[A Case of Noninvasive Ductal Carcinoma Arising in Benign Phyllodes Tumor]

A 70-year-old woman underwent a partial mastectomy with preoperative diagnosis of phyllodes tumor. Histopathological examination of the resected specimen revealed noninvasive ductal carcinoma of up to 20 mm in the phyllodes tumor. We note the possibility of a situation in which a phyllodes tumor is accompanied by cancer, and detailed pathological examination is necessary.

[A Case of Unresectable Colorectal Cancer with Complete Remission after Palliative Surgery Due to Continued Pharmacotherapy]

A 50s-year-old man was admitted to our hospital because of abdominal pain and vomitting. CT showed a thickened wall of the sigmoid colon, marked enlargement of the oral side, and a 30 mm tumor on the left lateral section of the liver. We diagnosed colonic obstruction due to sigmoid colon cancer with liver metastasis. We failed to place a colonic stent for decompression, so we performed a colostomy using the cecum. An exploratory laparoscopy was performed instead of curative surgery due to peritoneal disseminations, followed by chemotherapy and molecular targeted therapy. Although primary lesion, liver metastatic lesion and disseminated lesions were reduced by pharmacotherapy the patient developed a grade 2 skin disorder around the colostomy. Therefore, it was determined that molecular targeted therapy could not be continued. The resection of the primary lesion and closure of the colostomy were performed to continue pharmacotherapy. Pharmacotherapy was resumed after operation. The patient is currently getting complete remission, undergoing maintenance therapy with no skin disorders. In this case, surgery was performed as part of the multidisciplinary treatment. It suggested that palliative surgery might be an effective option in multidisciplinary treatment.

[A Case of Intussusception Due to Ileal Malignant Lymphoma of AYA Generation]

The case is a 17-year-old man. He had complained of right lower abdominal pain for a week. He had no symptoms such as fever, weight loss, or night sweats. He was diagnosed with intussusception by abdominal contrast-enhanced CT and was hospitalized. The day after hospitalization, lower gastrointestinal endoscopy was performed, and a tumor 25 mm in size was found in the invagination of the ileum. Intussusception was recovered by intestinal scope insufflation, and the tumor was found to be a type 1 tumor located approximately 5 cm proximal to the Bauhin's valve. On day 17 of hospitalization, he had intussusception again at the time of surgery, and performed laparoscopic reduction before performing laparoscopy-assisted partial resection of the small intestine and appendectomy. The postoperative course was good and he was discharged on POD12(on day 29 of hospitalization). Histopathological diagnosis was diffuse large B-cell lymphoma(DLBCL), and chemotherapy was to be administered at the referral hospital. In intussusception of the adolescents and young adults(AYA)generation, such as this case outside of childhood, it is necessary to treat the patient with consideration for the presence of neoplastic lesions such as malignant lymphoma. We report our case with some literature considerations.

[A Case of Rectal Cancer with Collet-Sicard Syndrome]

The case was a woman in her 50s. Total pelvic resection was performed for advanced rectal cancer(cT4b[vagina]N3M0, cStage Ⅲc), after neoadjuvant chemoradiation therapy. Five months after the operation, she was unable to stand due to severe back pain. Spinal MRI revealed multiple bone metastases and lumbar fractures. In addition, dysphagia and dysarthria rapidly progressed almost simultaneously with back pain. Initially, brain metastasis was suspected, but head MRI revealed Collet-Sicard syndrome due to skull base metastasis. Irradiation to the skull base and high cervical spine, thoracolumbar spine was started. After irradiation, her back pain and cranial nerve symptoms improved. She was discharged and received palliative treatment. About a month after discharge, she was hospitalized for recurrent dysphagia and died on day 5 of hospitalization. Collet-Sicard syndrome is caused by damage to the cranial nerves Ⅸ to Ⅻ and is often caused by a tumor. Trauma, vasculitis, and internal carotid artery dissection have been reported as other causes. Symptoms such as hoarseness, dysarthria, tongue atrophy, dysphagia, and headache have been reported. Collet-Sicard syndrome due to bone metastasis of colorectal cancer were very rare, and we found only one other report. We report our case with some literature considerations.

