normal. Bleeding time was 3 minutes and platelet function was normal. She received preoperatively high dose gamma-globulin administration and intraoperatively platelet transfusion. The operation was performed under combined epidural and general anesthesia. Intra- and post-operative course was uneventful.

Endoscopic nasobiliary drainage for bile duct injury after laparoscopic cholecystectomy

Bile duct injuries are a potential complication of laparoscopic cholecystectomy (LC). A patient who underwent successful endoscopic nasobiliary drainage (ENBD) for a bile duct injury sustained during LC is presented. Of particular note, the patient also had Chilaiditi's syndrome. A 59-year-old woman was admitted with symptomatic cholecystolithiasis and Chilaiditi's syndrome. LC was performed. Postoperatively, the patient complained of abdominal discomfort. Laboratory examination revealed cholestasis. Bilious material began spilling from an intraabdominal drain. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed bile leakage. ENBD was performed. Repeat ERCP 10 days later failed to show a bile leak or stenosis of the common bile duct. The patient improved rapidly and had no complaints after the procedure. ENBD is a useful endoscopic technique to prevent peritonitis from bile leakage after LC. Chilaiditi's syndrome is not a contraindication for LC.

Arterial ketone body ratio during hepatectomy

The arterial ketone body ratio (AKBR) has been proposed as an accurate indicator of liver mitochondrial redox potential. However, the efficacy of the AKBR as a biochemical marker has been recently called into question. To resolve this issue, we studied the effect of temporary vascular occlusion on the AKBR during hepatectomy. Twenty patients undergoing hepatectomy were divided into two groups: those with hepatocellular carcinoma with a history of hepatic cirrhosis (n = 10; cirrhotic group) and those with liver disease without cirrhosis (n = 10; non-cirrhotic group). To minimize blood loss during hepatectomy, temporary vascular occlusion was applied using the Pringle maneuver. Acetoacetate and beta-hydroxybutyrate concentrations in the arterial blood and the AKBR were determined before and after vascular occlusion. In 25% of the two groups combined, the AKBR increased following normothermic ischemia, as compared with the levels prior to clamping; in 20% of cases in the cirrhotic group, it increased immediately following reperfusion, as compared with the levels prior to clamping. Changes in the AKBR during hepatectomy did not correlate with preoperative hepatocellular function. An AKBR of less than 0.7 prior to clamping which persisted during surgery was not a consistent risk factor for postoperative complications. The AKBR was not a useful predictor of liver viability in partial liver resection with temporary vascular occlusion.

Surgical treatment of gastric cancer detected by mass screening

BACKGROUND/AIMS

It is crucial to improve the postoperative prognosis of patients with gastric cancer in geographic regions where the incidence of gastric cancer is high. This study compared the efficacy of surgical treatment in patients with gastric cancer detected by a mass screening survey with that of patients diagnosed in accordance with standard medical practice.

METHODOLOGY

The subjects included 189 patients with gastric cancer detected by a mass screening survey (screening group) who underwent surgical treatment from 1988 to 1995, and 517 patients who underwent a standard medical work-up (non-screening group).

RESULTS

The incidence of early gastric cancer, curative resectability rate, and 5-year survival rates between the screening and non-screening groups were 73.0% versus 48.4% (p < 0.01), 90.5% versus 66.7% (p < 0.01), and 86.2% versus 61.0% (p < 0.01), respectively.

CONCLUSIONS

Surgical treatment for patients with gastric cancer identified by mass screening is effective in saving lives and reduces the mortality from gastric cancer in the target population of mass screening. However, a further prospective randomized controlled study of this screening method will be necessary in the future.

Surgical outcome in early gastric cancer with lymph node metastasis

BACKGROUND/AIMS

Definitive surgical management of early gastric cancer with lymph node metastasis has not been established. This paper describes the clinico-pathologic characteristics of early gastric cancer with lymph node metastasis.

MATERIALS AND METHODS

A retrospective study of early gastric cancer with lymph node metastasis (32 patients) was performed to compare clinico-pathologic features with patients without lymph node metastasis (283 patients).

RESULTS

All patients with lymph node metastasis had submucosal gastric invasion. The incidence of histologically proven curative resection in patients with lymph node metastasis was significantly lower than in those without metastasis (40.6% versus 93.3%). The 5-year survival rate was poorer in patients with positive nodes than in those with negative nodes (83.8% versus 96.2%). Recurrence was more frequent in patients with involved nodes (12.5% versus 0.4%). Lymph node metastasis was more frequent with the following: submucosal invasion, tumor over 5 cm in size, positive venous involvement, and an advanced growth pattern.

