[A Case of Descending Colon Cancer with Distant Metastasis That Was Controlled Severe Side Effects of Chemotherapy and Achieved Long-Term CR]

A 69-year-old male patient with descending colon cancer with para-aortic lymph node metastasis underwent surgery to resect the primary tumor. After the surgery mFOLFOX6 plus panitumumab was introduced. Because 2 times drug-induced lung disease and Stevens Johnson syndrome were occurred, changes in chemotherapy regimen were required. 18 months after administration, complete response was achieved. The chemotherapy was discontinued 48 months after administration. He is alive without recurrence for 32 months after completion of treatment.

Surgery for multiple gastric gastrointestinal stromal tumors and large esophageal diverticulum related to germline mutation of the KIT gene: a case report

BACKGROUND

Familial gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the digestive tract caused by germline gain-of-function mutations in the KIT gene or platelet-derived growth factor receptor alpha gene (PDGFRA). These mutations cause not only multiple GISTs but also diffuse hyperplasia of interstitial cells of Cajal (ICCs), which is related to esophageal motility disorder.

CASE PRESENTATION

A 53-year-old man was referred to our hospital because of anemia and dysphagia. Fifteen years earlier, he had undergone a laparoscopic partial gastrectomy for multiple gastric GISTs with a germline mutation in exon 17 of the KIT gene. An upper gastrointestinal endoscopy revealed that the patient had multiple gastric GISTs and a large esophageal diverticulum directly above the esophagogastric junction. The largest gastric tumor was 7 cm, with a delle that might cause bleeding. Because the patient presented with dysphagia, we performed video-assisted thoracic esophagectomy and laparoscopic-assisted proximal gastrectomy simultaneously. The patient had survived without metastasis for 4 years after surgery and dysphagia had improved.

CONCLUSIONS

This is the first report of successful laparoscopic-thoracoscopic surgery for a patient with familial gastric GISTs accompanied with a large esophageal diverticulum.

Feasibility and learning curve for robotic surgery in a small hospital: A retrospective cohort study

Robotic surgery rates, typified by the use of the da Vinci Surgical System, have increased in recent years. However, robotic surgery is mostly performed in large hospitals and has not been fully implemented in small hospitals. Therefore, we aimed to verify the feasibility of robotic surgery in small hospitals and verify the number of cases in which perioperative preparation for robotic surgery is stable by creating a learning curve in small hospitals. Forty robot-assisted rectal cancer surgeries performed in large and small hospitals by a surgeon with extensive experience in robotic surgery were validated. Draping and docking times were recorded as perioperative preparation times. Unexpected surgical interruptions, intraoperative adverse events, conversion to laparoscopic or open surgery, and postoperative complications were recorded. Cumulative sum analysis was used to derive the learning curve for perioperative preparation time. Draping times were significantly longer in the small hospital group (7 vs 10 minutes, P = .0002), while docking times were not significantly different (12 vs 13 minutes, P = .098). Surgical interruptions, intraoperative adverse events, and conversions were not observed in either group. There were no significant differences in the incidence of severe complications (25% [5/20] vs 5% [1/20], P = .184). In the small hospital group, phase I of the draping learning curve was completed in 4 cases, while phase I of the docking learning curve was completed in 7 cases. Robotic surgery is feasible for small hospitals, and the preoperative preparation time required for robotic surgery stabilizes relatively early.

Simultaneous colonic metastasis of advanced gastric cancer: a case report

BACKGROUND

Although distant metastasis in gastric cancer can be present at the time of the initial diagnosis, colonic metastasis is extremely rare. This report describes a case of simultaneous colonic metastasis of advanced gastric cancer.

CASE PRESENTATION

The patient was a 78-year-old woman with nausea and epigastric pain. Upper gastrointestinal endoscopy revealed an advanced invasive ulcerative tumor in the lesser curvature of the stomach extending from the anterior to the middle portion. Colonoscopy revealed a 4-mm polyp-like lesion in the mid-transverse colon; therefore, a polypectomy was performed. Both gastric and colonic tumors showed poorly differentiated adenocarcinoma with signet ring cell carcinoma. After providing informed consent, the patient underwent a total gastrectomy. Histologic examination showed similar morphologic features of both gastric and colonic tumors. Immunohistochemistry staining showed that these tumor cells were positive for cytokeratin (CK) 7 and negative for CK20.

CONCLUSIONS

This was an extremely rare case of simultaneous colonic metastasis of advanced gastric cancer. Because missed metastasis can result in a poorer prognosis, we propose a systemic search including colonoscopy for patients with advanced gastric cancer, especially cases involving poorly differentiated adenocarcinoma or signet ring cell carcinoma.

