[A Case of Lymphoepithelial Cyst of the Pancreas for Which Malignancy Could Not Be Ruled Out Difficult Preoperative Diagnosis]

Lymphoepithelial cyst(LEC)of the pancreas is a relatively rare benign cystic disease of the pancreas. In this report, we describe a case of LEC in which a malignant tumor could not be ruled out by preoperative diagnosis and surgery was performed. The patient was a 72-year-old man. A simple CT scan of the chest and abdomen performed as a follow-up for another disease incidentally revealed a mass in the pancreatic tail. Enhanced CT of the abdomen showed a tumor approximately 3 cm in size at the pancreatic tail with no contrast effect. MRCP showed moderate signal on T2WI, high signal on T1WI, and high signal on T2WI on some cysts inside the pancreas. PET-CT showed slight uptake of FDG. Both tumor markers CEA and CA19-9 were normal. Therefore, malignant disease such as pancreatic IPMC could not be ruled out, and laparoscopic distal pancreatectomy plus splenectomy was performed. The pathology results showed a diagnosis of pancreatic lymphoepithelial cyst with slight differentiation into sebaceous gland.

[Peritoneal Recurrence of Gastric Cancer Treated with Chemoradiotherapy-A Case Report]

A 76-year-old male patient underwent a distal gastrectomy for advanced gastric cancer. As the postoperative serum CA19-9 level was elevated, chemotherapy was initiated. Computed tomography(CT)detected a solitary peritoneal recurrence in the left subhepatic space 17 months later. Consequently, chemoradiotherapy(CRT)at a total dose of 60 Gy, combined with S-1 therapy, was administered for local tumor control. After CRT, CT scans revealed a remarkable reduction in the peritoneal recurrence. Presently, 8 months after CRT, the patient remains alive with no indications of regrowth. CRT could prove efficacious as a treatment for gastric cancer patients with localized peritoneal recurrences.

[A Case of Pathologic Complete Response Achieved with Preoperative Pembrolizumab Therapy for Transverse Colon Cancer]

A 77-year-old female patient presented with a medical history of 4 cancerous lesions, each with a surgical history. She was referred to our hospital due to anemia. Upon examination, she was diagnosed with transverse colon cancer. Duodenal invasion was suspected, which made performing R0 surgery difficult; therefore, the NAC approach was chosen. Three courses of CAPOX were administered, resulting in tumor obstruction, leading to the formation of an ileum stoma. MSI testing revealed MSI-H, and pembrolizumab treatment was initiated. CT scans showed tumor shrinkage, and PET scans indicated no accumulation, resulting in a cCR. Colon resection including the lesion suspected of stenosis was performed with a strong desire for stoma closure and the determination of potential curative resection. Additionally, a partial resection of the duodenum was performed. Pathological examination did not reveal any evident tumor cells, leading to the determination for a pCR. The patient has been under postoperative surveillance for 1 year without any recurrence.

Prognostic Value of C-reactive Protein-to-albumin Ratio after Curative Resection in Patients with Colorectal Cancer

Objectives

The current retrospective study aimed to evaluate the association between combined preoperative and postoperative C-reactive protein-to-albumin ratio, which is correlated with prognosis in different types of malignancies, and prognosis after curative resection in patients with colorectal cancer.

Methods

This study enrolled 263 patients who underwent curative resection for stage II/III colorectal cancer. C-reactive protein-to-albumin ratio was calculated within 30 days before and 7 days after surgery. Receiver operating characteristic curve analyses were performed to determine the optimal cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio. The correlations between combined preoperative and postoperative C-reactive protein-to-albumin ratio and prognosis were analyzed.

Results

The cutoff values of preoperative and postoperative C-reactive protein-to-albumin ratio were 0.223 and 0.813, respectively; higher ratios were significantly associated with poor overall survival, based on the Kaplan-Meier curves (p < 0.001, p = 0.003, respectively). Further, preoperative and postoperative C-reactive protein-to-albumin ratios were correlated with poor progression-free survival (p < 0.001, p = 0.064, respectively). In the multivariate analysis, combined preoperative and postoperative C-reactive protein-to-albumin ratio was an independent predictor of overall survival and progression-free survival (p = 0.012, p = 0.044, respectively). Compared with low preoperative and postoperative C-reactive protein-to-albumin ratio, high ratios of that were significantly associated with poor overall survival (hazard ratio = 3.897, p = 0.006) and progression-free survival (hazard ratio = 2.130, p = 0.029).