CONCLUSIONS

Pre-operative and intra-operative evaluation for lymph node metastasis is essential for the appropriate surgical treatment of early gastric cancer.

Clinicopathologic features of submucosal carcinoma of the stomach

A retrospective study of 155 patients with submucosal gastric carcinoma compared the clinicopathologic features with mucosal and muscularis proprial gastric carcinoma. Fifty-seven percent of the patients presented with gastrointestinal symptoms, whereas 36.1% had been detected by mass screening. The incidence of curative resection, lymph node metastasis, and complications were 96.1, 20.6, and 14.8%, respectively. Two patients died of sepsis and pulmonary infarction 30 days post-operatively. Five patients died of recurrent gastric cancer 1-5 years postresection. The overall 5-year survival rate was 90.2%. Recurrence patterns, histologic type, lymph node metastasis, lymphatic and venous infiltration, and growth pattern were similar to those of muscularis proprial carcinoma rather than mucosal carcinoma. Therefore, curative gastrectomy with extended lymphadenectomy (D2) may be feasible for submucosal carcinoma of the stomach.

[A case of carcinoid tumor of left superior trunk treated by sleeve upper lobectomy]

A case of bronchial carcinoid was reported. A 39-year-old male was suffered from recurrent pneumonia. Bronchofiberscopy revealed a polipoid tumor nearly obstructing left superior bronchial trunk. CT scan showed a round tumor about 1 cm in diameter. Resection of the tumor was carried out by sleeve upper lobe loectomy. Histological diagnosis was typical carcinoid, and there was no lymph node matastasis. Postoperative course was uneventful. Granulation and stenosis were not observed at the part of anastomosis.

Chronic cholecystitis following hemobilia due to traumatic intrahepatic injury

We report a patient who presented with colicky abdominal pain, hematemesis, and melena following a blunt abdominal injury sustained in an automobile accident. Serologic tests suggested liver dysfunction and computed tomography (CT) revealed dilatation of the intrahepatic bile duct. Duodenoscopy demonstrated hemobilia originating from the duodenal papilla of Vater. Angiography revealed a pseudoaneurysm of the hepatic artery and angiographic embolization sucessfully stopped the hemorrhaging. However, even following the angiographic embolization, the patient remained symptomatic and repeat CT demonstrated thickening of the gallbladder wall and a lesion resembling a blood clot. We strongly suspected cholecystitis and performed a laparoscopic cholecystectomy. Grossly, the resected specimen revealed wall thickening with a congested mucosa and three blood clots; histologically, these changes were consistent with a diagnosis of chronic cholecystitis. The clinical message of this paper is that patients should be observed for this usual complication of hemobilia after liver injury.

Platysma musculocutaneous flap for reconstruction of trachea in esophageal cancer

In 2 patients with advanced cervical esophageal cancer invading the trachea, total laryngoesophagectomy with resection of the posterior portion of the trachea and lymph node dissection of the bilateral neck and superior mediastinum was carried out. The partial defect in the trachea was repaired with a platysma musculocutaneous flap. A permanent tracheostoma, composed of the tracheal remnant anteriorly and the platysma musculocutaneous flap posteriorly, was made just over the manubrium sterni.

Enhanced production of endogenous prostaglandin in obstructive jaundiced pancreas in dogs

Endogenous pancreatic prostaglandin production in control and obstructive jaundice was investigated using isolated and perfused dog pancreas. In both groups, spontaneous production of prostaglandin E2 and prostaglandin I2 was recorded, and the levels did not change in both groups. The production of both prostaglandins in jaundice, however, was higher than that in the control on stimulation by 8 x 10(-11) mol of cholecystokinin-octapeptide. Amylase release with cholecystokinin-octapeptide at an amount of 8 x 10(-11) mol in jaundice was higher than in the control. The amylase release in both groups, however, showed further elevation on indomethacin pretreatment. On incubation of pancreatic dispersed cells in both groups, prostaglandin production in jaundiced cells was higher than that in control cells. These data showed that enhanced endogenous prostaglandin in obstructive jaundice might be caused by the characteristic change of pancreatic cells, which increased susceptibility to cholecystokinin-octapeptide because of long-term exposure to abnormal blood components, and enhanced prostaglandins might act as a cytoprotector of acinar cells in the pancreas damaged by cholecystokinin-octapeptide administration.

