[Adenocarcinoma in the Lung Detected Due to the Development of Perforative Peritonitis Caused by Small Intestinal Metastasis-A Case Report]

Previous studies have reported that perforations of the small intestine caused by metastatic tumors prior to the diagnosis of primary lung cancer are very rare. A 79-year-old man was admitted to our hospital with acute lower abdominal pain. Abdominal computed tomography revealed intraperitoneal free air around the bowel wall thickening in the small intestine. The patient was diagnosed with acute peritonitis caused by perforation of the small intestine, and an emergency operation was performed. Laparotomy revealed perforation in the jejunum without any palpable tumor in the abdomen. Partial resection of the jejunum revealed an ulcerating lesion at the perforation site. Histological examination indicated small intestinal metastasis secondary to lung adenocarcinoma. Positron emission tomography performed after discharge showed a small reticular opacity with intense accumulation of FDG in the left lung. The patient was diagnosed with perforation of the small intestine metastasis secondary to lung adenocarcinoma. The postoperative course was uneventful; the patient received chemotherapy, and is alive 6months after the operation.

[A Case of Trousseau Syndrome Complication during Chemotherapy for Advanced Gastric Cancer]

The pathological condition which causes cerebrovascular disease through hypercoagulability associated with malignant tumors is known as Trousseau syndrome. Here, we report the case of a patient with Trousseau syndrome which developed as a complication during chemotherapy for advanced gastric cancer. A 70-year-old woman with multiple lymph node metastases of gastric cancer underwent TS-1 plus CDDP chemotherapy before surgery. She had symptoms of left hemiparesis during the first course of chemotherapy. She was diagnosed with acute cerebralinfarction using brain MRI, and blood tests indicated hypercoagulability. Therefore, it was strongly suspected that she had Trousseau syndrome. A total of 2 courses of chemotherapy were administered, along with anticoagulation therapy with edoxaban. She exhibited improved paralysis and received a totalgastrectomy after chemotherapy. According to recent reports, more than 90% of patients with malignant tumors have hypercoagulability, and more than 50% of them have thromboembolisms. It is therefore essential to obtain early diagnosis and provide anticoagulation therapy for cerebral infarction, and to provide treatment against malignant diseases in patients with Trousseau syndrome.

[A Case That Was Complicated with Pulmonary Artery Thrombosis during Chemotherapy of the Regimen of CapeOX plus Bevacizumab against Recurrence of Colon Cancer]

An 80-year-old woman with peritoneal dissemination after laparoscopic right hemicolectomy for appendicular carcinoma (mucinous adenocarcinoma, pT4aN1M0, stage Ⅲa)underwent CapeOX plus bevacizumab chemotherapy. The patient achieved stable disease over 5 courses of the treatment. Subjective and objective symptoms were not observed; however, chest computed tomography findings revealed a thrombus in the pulmonary artery that was considered to be associated with bevacizumab. Chemotherapy was discontinued, and anticoagulation therapy was initiated with heparin and then switched to apixaban. The thrombus resolved with treatment, but the patient died following an increase in peritoneal dissemination. CapeOX plus bevacizumab is a recommended colon cancer treatment, and even though it is generally considered safe, the side effects of bevacizumab include relatively rare occurrences of gastrointestinal perforation or thrombosis. The frequency of pulmonary embolism associated with bevacizumab is approximately 0.1%, and fatalities have been reported. The possibility of asymptomatic thrombosis warrants regular monitoring of this serious side effect in patients receiving bevacizumab. Early detection and prompt antithrombotic treatment are necessary to ensure patient safety and continued disease management.

[A Case of a Laparoscopically Resected Gastrointestinal Stromal Tumor of the Stomach]

During treatment for sigmoid colon diverticulitis, a 72-year-old man underwent abdominal computed tomography, which revealed a gastric tumor that was approximately 40mm in diameter. He then underwent a detailed examination after the remission of diverticulitis. The gastric mucosa was found to be unremarkable on gastrointestinal endoscopy. On ultrasonic endoscopy, however, a hypoechoic mass of approximately 40mm in diameter was detected in the fourth layer of the gastric fornix and was believed to be a gastric submucosal tumor(SMT). The tumor was laparoscopically resected, and histological analysis of the tumor revealed a high-risk gastrointestinal stromal tumor(GIST, modified-Fletcher classification). In many cases, when subgastric SMTs are approximately 2-5 cm in diameter and are without obvious malignant findings on endoscopic or computed tomographic examinations, they are followed-up. However, some recent case reports describing treatments for high- or medium-risk groups of patients with small GISTs have been published. When a small submucosal gastric tumor is suspected to be GIST, we believe that laparoscopic surgery is a minimally invasive and effective method for the diagnosis and treatment of the tumor.