Conclusions

Combined preoperative and postoperative C-reactive protein-to-albumin ratio, useful for prognostic prediction, can be a promising prognostic marker after curative resection in patients with colorectal cancer.

[A Case of Schwannoma in the Ascending Colon]

A 69-year-old man who was diagnosed with a submucosal tumor in the ascending colon by colonoscopy in X-7 year was presented. The endoscopic biopsy showed normal mucosa, and he had been followed up. During follow-up, computed tomography and colonoscopy performed in X year showed an enlargement of the tumor. Positron emission tomography-computed tomography showed intense FDG uptake. Malignant tumor was suspected, and laparoscopic-assisted right hemicolectomy was performed. The histopathological diagnosis showed spindle-shaped tumor cells proliferating in a fascicular manner. Immunohistochemical staining was positive for S-100 protein and negative for CD34, c-kit, and desmin, and schwannoma was diagnosed. Schwannomas are tumors derived from Schwann cells and therefore rarely develop in the gastrointestinal tract. Careful preoperative diagnosis is important because they do not normally metastasize or undergo malignant transformation.

Plasma trough concentration of imatinib and its effect on therapeutic efficacy and adverse events in Japanese patients with GIST

BACKGROUND

Imatinib mesylate (IM) is the standard chemotherapy for patients with gastrointestinal stromal tumors (GISTs) and has a favorable safety profile. Pharmacokinetics (PK), such as plasma trough concentration (Cmin), varies among patients, requiring the need for therapeutic drug monitoring (TDM) during IM administration. Despite some reports from overseas, the relationship between Cmin, adverse events (AEs), and treatment efficacy in Japanese patients with GIST has still been lacking. This study aimed to investigate the relationship between IM plasma concentration and AEs in Japanese patients with GISTs.

METHODS

This retrospective study analyzed the data of 83 patients who underwent IM treatment for GISTs at our institution between May 2002 and September 2021.

RESULTS

The IM Cmin was associated with any grade of AEs (with AEs vs. without AEs = 1294 (260-4075) vs. 857 (163-1886) ng/mL, P < 0.001), edema (with edema vs. without edema = 1278 (634-4075) vs. 1036 (163-4069) ng/mL, P = 0.017), and fatigue (with fatigue vs. without fatigue = 1373 (634-4069) vs. 1046 (163-4075) ng/mL, P = 0.044). Moreover, a Cmin ≥ 1283 ng/mL was a risk factor for severe AEs. The median progression-free survival (PFS) was 3.04 years in the lowest Cmin tertile (T1, < 917 ng/mL) compared with 5.90 years for T2 and T3 (P = 0.010).

CONCLUSION

Edema and fatigue are potentially associated with IM plasma trough concentrations of ≥ 1283 ng/mL in Japanese patients with GISTs. Further, maintaining an IM plasma trough concentration above 917 ng/mL may improve PFS.

[A Case of Retroperitoneal Leiomyosarcoma Treated with Repeated Surgical Resection]

A 55-year-old male revealed with a 5 cm-diameter mass in the lower abdomen on ultrasonography incidentally. Computed tomography showed a mass of 7 cm in size on the left side of the bladder. A malignant tumor was suspected, and surgically excised for purpose of diagnosis and treatment. Pathological examination confirmed retroperitoneal leiomyosarcoma, and the resection margins were negative. Follow-up computed tomography scan was performed every 3 months. Repeated resections were performed for twice recurrences within a year after surgery. A year after the first surgery, lung metastasis was detected and chemotherapy was started. Although retroperitoneal leiomyosarcoma is considered to have a poor prognosis, the present case had relatively good prognosis. This may be due to early detection and repeated surgical resection.

Assessing Bladder Radiotherapy Response With Quantitative Diffusion-Weighted Magnetic Resonance Imaging Analysis

AIMS

Radiotherapy with radiosensitisation offers opportunity for cure with organ preservation in muscle-invasive bladder cancer (MIBC). Treatment response assessment and follow-up are reliant on regular endoscopic evaluation of the retained bladder. In this study we aim to determine the role of diffusion-weighted magnetic resonance imaging (DWI) and apparent diffusion coefficient (ADC) analysis to assess bladder radiotherapy response.