Endoscopic and manometric study of the cardia in post-gastrectomy patients

This study was undertaken to clarify the incidence of hiatus hernia and the functional changes in the cardia of post-gastrectomy patients. One hundred and four post-gastrectomy patients and 399 non-gastrectomy patients were selected for endoscopic study, and the diagnosis of hiatus hernia was made by observing the shape of the cardia inside the stomach. A manometric study was also done on 12 patients with gastric carcinoma and 14 patients with gallstones. Hiatus hernia was observed in 37.5 per cent of the post-gastrectomy patients, this incidence being significantly higher than the 19.3 per cent of the non-gastrectomy patients (p less than 0.01). In the latter group alone the incidence of hernia steadily increased with advancing age. In the post-gastrectomy patients, reflux esophagitis and heartburn were observed in 20.2 per cent and 27.9 per cent, respectively. These incidences tended to be higher in the patients with hernia but there were no significant differences. The manometric study revealed that lower esophageal sphincter pressure was significantly decreased after gastrectomy, but not after cholecystectomy.

Involvement of endogenous prostaglandins in pancreatic endocrine and exocrine secretion in dog pancreas

The involvement of endogenous prostaglandins (PGs) in pancreatic endocrine and exocrine secretion was investigated, using the isolated and perfused dog pancreas. Spontaneous production of both PGE2 and 6-keto-PGF1 alpha was recorded in venous effluent. Prostaglandin production increased following stimulation with both 10 x 10(-11) and 20 x 10(-11) mol of CCK-8, but was not affected by a 5 x 10(-11) mol infusion. Insulin, glucagon, and amylase release was stimulated by 10 x 10(-11) mol of CCK-8. Indomethacin pretreatment with 10 mg/kg totally abolished endogenous PG production, but failed to suppress an insulin and glucagon response. On the other hand, an amylase response was accelerated by indomethacin pretreatment. Although low dose CCK-8 failed to stimulate endogenous prostaglandin production, a brisk exocrine secretion was not suppressed by indomethacin pretreatment. From the above results, we conclude that endogenous PGs do not appear to play an important role in pancreatic endocrine and exocrine secretion, but might have a cytoprotective effect on the pancreatic acinar cells damaged by CCK-8.

[Usefulness of subcutaneously implanted reservoir for postoperative therapy in hepatocellular carcinoma and liver metastases of colorectal carcinoma]

Hepatectomy has been a treatment of choice for hepatocellular carcinoma and metastatic liver carcinoma. Recurrence in residual liver after hepatectomy is clinically a serious problem. Since 1987, postoperative hepatic arterial infusion chemotherapy using subcutaneously implanted reservoir has been undertaken to improve the prognosis after hepatectomy in hepatocellular carcinoma and liver metastasis of colorectal carcinoma. The indications for reservoir implantation were determined for high-risk cases in hepatocellular carcinoma and all cases in liver metastasis. The tip of a catheter was placed at the root of the common hepatic artery via gastroduodenal artery. Lipiodol-ADM was injected for hepatocellular carcinoma every 2 months and MMC-5-FU was injected for liver metastasis of colorectal carcinoma every one or two weeks. Complications of this procedure in every 2 cases of reservoir infection proved to be catheter obstruction and hepatic artery obstruction. In the process of this treatment, we observed 3 recurrences in residual liver of hepatocellular carcinoma and one case of peritoneal dissemination and 3 recurrences in residual liver of liver metastasis of colorectal carcinoma. All are still alive.

Aerobic power as related to body growth and training in Japanese boys: a longitudinal study

Maximal aerobic power was measured for 5-6 successive years in 50 Japanese schoolboys starting from the age of 9 or 13 yr. and for 2-3 yr in 6 superior junior runners from the age of 14 yr. A large increase in aerobic power was observed during the adolescent growth spurt for 7 schoolboys who trained between the ages of 9 and 14 yr. Aerobic power for 43 average schoolboys increased from 45.0 to 52.2 ml/kg.min between the ages of 13 and 17 yr. The aerobic power of 6 superior junior runners increased from 63.4 to 73.4 ml/kg.min between the ages of 14 and 17 yr. A remarkable increase in aerobic power was not observed in trained boys before the age of peak height growth velocity (PHV). Beginning approximately 1 yr prior to the age of PHV and thereafter, training effectively increased aerobic power above the normal increase attributable to age and growth. The highly developed aerobic power found in superior junior runners may have been derived from strenuous training and partially by genetically superior endowment.