[A Case of Rapidly Growing Breast Spindle Cell Carcinoma]

We report a case of rapidly growing breast spindle cell carcinoma. The case was a 69-year-old female. Her chief complaint was right breast pain. She was being followed after surgery for left breast cancer but was seen because of right breast pain. In the right mammary gland CD area, a 27×27 mm large unclear mass lesion was observed, which had not been seen half a year prior. Right mastectomy and axillary dissection were performed following a preoperative diagnosis of pT2N1M0, pStage ⅡB ductal carcinoma. Currently, 2 years and 2 months have passed since the operation, and recurrence has not been observed. Case reports of rapidly growing breast spindle cell carcinoma are occasionally found, but no literature specifically defines acute growth. Here, we defined rapid growth using the tumor doubling time(DT)proposed by Gerstenberg et al. Of all the reported cases of breast spindle cell carcinoma, the DT was fewer than 90 days in most cases. Breast spindle cell carcinoma demonstrates rapid grown compared to normal breast cancer.

[A Case of Effective Peritoneo-Venous Shunt for Refractory Malignant Ascites in a Gastric Cancer Patient with Peritoneal Dissemination]

This paper reports a case of refractory ascites in a patient with gastric cancer. A peritoneo-venous shunt(PVS)was inserted in the patient, which contributed to extending the duration of home-based care as well as improving the patient's quality of life. The patient was a female in her 70s. She was diagnosed with gastric cancer and underwent total gastrectomy. Five years and 7 months after the surgery, she was diagnosed with peritoneal recurrence. Ascites temporarily decreased following chemotherapy, but gradually worsened thereafter. Since the patient required frequent puncture drainage for the ascites, cell-free concentrated ascites reinfusion therapy(CART)was performed. However, on the day prior to the scheduled second course of CART, marked abdominal distension was observed. Therefore, a PVS was inserted. No PVS-associated complications were observed. Following the insertion of the PVS, the patient's abdominal circumference and body weight markedly improved. Best supportive care(BSC)was provided to the patient as she became weak after undergoing several courses of chemotherapy on an outpatient basis. On the other hand, the PVS was working properly. The patient was able to continue her daily life activities at home. She died from the cancer after 164 days of the PVS insertion.

[A Case of Colon Metastasis from Invasive Lobular Carcinoma of the Breast]

The patient was a 48-year-old woman. She consulted our hospital with a chief complaint of vomiting. Colonoscopy showed stenosis and edematous mucosa, and biopsy was performed. Histological examination demonstrated the lesion to be colonic metastasis of breast cancer, invasive lobular carcinoma. Although colorectal metastasis of breast cancer has a poor prognosis and chemotherapy is considered as the main treatment modality, hormone therapy is also a treatment option depending on the condition.

[Long-Term Survival of a Rectal Cancer Patient with Virchow Lymph Node Metastasis, Liver Metastasis, and Para-Aortic Lymph Node Metastasis]

A 67-year-old female was diagnosed with Stage Ⅳ rectal cancer with paraaortic lymph node metastasis. The patient underwent Hartmann's operation with D3 lymph node and paraaortic lymph node dissection. Postoperative chemotherapy with FOLFIRI was then administered for 1 year. However, liver metastasis developed, for which partial hepatectomy was performed. Postoperative chemotherapy with S-1(20 courses)was then administered. Three years and 11 months following the first operation, lymph node metastases developed and resection of lymph nodes(No. 12p, No. 16b1int)was performed. Postoperative chemotherapy with capecitabine(Cape)(8 courses)was then administered. Five years and 7 months following the first operation, Virchow lymph node metastasis developed. Despite chemotherapy with Cape and bevacizumab (Bmab), Virchow lymph node swelling recurred, and resection was performed. Nine years and 4 months following the first operation, lymph node metastases developed, and resection of lymph nodes(Virchow, No. 16b1int)was performed. Postoperative chemotherapy with S-1(8 courses)was then administered. At present, 11 years and 4 months after the first operation, the patient, whose chemotherapy has been discontinued, is alive without recurrence.