MATERIALS AND METHODS

Patients with T2-T4aN0-3M0 MIBC suitable for radical radiotherapy were recruited prospectively to an ethics approved protocol. Following transurethral resection of the bladder tumour and prior to any treatment, magnetic resonance imaging including DWI was performed on a 1.5T system using b values of 0, 100, 150, 250, 500, 750 s/mm2. DWI was repeated 3 months after completing radiotherapy. Cystoscopy and tumour site biopsy were undertaken following this. The response was dichotomised into response (

RESULTS

Thirty-four patients were evaluated. Response was associated with a significant increase in ΔADC mean compared with poor response at ΔADCall (0.57 × 10-3 mm2/s versus -0.01 × 10-3 mm2/s; P < 0.0001) and ΔADCb100 (0.58 × 10-3 mm2/s versus -0.10 x 10-3 mm2/s; P = 0.007). A 48.50% increase in %ΔADCall mean was seen in response compared with a 1.37% decrease in poor response (P < 0.0001). This corresponded to a %ΔADCb100 mean increase of 50.34% in response versus a 7.36% decrease for poor response (P < 0.0001). Significant area under the curve (AUC) values predictive of radiotherapy response were identified at ΔADC and %ΔADC for ADCall and ADCb100 mean, 10th, 25th, 50th, 75th and 90th percentiles (AUC >0.9, P < 0.01). ΔADCall mean of 0.16 × 10-3 mm2/s and ΔADCb100 mean 0.12 × 10-3 mm2/s predicted radiotherapy response with sensitivity/specificity/positive predictive value/negative predictive value of 92.9%/100.0%/100.0%/75.0% and 89.3%/100.0%/100.0%/66.7%, respectively.

CONCLUSIONS

Quantitative DWI analysis can successfully provide non-invasive assessment of bladder radiotherapy response. Multicentre validation is required before prospective testing to inform MIBC radiotherapy follow-up schedules and decision making.

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Key Words

• Bladder cancer
• Diffusion-weighted MRI
• MRI
• Radiotherapy

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MESH Headings

• Diffusion Magnetic Resonance Imaging/methods
• Humans
• Magnetic Resonance Imaging
• Prospective Studies
• ROC Curve
• Urinary Bladder/diagnostic imaging
• Urinary Bladder Neoplasms/diagnostic imaging
• Urinary Bladder Neoplasms/pathology
• Urinary Bladder Neoplasms/radiotherapy

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Grants

• 28724 Cancer Research UK
• C33589/A19727 Cancer Research UK
• Department of Health
• C33589/A28284 Cancer Research UK

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Baseline Factors Predictive of the Receipt of Second-Line Chemotherapy After Nab-Paclitaxel Plus Gemcitabine for Patients With Advanced Pancreatic Cancer

OBJECTIVE

Second-line (2L) chemotherapy is important for improved survival in patients with advanced pancreatic cancer (APC). However, approximately half of patients with APC do not receive 2L chemotherapy because of disease progression or adverse events. Baseline factors predictive of the receipt of 2L chemotherapy remain unknown. Therefore, we investigated predictive factors for the receipt of 2L chemotherapy in patients with APC.

METHODS

Between January 2015 and March 2020, 53 patients with APC received nab-paclitaxel plus gemcitabine (AG) as first-line chemotherapy at our institute. Of these 53 patients, 29 patients received 2L chemotherapy, and 23 patients received best supportive care. Patients' characteristics were compared retrospectively, and predictive factors for the receipt of 2L chemotherapy were evaluated.

RESULTS

Sarcopenia and hypoalbuminemia at baseline were independent negative predictive factors for the receipt of 2L chemotherapy in multivariate analysis. Although the presence of sarcopenia did not affect the relative dose intensity through 8 weeks of AG therapy, patients with hypoalbuminemia had a significantly lower relative dose intensity.

CONCLUSIONS

Sarcopenia and hypoalbuminemia at baseline might be negative predictive factors for the receipt of 2L chemotherapy after AG treatment in patients with APC.