Low G9a expression is a tumor progression factor of colorectal cancer via IL-8 promotion

The histone methyltransferase G9a is expressed in various types of cancer cells, including colorectal cancer (CRC) cells. Interleukin (IL)-8, also known as C-X-C motif chemokine ligand 8 (CXCL8), is a chemokine that plays a pleiotropic function in the regulation of inflammatory responses and cancer development. Here, we examined the relationship between G9a and IL-8 and the clinical relevance of this association. We immunohistochemically analyzed 235 resected CRC samples to correlate clinical features. Samples with high G9a expression had better overall survival and relapse-free survival than those with low G9a expression. Univariate and multivariate analyses demonstrated that low G9a expression remained a significant independent prognostic factor for increased disease recurrence and decreased survival (P<0.05). G9a was expressed at high levels in commercially available CRC cell lines HCT116 and HT29. Knockdown of G9a by siRNA, shRNA, or the G9a-specific inhibitor BIX01294 upregulated IL-8 expression. The number of spheroids was significantly increased in HCT116 cells with stably suppressed G9a expression, and the number of spheroids was significantly decreased in HCT116 cells with stably suppressed IL-8 expression. Thus, the suppression of IL-8 by G9a may result in a better prognosis in CRC cases with high G9a expression. Furthermore, G9a may suppress cancer stemness and increase chemosensitivity by controlling IL-8. Therefore, G9a is a potential novel marker for predicting CRC prognosis, and therapeutic targeting of G9a in CRC should be contraversial.

High postoperative carcinoembryonic antigen as an indicator of high‑risk stage II colon cancer

Postoperative carcinoembryonic antigen (post-CEA) has recently been reported to be a reliable prognostic factor for colon cancer. However, most clinicians decide whether or not to conduct adjuvant chemotherapy (AC) for stage II colon cancer according to major guidelines, which do not include post-CEA in their high-risk criteria. The present study aimed to assess post-CEA in stage II colon cancer for which the significance of AC is unknown. The present study analyzed 199 consecutive patients with stage II colon cancer who underwent curative surgery between January 2007 and December 2016. The CEA value was considered high when it was ≥5.0 ng/ml. The prognostic value of high post-CEA values was assessed. Overall, 19 patients exhibited high post-CEA levels. Kaplan-Meier survival curve analysis demonstrated that patients with high post-CEA levels had significantly worse relapse-free survival (RFS) and overall survival (OS) than those with normal post-CEA [RFS, 63.5 (high post-CEA) vs. 88.0% (normal post-CEA), P=0.003; OS, 76.5 (high post-CEA) vs. 96.8% (normal post-CEA), P<0.001]. Multivariate analysis demonstrated that high post-CEA remained a significant independent risk factor for worse RFS [hazard ratio (HR), 3.98; P=0.006]. The same was also demonstrated for patients without AC (HR, 5.43; P=0.008). To the best of our knowledge, the present study was the first to demonstrate that high post-CEA levels may be an indicator of high-risk stage II colon cancer, even for patients without AC. These results highlight the need for a multicenter prospective study.

Grip strength as a predictor of postoperative delirium in patients with colorectal cancers

Background

The population is aging rapidly, and the population of patients who undergo surgeries is aging, too. Elderly patients have much risk of postoperative delirium, which increases the number of adverse events. The aim of this study was to investigate the risk factors of postoperative delirium in elderly patients with colorectal cancer.

Methods

We conducted a retrospective cohort analysis of consecutive patients aged 70 years and older who underwent surgeries for colorectal cancer at our department in the period from May 2012 to October 2019. We investigated the correlation between the incidence of postoperative delirium and Comprehensive Geriatric Assessment (CGA) scores, comorbidities, and perioperative factors. Postoperative delirium was retrospectively diagnosed by checking clinical records.

Results

Postoperative delirium was diagnosed in 36 of 271 patients (13.3%) with colorectal cancer. Among many comorbidities, only renal disease was significantly associated with postoperative delirium. Among the items in the CGA, age; Mini‐Mental State Exam (MMSE), Barthel Index, Instrumental Activities of Daily Living (IADL), Vitality Index, and Geriatric Depression Scale (GDS) scores; and grip strength were associated with postoperative delirium. Among perioperative factors, blood transfusion was associated with postoperative delirium. Multivariate logistic regression analysis identified older age, MMSE, GDS, and grip strength as significant independent risk factors for postoperative delirium.

Conclusions

This single‐center retrospective observational study demonstrated that grip strength is an independent predictor of postoperative delirium, along with age, MMSE, and GDS.