[A Case of Gallbladder Jejunal Anastomosis and Duodenal Jejunal Anastomosis to Maintain QOL for an Elderly Patient with Pancreatic Cancer]

An 87-year-oldwoman was admittedto our hospital with abdominal pain andfever. Computedtomography showeda 25 mm tumor mass in the pancreatic headandshowedd ilatation of the pancreatic duct andcommon bile duct. She was diagnosed with obstructive cholangitis due to pancreatic head cancer. An endoscopic naso-biliary drainage(EUS)tube was inserted, and an endoscopic ultrasound(ENBD)examination was performed. At this time, duodenal perforation occurred, and an emergency operation was performed. During the laparotomy, perforation was found in the anterior wall of the duodenum. The contamination in the abdominal cavity and the degree of tissue damage in the duodenum were mild. Gall bladder jejunal andd uodenal jejunal anastomoses were performedfor biliary bypass andto close the perforation andbypass the gastrointestinal tract, respectively. She hadno postoperative complications andwas discharged 13 days postoperatively. Oral intake was possible after discharge, andthe patient returnedhome without complications. She died 5 months postoperatively. In this case, we performedbile duct andgastrointestinal bypass surgery prophylactically. Although this surgery will not be effective for all patients, we thought that it wouldbe useful for predicting the patient's future condition and for increasing the procedural options, even in case of emergency surgery.

[A Case of HER2 Positive Locally Advanced Breast Cancer Successfully Treated with a Combination Therapy of Eribulin, Trastuzumab and Pertuzumab]

The patient was an 82-year-oldwoman. She consultedour hospital with a chief complaint of left breast mass. MRI showed enhancedtumor with skin andextensive pectoral muscle invasion, so it was unresectable. Immunohistopathological analysis revealeda HER2-positive lesion. We administerederibulin, trastuzumab andpertuzumab, after which the tumor became resectable. Histological examination revealedremarkable response. Combination therapy of eribulin, trastuzumab andpertuzumab was well toleratedandconsid eredto be effective.

[Pulmonary Metastasis Resection Twice after Curative Resection of Esophageal Cancer-A Long-Term Survival Case]

The prognosis of patients with esophageal cancer recurrence is poor, and surgical treatment is rarely performed. Here, we report on a patient with long-term survival who underwent pulmonary metastasis resection twice after curative resection of esophageal cancer. A 62-year-old male underwent curative resection of esophageal cancer after preoperative chemoradiotherapy. The histopathological diagnosis was poorly differentiated squamous cell carcinoma(pT2N1M0, fStage Ⅱ). Five months after the operation, right lung metastasis(right-S2)was detected. Accordingly, pulmonary metastasis resection was performed. Fourteen months after the initial operation, left lung metastases(left-S3/S6)were detected. The patient underwent resection again for the pulmonary metastases. The patient died of pneumonia without recurrence 8 years 3 months after the initial operation. In selected cases, surgical resection seems effective for treating distant esophageal cancer metastasis, suggesting that surgery should be an option in cases of accumulation of numerous distant metastases in esophageal cancer.

[A Comparison of the Treatment Methods for Obstructive Colorectal Cancer]

PURPOSE

Emergency surgery for obstructive colorectal cancer is considered to be associated with a high degree of risk, and surgery may after decompression is considered to be safer. In cases of obstructive colorectal cancer, decompression can be achieved with surgery, an ileus tube, or a stent, depending on the disease condition. We herein compare the treatment methods for obstructive colorectal cancer.

METHODS

Forty-two patients with obstructive colorectal cancer underwent emergency treatment between January 2012 and December 2016.

RESULTS

Among the patients with obstructive colorectal cancer, 18 receiveda stent, 10 receiveda nasal ileus tube, 6 receiveda transanal ileus tube, 5 underwent stoma construction, and 3 underwent emergency surgery without decompression. The stent group showed the highest laparoscopic operation rate. There was no significant difference in the overall survival of the treatment groups. One patient in the stent group developed duplicated cancer.