[A Case of Giant Intestinal GIST That Was Resected Just after TAE]

A 42-year-old woman visited our hospital complaining of fever and diarrhea. She had abdominal swelling and muscular defense. CT revealed a lobulated tumor occupying the lower abdomen. The tumor contained solid and cystic areas. The main artery vascularizing the tumor was the ileocecal artery, so we considered the tumor to be derived from the intestine or mesentery. We anticipated massive bleeding due to resection, and immediately after the embolization of the artery just before the operation. A vascular bundle from the terminal ileum and mesentery was found on the dorsal side of the tumor, and an outflow from the inferior mesenteric vein was also observed. We ligated each vessel and performed ileocecal resection. The operation lasted 4 hours and 18 minutes, with an estimated blood loss of 2,585 mL, requiring the transfusion of 6 units of concentrated red blood cells. According to histopathological findings, tumor cells with spindle-shaped to ellipsoidal nuclei proliferated in bundles and intricately, and immunostaining was positive for c-kit and DOG-1. We identified the tumor as high-risk GIST. The clinical course after the operation was uneventful. She continued to take imatinib for 3 years and is currently alive and without recurrence for 6 years after the operation.

Propranolol suppresses gastric cancer cell growth by regulating proliferation and apoptosis

BACKGROUND

Despite improvements in gastric cancer treatment, the mortality associated with advanced gastric cancer is still high. The activation of β-adrenergic receptors by stress has been shown to accelerate the progression of several cancers. Accordingly, increasing evidence suggests that the blockade of β-adrenergic signaling can inhibit tumor growth. However, the effect of β-blockers, which target several signaling pathways, on gastric cancer remains to be elucidated. This study aimed to investigate the anti-tumor effects of propranolol, a non-selective β-blocker, on gastric cancer.

METHODS

We explored the effect of propranolol on the MKN45 and NUGC3 gastric cancer cell lines. Its efficacy and the mechanism by which it exerts anti-tumor effects were examined using several assays (e.g., cell proliferation, cell cycle, apoptosis, and wound healing) and a xenograft mouse model.

RESULTS

We found that propranolol inhibited tumor growth and induced G1-phase cell cycle arrest and apoptosis in both cell lines. Propranolol also decreased the expression of phosphorylated CREB-ATF and MEK-ERK pathways; suppressed the expression of matrix metalloproteinase-2, 9 and vascular endothelial growth factor; and inhibited gastric cancer cell migration. In the xenograft mouse model, propranolol treatment significantly inhibited tumor growth, and immunohistochemistry revealed that propranolol led to the suppression of proliferation and induction of apoptosis.

CONCLUSIONS

Propranolol inhibits the proliferation of gastric cancer cells by inducing G1-phase cell cycle arrest and apoptosis. These findings indicate that propranolol might have an opportunity as a new drug for gastric cancer.

Clinical significance of surgical intervention for imatinib-resistant gastrointestinal stromal tumors in the era of multiple tyrosine kinase inhibitors

PURPOSE

Imatinib is the standard treatment for unresectable and metastatic GIST. In the late stages, patients undergoing imatinib show drug resistance. Surgical intervention has been occasionally performed for resistant lesions. However, the clinical significance of such intervention remains unclear.

METHODS

Between 2006 and 2015, 37 patients were diagnosed with imatinib-resistant GISTs. We performed surgical intervention only for localized resistant lesions. We retrospectively investigated the background characteristics, data on surgical intervention and subsequent treatment, progression-free survival (PFS), and overall survival (OS).

RESULTS

Eighteen patients diagnosed with localized resistance received surgical intervention (S-group) and 19 patients diagnosed with generalized resistance were received other TKIs (M-group). In S-group, no serious complications occurred, and all patients restarted imatinib after resection. The median PFS was 14.5 months. Five patients underwent surgical intervention multiple times followed by the continuation of imatinib, and the median duration of imatinib continuation was 22.2 months. Second-line TKIs were administered to 93% of the patients and the dose-intensity and outcome were similar in both groups. The median OS was 47.2 months after surgery.

CONCLUSIONS

Surgical intervention could be performed safely and therefore could be followed by the continuation of TKI therapy. Surgical intervention based on the appropriate criteria of resistance might thus be useful for imatinib-resistant GISTs.