[A Giant Appendiceal Mucinous Neoplasm Treated with Laparoscopic Surgery]

We encountered a case of giant appendiceal mucinous neoplasm that was treated with laparoscopic surgery. The patient was a 77-year-old man with constipation. Lower endoscopy demonstrated a giant SMT-like tumor in the cecum, and abdominal computed tomography revealed a giant appendiceal mucinous neoplasm and nearby lymph nodes swelling. Hematological examination showed an elevated serum CEA level. We performed laparoscopic ileocecal resection for a definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was low-grade appendicealmucinous neoplasm(LAMN). Laparoscopic surgery can be considered safe for the resection of appendicealmucinous neoplasm when it is performed with a carefulsurgicalapproach.

[A Giant Malignant Lymphoma of the Ileocecum Treated with Laparoscopic Surgery]

We experienced a case ofa giant malignant lymphoma ofthe ileocecum treated with laparoscopic surgery. A 78-year-old man presented with right flank pain. Lower endoscopy and abdominal computed tomography revealed a giant tumor in ileocecum. Biopsy results suggested malignant lymphoma or adenocarcinoma. We performed a laparoscopic ileocecal resection for definite diagnosis and treatment. The postoperative course was uneventful. The pathological diagnosis was malignant diffuse large B-cell lymphoma. The patient underwent chemotherapy and is being followed. Laparoscopic surgery can be considered useful to resect gastrointestinal malignant lymphoma.

Evaluation of lymph node metastasis in patients with gastric cancer: a comparison of the directionality of lymph node metastasis and the total number of metastatic lymph nodes

PURPOSE

The clinical impact of the directionality of lymph node (LN) metastasis was assessed in comparison with the staging by the Japanese Classification of Gastric Carcinoma (JCGC), a numerical LN staging system.

METHODS

Two hundred forty-one gastric cancer patients who were diagnosed pathologically to have LN metastasis, and 54 patients who underwent preoperative multidetector-row computed tomography (MDCT) with an image thickness of 1 mm were classified into three groups (unidirectional [Uni-], bidirectional [Bi-], and tridirectional [Tri-] groups) depending on the directionality of their LN metastasis.

RESULTS

The prognosis of the Uni-group was better than that of the Bi- or the Tri-group when assessed on the basis of the pathological findings of metastatic LN and also the preoperative MDCT findings. The exact preoperative evaluation was 70.2 % for the directionality system and 61.7 % for the JCGC system, respectively. The stages were less frequently underestimated by the directionality system than the JCGC system (P < 0.02, 19.1 vs. 34.0 %), and the staging could be more precisely performed by both systems in combination.

CONCLUSIONS

More precise preoperative evaluation of disease stage could be obtained by the directionality system and the JCGC system in combination.

Clinicopathologic features and risk factors for extrahepatic recurrences of hepatocellular carcinoma after curative resection

BACKGROUND

The aim of this study was to clarify the clinicopathologic features of hepatocellular carcinoma (HCC) patients with extrahepatic metastasis after the removal of primary HCC, and the risk factors of extrahepatic recurrence.

METHODS

Clinicopathologic data were available for 264 HCC patients who underwent an R0 resection for HCC. Twenty-six patients who developed extrahepatic recurrence during the follow-up period (EXT group) were compared with patients who remained free from recurrence for at least 5 years after resection (n = 46) (No R group) or had only intrahepatic recurrences (n = 193) (INT group). We also estimated the risk factors of extrahepatic recurrence and survival in these 26 patients.

RESULTS

There were significant differences in primary tumor size, patient's age, findings in the noncancerous portion, macroscopic type, ductal invasion, intrahepatic metastasis, hepatic involvement and curability of primary tumor, treatment for recurrent tumor, and prognosis between the EXT group and the other groups. Extrahepatic recurrence was significantly associated with six factors by univariate analyses: age, indocyanine green (ICG) 15-min retention rate, tumor size, hepatic involvement of primary tumor, type of hepatectomy, and TNM stage, of which tumor size was an independent risk factor. Resection of recurrent tumor was the only independent favorable factor for survival of patients with extrahepatic recurrence.