CONCLUSION

Stent placement can be considered to be a viable option in the emergency treatment for obstructive colorectal cancer because laparoscopic surgery anda preoperative examination can be performed.

Successful resection of metachronous para-aortic, Virchow lymph node and liver metastatic recurrence of rectal cancer

A 66-year-old female presented with the main complaint of defecation trouble and abdominal distention. With diagnosis of rectal cancer, cSS, cN0, cH0, cP0, cM0 cStage II, Hartmann’s operation with D3 lymph node dissection was performed and a para-aortic lymph node and a disseminated node near the primary tumor were resected. Histological examination showed moderately differentiated adenocarcinoma, pSS, pN3, pH0, pP1, pM1 (para-aortic lymph node, dissemination) fStage IV. After the operation, the patient received chemotherapy with FOLFIRI regimen. After 12 cycles of FOLFIRI regimen, computed tomography (CT) detected an 11 mm of liver metastasis in the postero-inferior segment of right hepatic lobe. With diagnosis of liver metastatic recurrence, we performed partial hepatectomy. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer with cut end microscopically positive. After the second operation, the patient received chemotherapy with TS1 alone for 2 years. Ten months after the break, CT detected a 20 mm of para-aortic lymph node metastasis and a 10 mm of lymph node metastasis at the hepato-duodenal ligament. With diagnosis of lymph node metastatic recurrences, we performed lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as metastatic rectal cancer in para-aortic and hepato-duodenal ligament areas. After the third operation, we started chemotherapy with modified FOLFOX6 regimen. After 2 cycles of modified FOLFOX6 regimen, due to the onset of neutropenia and liver dysfunction, we switched to capecitabine alone and continued it for 6 mo and then stopped. Eleven months after the break, CT detected two swelling 12 mm of lymph nodes at the left supraclavicular region. With diagnosis of Virchow lymph node metastatic recurrence, we started chemotherapy with capecitabine plus bevacizumab regimen. Due to the onset of neutropenia and hand foot syndrome (Grade 3), we managed to continue capecitabine administration with extension of interval period and dose reduction. After 2 years and 2 mo from starting capecitabine plus bevacizumab regimen, Virchow lymph nodes had slowly grown up to 17 mm. Because no recurrence had been detected besides Virchow lymph nodes for this follow up period, considering the side effects and quality of life, surgical resection was selected. We performed left supraclavicular lymph node dissection. Histological examination revealed moderately differentiated adenocarcinoma as a metastatic rectal cancer. After the fourth operation, the patient selected follow up without chemotherapy. Now we follow up her without recurrence and keep her quality of life high.

A Novel Method for Real-Time Audio Recording With Intraoperative Video

OBJECTIVE

Although laparoscopic surgery has become widespread, effective and efficient education in laparoscopic surgery is difficult. Instructive laparoscopy videos with appropriate annotations are ideal for initial training in laparoscopic surgery; however, the method we use at our institution for creating laparoscopy videos with audio is not generalized, and there have been no detailed explanations of any such method. Our objectives were to demonstrate the feasibility of low-cost simple methods for recording surgical videos with audio and to perform a preliminary safety evaluation when obtaining these recordings during operations.

DESIGN

We devised a method for the synchronous recording of surgical video with real-time audio in which we connected an amplifier and a wireless microphone to an existing endoscopy system and its equipped video-recording device. We tested this system in 209 cases of laparoscopic surgery in operating rooms between August 2010 and July 2011 and prospectively investigated the results of the audiovisual recording method and examined intraoperative problems.

SETTING

Numazu City Hospital in Numazu city, Japan.

PARTICIPANTS

Surgeons, instrument nurses, and medical engineers.

RESULTS

In all cases, the synchronous input of audio and video was possible. The recording system did not cause any inconvenience to the surgeon, assistants, instrument nurse, sterilized equipment, or electrical medical equipment. Statistically significant differences were not observed between the audiovisual group and control group regarding the operating time, which had been divided into 2 slots-performed by the instructors or by trainees (p > 0.05).

CONCLUSIONS

This recording method is feasible and considerably safe while posing minimal difficulty in terms of technology, time, and expense. We recommend this method for both surgical trainees who wish to acquire surgical skills effectively and medical instructors who wish to teach surgical skills effectively.