[A Case of Early Rectal Cancer Accompanied by Multiple Liver Abscesses]

An 81-year-old female who suffered from headache and general fatigue was diagnosed multiple liver abscesses by abdominal computed tomography(CT). Antibiotics and percutaneous transhepatic abscess drainage(PTAD)were performed, liver abscesses were improved. During the treatment, followed abdominal CT indicated lower rectal tumor. An early rectal cancer accompanied by multiple liver abscesses was diagnosed and performed surgery. The histological diagnosis was Rb, type 1, tub2, pT1b(SM 8,000 μm), Ly0, V1a, pN0, pStage Ⅰ. After surgery, the patient remains free from liver abscess. We report early colorectal cancer with multiple liver abscesses in Japanese literature.

[A Case of Locally Advanced Appendiceal Cancer with Radical Resection after CAPOX plus Bevacizumab]

We report a case of a male in his sixties with appendiceal cancer who underwent radical resection following CAPOX plus bevacizumab neoadjuvant chemotherapy. The patient presented to our hospital with a chief complaint of chronic low abdominal pain. Contrast-enhanced CT before neoadjuvant chemotherapy revealed an inhomogeneous tumor in the ileocecal region. Invasion to the bladder and the sigmoid colon was also observed. A colonoscopy showed an elevated lesion, which was caused by extramural invasion to the sigmoid colon. Pathological examination of the sigmoid colon tumor revealed well differentiated tubular adenocarcinoma and KRAS codon13 G13D. Hence, we diagnosed the patient with locally advanced appendiceal cancer with invasion to the bladder and sigmoid colon. We administered CAPOX plus bevacizumab as neoadjuvant chemotherapy. Contrast-enhanced abdominal CT after neoadjuvant chemotherapy revealed shrinkage of the primary tumor and reduction in the invasion to the bladder and sigmoid colon. We performed ileocecal resection(+D3), a partial sigmoidectomy, and partial bladder resection on the 135th day from the diagnosis. The resected specimen showed an appendiceal tumor with invasion to the bladder and sigmoid colon. The pathological diagnosis was Ⅴ, yType 5, tub2>tub1, ypT4b, ypN0, ycH0, ycM0, ycPUL0, Ly1b, V1b(VB), Pn01b, pStage Ⅱa, and the histological treatment effect of preoperative therapy was Grade 1b. Our experience indicates that in patients with locally advanced appendiceal cancer, multimodal treatment with neoadjuvant chemotherapy is an effective option.

A case of multiple serous cystadenoma of pancreas

Introduction

Typically, SCN is single and doesn't invade around tissue. In our case, tumors were multiple and had gradually grown and caused vein stenosis. This is extremely rare and unique resected multiple SCN case. In addition, I report that it was thought to be educational that even benign tumors could cause such changes.

Presentation of case

A 60-year-old female was diagnosed with 3 multilocular cystic tumors in distal pancreas by contrast enhanced computed tomography (CT) at the preoperative staging for rectal neoplasm. The diameters of cystic tumors were 22/23/29 mm. The CT showed that the tumors had multiple internal septa enhanced in the arterial phase and the second tumor contained internal calcifications located centrally. The main pancreatic duct was not dilated. Although SCN often occurred single and multiple SCN was very rare, we diagnosed that the tumors were suspected microcystic type SCN because they had typical image findings. So, we planned to follow up every six months after resection for rectal neoplasm. 2 years and half later, they had gradually grown, and splenic vein stenosis appeared. The pancreatic parenchyma atrophy and dilatation of the main pancreatic duct had been gradually progressing. We performed distal pancreatectomy because of possibility of malignancy. The histopathological findings showed that 2 cystic tumors the side of pancreatic head had a connection and had typical findings of SCA of pancreas. The other tumor was independent from two tumors. They had no malignant findings.

Discussion

At first, we expected tumor invasion had caused the changes. But tumors had no malignant findings, so we considered that compression from the tumor had caused stenosis, and obstructive pancreatitis had induced the pancreatic parenchyma atrophy.

Conclusion

We learned from this case that not only invasion but also compression caused vein stenosis and pancreatic duct dilation.

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Multiple serous cystic neoplasms are rare tumors.

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The tumors had gradually grown and main pancreatic duct dilatation had appeared.

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We performed laparotomy because we couldn't deny local infiltration.

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The main pancreatic duct dilatation had been caused by the compression.