CONCLUSIONS

HCC patients with extrahepatic recurrence had advanced primary tumors and poor prognosis. HCC patients with primary tumors larger than 60 mm were predicted to develop extrahepatic recurrence. Resection of recurrent tumor can improve the prognosis of HCC patients with extrahepatic recurrence.

Total pancreatectomy for pancreatic carcinoma: evaluation of safety and efficacy

BACKGROUND/AIMS

To determine the safety and the efficacy of total pancreatectomy for the curative treatment of pancreatic carcinoma.

METHODOLOGY

Retrospective analysis was performed using 10 patients receiving total pancreatectomy.

RESULTS

The median duration of the operative procedure was 8.7 hours and the median estimated blood loss was 2,700mL. Seven patients developed postoperative complications, including infections in 5 cases. There was no death associated with the operative procedure itself. Median period of postoperative hospital stay was 55 days. Anastomotic ulcer was prevented by administration of proton- pump inhibitors. Blood glucose level was well controlled by subcutaneous injection of sliding scale insulin during the postoperative period and the dosage of insulin required was 0.45±0.13units/kg body weight/ day at the time of discharge. The mean HbA1c level at 3 months after the operation was 6.1%. Four patients needed medication with anti-diarrheal drugs.

CONCLUSIONS

Total pancreatectomy could be performed safely and postoperative daily performance was reasonable with effective medication. We suggest that total pancreatectomy should be considered for the treatment of pancreatic carcinoma when the patient status is appropriate for this procedure.

Case involving long-term survival after esophageal cancer with liver and lung metastases treated by multidisciplinary therapy: report of a case

A 57-year-old male with lower esophageal cancer underwent subtotal esophagectomy with lymphadenectomy. The histopathological diagnosis was poorly differentiated squamous cell carcinoma, pT2N1M0 pStageIIB. After one course of postoperative adjuvant chemotherapy involving low-dose CDDP/5FU, a PET-CT scan obtained 12 months after surgery revealed a solitary liver metastasis in the S2 area. The patient then underwent five courses of docetaxel chemotherapy (80 mg/body, tri-weekly), and a partial response was observed. We also performed radiofrequency ablation (RFA), after which a complete response was observed. Twenty months after surgery, we detected local liver recurrence in the same position and performed additional RFA. Twenty-four months after surgery, a solitary lung metastasis was detected in the left S2 area and the patient was administered five additional courses of docetaxel therapy. Subsequently, PET-CT revealed growth of lung and liver tumors without recurrence in other areas. Twenty-nine months after surgery, we partially excised metastatic liver and lung tumors, and no subsequent recurrence has since been detected. The prognoses of patients who suffer from esophageal cancer organ recurrence are known to be extremely poor, and optimal therapeutic strategies for treating these patients have not been established. This long-term survival case suggests that multidisciplinary therapy for the treatment of liver and lung recurrence after esophagectomy is effective.

A case of a superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta

Superficial carcinoma of the esophagus with isolated para-aortic lymph node metastasis is quite rare. A 56-year-old female demonstrated a type 0-IIa+IIb lesion in the middle thoracic esophagus on endoscopic examination. Enhanced computed tomography and positron emission tomography demonstrated two swollen lymph nodes on the right side of the inferior vena cava, but did not demonstrate either a primary lesion or regional lymph node metastasis. A retroperitoneal videoscopic lymph node biopsy was thus performed, and the histopathological diagnosis was metastasis of squamous cell carcinoma. Induction chemotherapy was administered with cisplatin/5-FU, and followed by definitive chemoradiotherapy with cisplatin/5-FU plus 60 Gy radiation. The patient showed satisfactory responses in both the primary and metastatic lesions. This is the first case report describing superficial carcinoma of the esophagus with isolated lymph node metastasis around the abdominal aorta. A precise histological diagnosis of the lymph node is quite important in such cases, and an adequate curative effect can be expected.

Intraoperative real-time cholangiography and C-tube drainage in donor hepatectomy reduce biliary tract complications

BACKGROUND

In living-donor liver transplantation, biliary tract complications are a serious problem for recipients and donors.