Esophageal intramural pseudodiverticulosis of the residual esophagus after esophagectomy for esophageal cancer

A 91-year-old man was referred to our hospital with intermittent dysphagia. He had undergone esophagectomy for esophageal cancer (T3N2M0 Stage III) 11 years earlier. Endoscopic examination revealed an anastomotic stricture; signs of inflammation, including redness, erosion, edema, bleeding, friability, and exudate with white plaques; and multiple depressions in the residual esophagus. Radiographical examination revealed numerous fine, gastrografin-filled projections and an anastomotic stricture. Biopsy specimens from the area of the anastomotic stricture revealed inflammatory changes without signs of malignancy. Candida glabrata was detected with a culture test of the biopsy specimens. The stricture was diagnosed as a benign stricture that was caused by esophageal intramural pseudodiverticulosis. Accordingly, endoscopic balloon dilatation was performed and anti-fungal therapy was started in the hospital. Seven weeks later, endoscopic examination revealed improvement in the mucosal inflammation; only the pseudodiverticulosis remained. Consequently, the patient was discharged. At the latest follow-up, the patient was symptom-free and the pseudodiverticulosis remained in the residual esophagus without any signs of stricture or inflammation.

Laparoscopic resection of a retroperitoneal schwannoma located in the hepatic hilus

Schwannomas are tumors and commonly occur in the head and neck region; however, they rarely present in the retroperitoneum. A 79-year-old man was admitted to our hospital for a follow-up of a tumor in the hepatic hilus. A 2.8 × 2.5 cm solid tumor located between the hepatic hilus and common hepatic artery was originally identified, and the size of the tumor had increased from 2.0 × 2.0 cm to 2.8 × 2.5 cm over the course of 3 years. The patient underwent percutaneous sonopsy, and the tumor was subsequently diagnosed as a benign schwannoma. Since the patient wished to undergo an operation, we performed laparoscopic surgery. During the operation, the tumor was detected in the retroperitoneal space, where it was strongly adhered between the left gastric artery and common hepatic artery. At this point, no major vessels had vascularized the tumor. We then completely removed the tumor from the retroperitoneal space without any complications. The clinical course was uneventful, and the patient was discharged on postoperative day 4 without any symptoms. Later, a definitive histopathologic examination revealed a benign schwannoma. Here, we report this rare case of a retroperitoneal schwannoma located in the hepatic hilus.

Expression profiling of the ephrin (EFN) and Eph receptor (EPH) family of genes in atherosclerosis-related human cells

Ephrin B1 and its cognate receptor, Eph receptor B2, key regulators of embryogenesis, are expressed in human atherosclerotic plaque and inhibit adult human monocyte chemotaxis. Few data exist, however, regarding the gene expression profiles of the ephrin (EFN) and Eph receptor (EPH) family of genes in atherosclerosis-related human cells. Gene expression profiles were determined of all 21 members of this gene family in atherosclerosis-related cells by reverse transcription-polymerase chain reaction analysis. The following 17 members were detected in adult human peripheral blood monocytes: EFNA1 and EFNA3 - EFNA5 (coding for ephrins A1 and A3 - A5); EPHA1, EPHA2, EPHA4 - EPHA6 and EPHA8 (coding for Eph receptors A1, A2, A4 - A6 and A8); EFNB1 and EFNB2 (coding for ephrins B1 and B2); and EPHB1 - EPHB4 and EPHB6 (coding for Eph receptors B1 - B4 and B6). THP-1 monocytic cells, Jurkat T cells and adult arterial endothelial cells also expressed multiple EFN and EPH genes. These results indicate that a wide variety of ephrins and Eph receptors might affect monocyte chemotaxis, contributing to the development of atherosclerosis. Their pathological significance requires further study.

Progression from macular retinoschisis to retinal detachment in highly myopic eyes is associated with outer lamellar hole formation

Aims:

To investigate the morphological changes that occur during the development of an early retinal detachment (RD) from a myopic macular retinoschisis (MRS) by optical coherence tomography (OCT).