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This is unique that even benign tumors could cause pancreatic duct dilatation.

TAS-116 inhibits oncogenic KIT signalling on the Golgi in both imatinib-naïve and imatinib-resistant gastrointestinal stromal tumours

BACKGROUND

Despite the effectiveness of imatinib mesylate (IM), most gastrointestinal stromal tumours (GISTs) develop IM resistance, mainly due to the additional kinase-domain mutations accompanied by concomitant reactivation of KIT tyrosine kinase. Heat-shock protein 90 (HSP90) is one of the chaperone molecules required for appropriate folding of proteins such as KIT.

METHODS

We used a novel HSP90 inhibitor, TAS-116, which showed specific binding to HSP90α/β with low toxicity in animal models. The efficacy and mechanism of TAS-116 against IM-resistant GIST were evaluated by using IM-naïve and IM-resistant GIST cell lines. We also evaluated the effects of TAS-116 on the other HSP90 client protein, EGFR, by using lung cell lines.

RESULTS

TAS-116 inhibited growth and induced apoptosis in both IM-naïve and IM-resistant GIST cell lines with KIT activation. We found KIT was activated mainly in intracellular compartments, such as trans-Golgi cisternae, and TAS-116 reduced autophosphorylated KIT in the Golgi apparatus. In IM-resistant GISTs in xenograft mouse models, TAS-116 caused tumour growth inhibition. We found that TAS-116 decreased phosphorylated EGFR levels and inhibited the growth of EGFR-mutated lung cancer cell lines.

CONCLUSION

TAS-116 may be a novel promising drug to overcome tyrosine kinase inhibitor-resistance in both GIST and EGFR-mutated lung cancer.

Lipolysis-stimulated lipoprotein receptor overexpression is a novel predictor of poor clinical prognosis and a potential therapeutic target in gastric cancer

The prognosis of patients with advanced gastric cancer (GC) remains poor despite the recent advances in molecular targeted therapies, and the search for biomarkers that can predict prognosis and additional new agents with acceptable toxicity profiles are needed. Lipolysis-stimulated lipoprotein receptor (LSR) is a lipoprotein receptor that binds to triglyceride-rich lipoproteins and related to some malignancies. Herein, we examined the association between LSR expression and the prognosis of patients with GC, and investigated the antitumor effect of a previously developed anti-human LSR monoclonal antibody (#1-25). We first performed immunohistochemical analysis of LSR protein expression in GC and normal tissues, and then examined its association with the prognosis of 110 patients with GC. LSR was overexpressed in most of primary GC and metastatic tumors, but not in normal tissues. Patients with strong LSR expression (N = 80, 72.7%) had significantly poorer overall survival (OS) than those with weak expression (P = 0.017). Multivariate analysis identified strong LSR (as well as pT) as independent and significant prognostic factors for OS. Next, we demonstrated that very low density lipoprotein (VLDL) treatment increases cell proliferation in LSR-expressing GC cell lines in vitro; LSR inhibition using #1-25 inhibited VLDL-induced proliferation by suppressing JAK/STAT and PI3K signaling. In vivo, we demonstrated a marked antitumor effect of #1-25 in 2 distinct GC cell line xenograft mice models. Our findings suggest that LSR plays a key functional role in GC development, and that this antigen can be therapeutically targeted to improve GC treatment.

Evolving affinity between Coulombic reversibility and hysteretic phase transformations in nano-structured silicon-based lithium-ion batteries

Nano-structured silicon is an attractive alternative anode material to conventional graphite in lithium-ion batteries. However, the anode designs with higher silicon concentrations remain to be commercialized despite recent remarkable progress. One of the most critical issues is the fundamental understanding of the lithium-silicon Coulombic efficiency. Particularly, this is the key to resolve subtle yet accumulatively significant alterations of Coulombic efficiency by various paths of lithium-silicon processes over cycles. Here, we provide quantitative and qualitative insight into how the irreversible behaviors are altered by the processes under amorphous volume changes and hysteretic amorphous-crystalline phase transformations. Repeated latter transformations over cycles, typically featured as a degradation factor, can govern the reversibility behaviors, improving the irreversibility and eventually minimizing cumulative irreversible lithium consumption. This is clearly different from repeated amorphous volume changes with different lithiation depths. The mechanism behind the correlations is elucidated by electrochemical and structural probing.