[Laminin-dependent growth arrest of human hepatic carcinoma cell line, HuH-7, in association with expression of p21/WAF-1 protein]

Laminin-overlay to the culture of a human hepatocellular carcinoma cell line, HuH-7, resulted in changes in the cell behavior; suppression of the cell growth, conversion of the cell morphology, and the elevated secretion of cellular AFP in the culture medium, implying that the cells had undergone apparent differentiation in vitro. Together with the behavioral changes, the cells showed positive immunohistochemical staining of the anti-p 21/WAF 1 antibody over the cell nucleus and the amount of p 21/WAF-1 proteins was increased in the cells. p53 protein was detected both in the control cells and the cells with the laminin overlay. These findings indicate that the laminin-dependent changes in the cell behavior are closely associated with the activation of the cyclin-dependent kinase inhibitor, p 21/WAF-1, and that? is uncoupled with the p 53 expression.

Adenomyoma of the common hepatic duct

A very rare case of adenomyoma of the common hepatic duct is described. A 54-year-old woman was admitted with impending obstructive jaundice secondary to adenomyoma of the common hepatic duct. Our impression, formulated from her clinical presentation, endoscopic investigations, and biochemical and radiological findings, was a cancer of the proximal common hepatic duct. The patient was treated successfully by combination surgical resection and hepaticojejunostomy. Despite our obtaining an intraoperative frozen section, final histological examination was required to confirm the diagnosis. The patient remains well 16 months postoperatively. A survey of the world literature revealed that this is the second report of adenomyoma occurring in the common hepatic duct.

Heterotopic gastric mucosa of the gallbladder

A case of heterotopic gastric mucosa in the fundus of the gallbladder is reported. A 23-year-old man, who had been healthy and asymptomatic, visited our hospital because of abnormal findings in a liver enzyme test given during a routine health screening. Ultrasonography demonstrated a highly echogenic polypoid mass in the fundus of the gallbladder. The gallbladder mass was confirmed by both computed tomography and intravenous cholangiogram. After a 10-month follow up, laparoscopic cholecystectomy was performed. Intraoperative touch smear cytology of this lesion revealed class II cells. The surgical specimen revealed a 15 x 10 x 5 mm polypoid lesion in the fundus, with no gallstones in the gallbladder. Histologically, the polypoid lesion consisted of both fundic type and pyloric type gastric glands located in the mucosa of the gallbladder. In the literature, 42 cases of heterotopic gastric mucosa of the gallbladder have been reported, only 3 of which, including this present case, were found incidentally, with no apparent symptoms.

[Acute respiratory failure based on liver dysfunction in canine liver ischemia model]

From the analysis of 182 consecutive surgical patients who underwent hepatectomy and/or were associated with liver cirrhosis during 1963-1982, acute respiratory failure was proved to be so much often in those patients. The case rate of this complication tends to increase according to resected size of liver tissue and severity of liver cirrhosis. Those cases showed clinical signs of pulmonary interstitial edema and were often associated with coagulopathy and endotoxemia. In order to clarify the pathophysiological mechanism of the acute respiratory failure based on liver dysfunction, a canine experimental model in which blood inflow into the liver was completely blocked was newly devised, and respiratory state in this model was analysed. The following results were obtained. The increase of EVLW (extravascular lung water) measured by modified double indicator dilution method was linear to the increase of PWP (pulmonary wedge pressure) in both liver failure group and control group. But the coefficient of the regression line was three times larger in the former group than in the latter. It suggests that permeability of pulmonary capillary was highly increased in liver failure group. All dogs with liver failure showed typical symptomes of lung edema at maximal PWP. Disseminated intravascular coagulation, consumption of neutrophils, decrease of CH50 and serum opsonin were thought to be mediators of the increase of lung vascular permeability. Steroid and PGI2 blocked the increase of the lung vascular permeability completely but not the increase of lung vascular resistance in this experimental model.