METHODS

We applied intraoperative real-time cholangiography using a C-arm and/or C-tube drainage to reduce biliary tract complications in donor hepatectomy. From 2003 to 2010, intraoperative real-time cholangiography and C-tube drainage was applied to 39 and 19 donor cases, respectively. Fifteen donor cases had both procedures.

RESULTS

We confirmed the division line of the hepatic duct by visualizing a stricture on the monitor of the C-arm by pulling a thread and dissecting the proper site of the bile duct. The number of hepatic ducts of the graft to be anastomosed was 1 in 11 cases and 2 or 3 in 8 of the 19 cases without intraoperative real-time cholangiography, and it was 1 in 32 cases and 2 in 7 of the 39 cases with intraoperative real-time cholangiography. Bile leakage from the resection occurred in seven donors without, and in none of those with, C-tube drainage.

CONCLUSION

In living-donor liver transplantation, intraoperative real-time cholangiography enables effective determination of the precise division line of the hepatic duct. Moreover, C-tube drainage is effective for reducing bile leakage from the resected surface of the liver of donors.

[A case with juvenile hepatocellular carcinoma without hepatitis underwent right hepatic Trisegmentectomy]

A 20-year-old man with juvenile hepatocellular carcinoma (HCC) without HBV, nor HCV infections. A complaint of pain in the right abdomen, wherein a bulky hepatic tumor occupying a large area of the right lobe as well as tumors that were 20 mm and 10 mm in size in liver regions S2 and S3, respectively, were observed via an abdominal CT scan. A biopsy resulted in a diagnosis of well-differentiated hepatocarcinoma. The main voluminous tumor mass in the right lobe was resected, but the tumor still remained in the lateral segment after the surgery. On day 21 after the surgery, we initiated a therapy for the remaining tumor. He is still alive 36 months after surgery.

[A case report of cholangiectasis with cholangiocarcinoma]

This is a case report of cholangiectasis with cholangiocarcinoma in a 37-year-old female. Both computed tomography (CT) and endoscopic retrograde cholangio-pancreatography (ERCP) demonstrated gallstone, and intrahepatic bile duct dilatation with the stone. The diagnosis was intrahepatic cholangiectasis without common bile duct-dilatation. Hepatectomy of segment 3 with resection of the extrahepatic bile duct and reconstruction of the biliary tract was performed. Upon pathological examination, an early stage of cholangiocarcinoma was pointed out within the small range of common bile duct without dilatation or stone. Cholangiocarcinoma with cholangiectasis has been reported to be induced by counter flow of pancreas and intestinal juice because of the pancreaticobiliary maljunction. So we usually choose a diversion operation as our tactics to get rid of the counter flow of those digestive juices. Despite the above-mentioned tendency, this is a very rare case of carcinogenesis in common bile duct without dilatation.

Use of multidetector-row computed tomography to evaluate branch duct type intraductal papillary mucinous neoplasms of the pancreas: influence on surgical decision-making

BACKGROUND/AIMS

The purpose of this study was to evaluate factors predictive of the malignant grade associated with branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) using multidetectorrow computed tomography (MDCT).

METHODOLOGY

We reviewed the morphological features of 26 BDIPMNs using MDCT. Tumor size, caliber of the main pancreatic duct, number of mural nodules, diameter of the largest mural nodule and volume of the largest mural nodule were assessed and correlated with the pathological findings.

RESULTS

By multiple- and single-regression analyses and Mann-Whitney U test, significant differences in the caliber of the main pancreatic duct and number of mural nodules were observed between adenoma and non-invasive carcinoma and in the number of mural nodules between adenoma and invasive carcinoma. No significant differences were observed between non-invasive carcinoma and invasive carcinoma. Based on the differential diagnostic criterion of 1 or more mural nodules for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma, the sensitivities were 60% and 100%, respectively, and the specificity was 93% for both.

CONCLUSIONS

Although it was impossible to distinguish non-invasive carcinoma from invasive carcinoma, MDCT was reliable for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma.