Single-incision totally extraperitoneal inguinal hernia repair is safe and feasible in elderly patients: A single-center experience of 365 procedures

The aim of this study was to evaluate the feasibility and safety of SILS for totally extraperitoneal inguinal hernia repair in elderly patients. A retrospective analysis of 365 patients who underwent of SILS for totally extraperitoneal inguinal hernia repair from January 2012 to November 2015 at Osaka Police Hospital was performed, and the outcomes of patients aged <80 years and those aged ≥80 years were compared. There was a greater proportion of patients with an ASA score ≥3 among those ≥80 years than among those <80 years. The mean operative time for unilateral inguinal hernia was 94 min in patients <80 years and 98 min in patients ≥80 years. The mean operative time for bilateral inguinal hernia was 133 min in patients <80 years and 130 min in patients ≥80. Intraoperative bleeding was minimal in all patients. Conversion to a different operative procedure occurred in 3% (10/322) of patients <80 years and in 5% (2/43) of patients ≥80 years (P = 0.6). The mean postoperative hospital stay was 2.2 days for patients <80 years and 2.2 days for patients ≥80 years. The mean follow-up period 21 ± 14 months (range, 3-50 months) for patients <80 years and 17 ± 14 months (range, 3-50 months) for patients ≥80 years (P = 0.3). Postoperative complications were seen in 12% (38/322) of patients <80 years and in 14% (6/43) of patients ≥80 years (P = 0.7). A seroma was seen in 9% (28/322) of patients <80 years and in 12% (5/43) of patients ≥80 years (P = 0.6). A wound infection occurred in 2% (8/322) of patients <80 years. These seromas and wound infections were managed conservatively. Pulmonary embolism was seen in one patient <80 years (0.3%). There was no mortality or recurrence in either group. SILS for totally extraperitoneal inguinal hernia repair has good cosmesis and can be performed in elderly patients with acceptable morbidity and mortality.

[Curative Resection for Chemorefractory Advanced Gastric Cancer with Pancreatic Invasion by Pancreatoduodenectomy - A Case Report]

A 37-year-old woman was diagnosed with advanced gastric cancer. Pancreatic invasion of the tumor and positive cytology from peritoneal washing was found on staging laparoscopy. The patient received chemotherapy consisting of S-1 and CDDP, but the tumor size increased after 5 courses. The patient then received 2 courses of second line chemotherapy consisting of biweekly CPT-11; however, the tumor progressed and caused stenosis of the stomach. After gastrojejunostomy for the stenosis, negative cytology of intraperitoneal lavage was found. The patient underwent pancreatoduodenectomy with right hemicolectomy and wedge resection of the portal vein as curative resection. The patient was alive without recurrence 10 months after the surgery.

Single-incision totally extraperitoneal inguinal hernia repair as a teaching procedure: one center's experience of more than 300 procedures

PURPOSE

To evaluate resident doctors' proficiency in performing single-incision laparoscopic surgery for totally extraperitoneal inguinal hernia repair (SILS-TEP), and assess patient outcomes by comparing procedures performed by resident surgeons vs. those performed by staff surgeons.

METHODS

We analyzed retrospectively 301 patients who underwent SILS-TEP between January 2011 and May 2015 at Osaka Police Hospital.

RESULTS

The mean operative times for unilateral and bilateral hernia repairs in the resident-surgeon and the staff-surgeon groups were 99 vs. 88 min, respectively (p < 0.05), and 130 vs. 137 min, respectively. There was no significant difference in the incidence of conversion to a different procedure between the groups. The mean postoperative hospital stay was 2.0 days for patients from the resident-surgeon group vs. 2.8 days for those from the staff-surgeon group (p < 0.05). Seromas and wound infections developed in 8 % (12/148) of patients from the resident-surgeon group vs. 12 % (19/153) of those from the staff-surgeon group. No other major complications or hernia recurrence were noted in either group.

CONCLUSIONS

SILS-TEP was performed safely, with low morbidity and no recurrence, by the resident surgeons under appropriate guidance by staff surgeons.

A national common massive transfusion protocol (MTP) is a feasible and advantageous option for centralized blood services and hospitals

BACKGROUND

A common national MTP was jointly implemented in 2011 by the national blood service (Blood Services Group) and seven participating acute hospitals to provide rapid access to transfusion support for massively haemorrhaging patients treated in all acute care hospitals.