Hyperpolarizing responses in the soma of crayfish median giant fiber

Hyperpolarizing responses of the somata of median giant fibers of crayfish were investigated under current clamp and voltage clamp conditions in normal saline. The responses consisted of a peak [mean delta Vm (peak)=-217 mV] followed by a plateau (-107 mV), and could be classified into N-type and G-type. In the N-type cells, the current clamp I-V curve showed a transient phase to the peak. The phase corresponded to the negative slope region of the voltage clamp I-V curve. There was no negative slope region in the G-type cells. In the transient and the peak phases, the instantaneous I-V curves showed nonlinearity, and the shifts of the electromotive forces (delta EMF) from the resting level were slightly negative or zero. In the plateau phase, however, the instantaneous I-V curve was linear and delta EMF was large and positive (33.2 mV). The membrane resistance, which was larger (X2.3) at the peak than at the resting state, decreased (X0.23) gradually during the plateau phase. delta EMF during the hyperpolarizing response consisted of two components: a fast component (1.7 msec) and a slow one (113 msec). The amplitudes of delta EMF (27.4 mV) of these components in the depolarizing direction increased gradually, once the response had reached the peak. The fast and slow delta EMF's attained 17.0 and 10.4 mV respectively at the end of 100 msec current pulse. It is shown that constant charge triggers the plateau process and that this threshold voltage-current curve is hyperbolic. It is a possibility that the plateau is caused by membrane breakdown.

Impedance changes during the electrical and mechanical activities of a bullfrog heart

Electrical impedance of a bullfrog ventricle was recorded epicardially by the V-I method and the bridge method together with an electrocardiogram (ECG) and a contraction curve, in terms of shortening. Impedance change during one cardiac cycle of a contracting ventricle corresponded completely to the contraction curve in its time course: impedance decreased during systole and attained minimum at the peak of contraction, and the durations of both curves were almost identical. The ratio of impedance just before T-wave to that just after R-wave ([ZT]/[ZR]) of an in situ heart was increased when the ventricle contracted isovolumetrically by means of mineral oil: the ratio was far less than 1.0 in control ventricle, while it was more than 1.0 in oil-filled one (2/3 cases). Upon isometric condition or treatment of cadmium the motion restricted ventricle caused an increase in the impedance ratio ([ZT]/[ZR]) to higher than 1.0, as in the case of oil-filled ventricle. The epicardial recording of ventricular impedance seems to consist of two components: contraction(shortening-dependent impedance change, which reflects the membrane activity. Vigorous contraction will probably mask the latter and reveal only the former.

Effects of cadmium on the impedance locus of the abdominal skin of the bullfrog (Rana catesbeiana)

An impedance locus consisting of two superimposed semicircular arcs was revealed on the abdominal skin of the bullfrog. The decrease of skin resistance upon epidermal application of Cd (2 mM), which was related to Na active transport, proved to be due solely to the reduction in the size of the high frequency arc.

Cadmium-induced decrease in the outer facing skin resistance of a bullfrog (Rana catesbeiana)

Effects of cadmium on the electrical properties of frog skin were investigated by using the microelectrode technique. The epidermal application of 2 mM Cd for 5 min increased both the short circuit current and the skin potential, and decreased the skin resistance (RM). Cadmium also decreased intracellular potential with reference to the epidermal solution (PDi) and the electrical resistance between the epidermal solution and the tip of a microelectrode (RM1) located in the stratum germinativum. deltaRM that is RM,Cd-RM, control seemed to approximately coincide with deltaRM1 which is RM1,Cd-RM1,control. Comparing with our previous results, i.e., Cd decreased RNa (the resistance to the active Na current) and increased Rsigma (the resistance to the passive ions) but did not altered ENa (the electromotive force of active Na current) in the later stage (15 min or later). Cd seemed to decrease the RNa component at the epidermal side of the skin in the early stage (less than 5 min).

Effects of cadmium on the active transport of sodium by the abdominal skin of a bullfrog (Rana catesbeiana)

Effects of Cd on the active transport of Na in SO4-Ringer's solution on the abdominal skin of a bullfrog (Rana catesbeiana) were investigated. The short circuit current (SCC), potential difference (PD), and Na flux were determined. The skin resistance (Rm), the electromotive force of active Na transport (Ena), and the resistance to the active Na current (Rna) were calculated from the measured data. The application of Cd to the epidermal side at 2 mM was more effective in increasing SCC than that to the dermal side at the same concentration. The time course of changes in SCC induced by Cd were classified into three types: (I) a simple increase in SCC during Cd application, (II) an early decrease followed by an increase in SCC, and (III) a decrease in SCC except for a small increase in the initial short period. Type I response was observed in the majority of cases (about two-thirds). Types II and III were observed in 7 and 32 percent of 28 cases, respectively. The Cd-induced changes in SCC were analyzed on the basis of changes in ENa and RNa. In Type I, the increase in SCC was due to a remarkable decrease in RNa without an appreciable change in ENa (since SCC = ENa/RNa). In Types II and III, the changes in SCC in the early and the later stages could be explained by the differences in the extents to which ENa and RNa decreased. The experimental and calculated ratios of PDcd to PDcontrol in these stages were in good agreement with each other.