Methods:

The OCT images of five eyes of five consecutive patients with myopic MRS who developed an RD during the follow-up period were studied.

Results:

The progression from MRS to early RDs went through four stages. In stage 1, OCT images appeared to show a focal irregularity of the thickness of external retina. In stage 2, an outer lamellar hole developed within the thickened area and a small RD developed. In stage 3, the column-like structures overlying the hole seemed to be separated horizontally, and the outer lamellar hole appeared to be larger vertically. In stage 4, the upper edge of the external retina was further elevated and attached to the upper part of the retinoschisis layer accompanied by further enlargement of the RD.

Conclusions:

This longitudinal study showed that the progression from myopic MRS to RD passes through four stages, and the formation of an outer lamellar hole predisposes the retina to a RD. These OCT findings might be useful for considering the surgical indication for eyes with a myopic MRS.

Use of multiplex PCR and real-time PCR to detect human herpes virus genome in ocular fluids of patients with uveitis

AIM

To measure the genomic DNA of human herpes viruses (HHV) in the ocular fluids and to analyse the clinical relevance of HHV in uveitis.

METHODS

After informed consent was obtained, a total of 111 ocular fluid samples (68 aqueous humour and 43 vitreous fluid samples) were collected from 100 patients with uveitis. The samples were assayed for HHV-DNA (HHV1-8) by using two different polymerase chain reaction (PCR) assays, qualitative PCR (multiplex PCR) and quantitative PCR (real-time PCR).

RESULTS

In all of the patients with acute retinal necrosis (n = 16) that were tested, either the HSV1 (n = 2), HSV2 (n = 3), or VZV (n = 11) genome was detected. In all patients, high copy numbers of the viral DNA were also noted, indicating the presence of viral replication. In another 10 patients with anterior uveitis with iris atrophy, the VZV genome was detected. When using multiplex PCR, EBV-DNA was detected in 19 of 111 samples (17%). However, real-time PCR analysis of EBV-DNA indicated that there were only six of the 19 samples that had significantly high copy numbers. The cytomegalovirus (CMV) genome was detected in three patients with anterior uveitis of immunocompetent patients and in one immunocompromised CMV retinitis patient. In addition, one patient with severe unilateral panuveitis had a high copy number of HHV6-DNA. There was no HHV7- or HHV8-DNA detected in any of the samples.

CONCLUSIONS

A qualitative multiplex PCR is useful in the screening of viral infections. However, the clinical relevance of the virus infection needs to be evaluated by quantitative real-time PCR.

P2Y2 receptor elevates intracellular calcium concentration in rabbit eye suprachoroid

Effects of ATP on the intracellular free calcium ion concentration ([Ca2+]i) in the rabbit eye suprachoroid were investigated by means of fura-2 microfluorophotometry. ATP application (10 to 100 microM) elicited a dose-dependent biphasic [Ca2+]i-increase: a fast phase typically peaking within 30 s and a following slow plateau phase, which lasted during the presence of ATP. The slow plateau phase was markedly diminished by removal of extracellular Ca2+, whereas the fast phase remained. An inhibitor of Ca2+ release from the sarcoplasmic reticulum (TMB-8), an endoplasmic Ca2+-ATPase inhibitor (thapsigargin) and a phospholipase C (PLC) inhibitor (U-73122) diminished the fast phase. A P2 receptor antagonist (Suramin) inhibited the ATP-induced [Ca2+]i-response. The potency order of ATP and related substances in producing the [Ca2+]i-elevation was UTP approximately equals ATP>ATP-gamma-S>ITP>ADP. beta,gamma-MethyleneATP, 2-methylthioATP and UDP evoked no response. This order is consistent with the P2Y2 receptor characteristics. Cross-desensitization between ATP and UTP excludes the co-existence of the other types of receptors. In conclusion, the ATP-induced [Ca2+]i-elevation in the rabbit eye suprachoroid was elicited by the Ca2+ release from the PLC-dependent, thapsigargin-sensitive intracellular Ca2+ storage sites by activating P2Y2 nucleotide receptors.