METHODS

Through a systematic clinical workflow, blood components are transfused in a ratio of 1:1:1 (pRBC: whole blood-derived platelets: FFP), together with cryoprecipitate for fibrinogen replacement. The composition of components for the MTP is fixed, although operational aspects of the MTP can be adapted by individual hospitals to suit local hospital workflow. The MTP could be activated in support of any patient with critical bleeding and at risk of massive transfusion, including trauma and non-trauma general medical, surgical and obstetric patients.

RESULTS

There were 434 activations of the MTP from October 2011 to October 2013. Thirty-nine per cent were for trauma patients, and 30% were for surgical patients with heavy intra-operative bleeding, with 25% and 6% for patients with gastrointestinal bleeding and peri-partum haemorrhage, respectively. Several hospitals reported reduction in mean time between request and arrival of blood. Mean transfusion ratio achieved was one red cell unit: 0·8 FFP units: 0·8 whole blood-derived platelet units: 0·4 units of cryoprecipitate. Although cryoprecipitate usage more than doubled after introduction of MTP, there was no significant rise in overall red cells, platelet and FFP usage following implementation.

CONCLUSION

This successful collaboration shows that shared transfusion protocols are feasible and potentially advantageous for hospitals sharing a central blood provider.

Type II EATL (epitheliotropic intestinal T-cell lymphoma): a neoplasm of intra-epithelial T-cells with predominant CD8αα phenotype

In this multicentre study, we examined 60 cases of Type II enteropathy-associated T-cell lymphoma (EATL) from the Asia-Pacific region by histological review, immunohistochemistry and molecular techniques. Patients were mostly adult males (median age: 58 years, male:female 2.6:1), presenting with abdominal pain (60%), intestinal perforation (40%) and weight loss (28%). None had a history of coeliac disease and the median survival was only 7 months. Histologically, these tumours could be divided into (i) central tumour zone comprising a monotonous population of neoplastic lymphocytes, (ii) peripheral zone featuring stunted villi and morphologically atypical lymphocytes showing epitheliotropism, and (iii) distant mucosa with normal villous architecture and cytologically normal intra-epithelial lymphocytes (IELs). Characterized by extensive nuclear expression of Megakaryocyte-associated tyrosine kinase (MATK) (87%) and usually a CD8(+)CD56(+) (88%) cytotoxic phenotype, there was frequent aberrant expression of CD20 (24%). T-cell receptor (TCR) expression was silent or not evaluable in 40% but of the remainder, there was predominant expression of TCRαβ over TCRγδ (1.6:1). In keeping with the normal ratio of IEL subsets, CD8(+) cases showed predominant CD8αα homodimer expression (77%), regardless of TCR lineage. These tumours constitute a distinct entity from classical EATL, and the pathology may reflect tumour progression from IEL precursors, remnants of which are often seen in the distant mucosa.

The anti-tumour activity of allogeneic cytokine-induced killer cells in patients who relapse after allogeneic transplant for haematological malignancies

We performed a Phase I/II clinical trial to study the feasibility, toxicity and efficacy of allogeneic cytokine-induced killer (CIK) cell expansion, and treatment for patients with haematological malignancies who relapsed after allogeneic haemopoietic SCT (allo-HSCT). Allogeneic CIK cells were successfully generated for a total of 24 patients, including those from patients' own leukapheresis products in 5 patients who had no access to further donor cells. The median CD3(+) T-cell expansion was 9.33 (1.3-38.97) fold, and CD3(+)CD56(+) natural killer (NK)-like T-cell expansion was 27.77 (2.59-438.93) fold. A total of 55 infusions were done for 16 patients who had either failed or progressed after initial response to various individualized chemotherapy regimens and donor lymphocyte infusion (DLI), at doses ranging from 10 to 200 million CD3(+) cells/kg. Response attributable to CIK cell infusion was observed in five patients. These included two with ALL, two with Hodgkin's disease (HD) and one with AML, and two of whom had a response sustained for more than 2 years. Acute GVHD occurred in three and was easily treatable. This study provides some evidence suggestive of the efficacy of allogeneic CIK cells even after failure of DLI in some cases.