Long-term survival of a patient with common bile duct cancer after Virchow's node recurrence: Report of a case

A 62-year-old male patient with common bile duct (CBD) cancer underwent pancreaticoduodenectomy with lymphadenectomy in 2002. Histological examinations revealed moderately differentiated tubular adenocarcinoma with lymph node metastasis around the pancreas head and hepatoduodenal ligament. No adjuvant chemotherapy was performed, due to the risk of side effects. Two years after the first operation, new lesions developed at the left supraclavicular area. These lesions were considered to be Virchow's node metastasis of the original CBD cancer. However, we could not detect any other metastatic lesions in the intraabdominal lymph nodes around the aorta. We resected the lesion. Histological examinations showed a similar histological appearance of this lesion to that of the CBD cancer resected in 2002. At present, the patient has survived for more than 80 months after receiving the second surgery. In selected cases, surgery might be considered even for a Virchow's node metastasis of CBD cancers if there are no other recurrent lesions.

Risk factors and management of postoperative bile leakage after hepatectomy without bilioenteric anastomosis

BACKGROUND/AIMS

Bile leakage frequently causes major complications after hepatic resection. We investigated perioperative risk factors and management of postoperative bile leakage after hepatic resection without extrahepatic biliary resection and reconstruction.

METHODS

We included 247 consecutive patients who underwent elective hepatic resection without bilioenteric anastomosis at our institution between 2002 and 2009. Perioperative risk factors, including patient and surgical variables, were evaluated using univariate and logistic regression analyses.

RESULTS

Postoperative bile leakage occurred in 26 patients (10.5%). The surgical drain was retained in 6 patients (23%); 9 (35%) underwent drain salvage and 11 (42%) underwent percutaneous puncture under computed tomography or ultrasound guidance. Eight patients underwent endoscopic nasobiliary drainage (ENBD) for postoperative bile leakage, and bile leakage healed at a median interval of 19.5 days after ENBD. By univariate analysis, postoperative bile leakage was associated with central bisectionectomy, surgical time and intraoperative blood loss. Logistic regression analysis identified central bisectionectomy as an independent risk factor for postoperative bile leakage (p = 0.0003, odds ratio 16.724).

CONCLUSION

Meticulous procedures are necessary during parenchymal hepatic resection, especially during central bisectionectomy. Drain management should be precise in the case of postoperative bile leakage. We believe ENBD may rapidly cure postoperative major bile leakage.

Clinical evaluation of JCGC and TNM staging on multidetector-row computed tomography in preoperative nodal staging of gastric cancer

BACKGROUND/AIMS

Multidetector row computed tomography (MDCT) has emerged as a new diagnostic technology in various cancers. The aim was to evaluate its clinical compatibility with the 13th Japanese Classification of Gastric Carcinoma (JCGC), the 6th TNM and the new 14th JCGC/ 7th TNM systems in preoperative nodal staging (N-stage) of gastric cancer.

METHODOLOGY

Between January 2005 and December 2007, 92 consecutive patients with gastric cancer underwent preoperative MDCT at a slice thickness of 1.0 mm.

RESULTS

The 13th JCGC N-stage on MDCT demonstrated the potential correlation with pathological findings (p=0.057). However, preoperative 6th TNM and the new 14th JCGC/7th TNM N-stage on MDCT from N1 to N3 did not significant correlate with pathological findings (p=0.979, 0.847) because the number of metastatic lymph nodes detected preoperatively on MDCT was significantly smaller than that detected on pathological diagnosis (p<0.0001).

CONCLUSIONS

Nodal staging in the 13th JCGC staging system correlates with histological examination better than the 6th TNM and 14th JCGC/7th TNM staging systems. The optimal preoperative nodal staging using the current 14th JCGC/7th TNM staging system on MDCT needs further investigation.

Long-term survivors of esophageal carcinoma with distant lymph node metastasis

BACKGROUND/AIMS

Clinical extra-regional lymph node metastasis, M1 lymph node metastasis (M1 LYM), has been recognized as a far advanced condition in esophageal cancer. However, some patients with M1 LYM survive long-term. The purpose of this study was to identify the clinicopathological features of those patients with M1 LYM achieving long-term survival.

METHODOLOGY

Between 2002 and 2008, 31 patients with squamous cell carcinoma of the thoracic esophagus with M1 LYM were treated at our institution. Of the 31 patients, four survived for more than three years. These four patients were examined retrospectively.

RESULTS

Cervical lymph node metastasis was the cause of M1 LYM and no regional nodal metastasis was detected in any of the four patients. Primary lesions were non-T4 and located at the middle or lower thoracic esophagus in these patients. Two patients underwent radical esophagectomy with three-field lymphadenectomy and complete resection was confirmed by pathological examination. The other two patients underwent definitive chemoradiotherapy and complete response was confirmed. Three patients are alive without recurrence but one, who underwent definitive CRT, died of local recurrence.

CONCLUSION

Solitary metastasis localized at the cervical node might be targeted specifically in an effort to improve the prognosis of M1 LYM patients with esophageal cancer.

Expression of cancer stem cell markers CD133 and CD44 in locoregional recurrence of rectal cancer

BACKGROUND

Recent findings suggest that cells with surface CD markers include cancer stem cells (CSCs) which can produce a cancer cluster, and that the presence of CSCs may be linked with prognosis. CD133 and CD44 are among the most useful markers for identification of colorectal CSCs.

MATERIALS AND METHODS

An immunohistological analysis of CD133 and CD44 was performed using tissue from cases shown to be locoregionally recurrent or non-recurrent clinico-pathologically.

RESULTS

The CD133-positive rates were 38.7% and 59.23% in non-recurrent and recurrent cases, respectively, and the CD44-positive rates were 35.5% and 44.4%, respectively. Expression of the CD markers had no correlation with other clinicopathological factors. The prognosis of patients who were positive for both markers was significantly worse than that of other patients.

CONCLUSION

These results suggest that detection of CD133 and CD44 can provide useful information for selection of treatment and performance of intensive follow-up of colorectal cancer.

Prognostic impact of cancer-related symptoms in recurrent gastric cancer patients

BACKGROUND/AIMS

Although routine postoperative follow-up is generally performed for early detection of recurrences, there is no evidence that the periodic follow-up improves survival in patients with gastric cancers. This study aimed to assess the prognostic impact of cancer-related symptomatic status during postoperative followup in gastric cancer patients.

METHODOLOGY

A total of 81 gastric cancer patients, who developed recurrences after curative surgery, were retrospectively evaluated for clinicopathological findings with regard to the relationship to cancer-related symptoms at the time recurrences were diagnosed.

RESULTS

Undifferentiated tumor type, advanced T-stage (T3/4) and peritoneal recurrence were more common in symptomatic patients groups, whereas differentiated tumor type and both locoregional and hematogenous recurrences were more common in asymptomatic patients (p = 0.02, 0.03 and 0.03, respectively). Disease-free survival showed that there were no significant differences between the asymptomatic and symptomatic patient group. However, the post-recurrence survival in patient with symptoms was significantly worse than that in those without symptoms (p < 0.01).

CONCLUSIONS

Cancer-related symptomatic status at the time recurrences are diagnosed might provide prognostic information predicting post-recurrence survival. However, we have to conclude that even intensive follow-up did not contribute to the early detection of recurrences in patients with gastric cancers.

Optimal surgical treatment for patients with pT2 gallbladder cancer

BACKGROUND/AIMS

Wall invasion is one of the significant prognostic factors of gallbladder cancer (GBC). Even extended surgery associated with hepatectomy does not always improve the prognosis of pathological T2 (pT2) (the tumor invades perimuscular connective tissue pathologically) GBC patients. The purpose of this study was to identify factors associated with long-term survival of pT2 GBC patients.

METHODOLOGY

Fifty-three patients with GBC had undergone radical resection from 1995 to 2009 in our institution. Among them, there were 23 pT2 patients. We reviewed clinico-pathologic features of the pT2 GBC patients and evaluated prognostic factors.

RESULTS

The 5-year survival rates for pT1, pT2, pT3, and pT4 in TNM classification by the International Union against Cancer (UICC) were 100%, 55.2%, 38.5% and 25.0%, respectively. In the 23 patients with pT2 GBC, the absence of lymph node metastasis and a periductal cancer-free surgical margin were significant favorable factors by univariate analysis. The 5-year survival rate of pT2 GBC patients with a periductal cancer-free surgical margin was 65.8% and that of pT2 GBC patients who did not have lymph node metastasis was 71.2%.

CONCLUSIONS

In the treatment of pT2 GBC patients, radical resection to achieve RO including surgical margins and lymph nodes in spite of surgical procedures contributes to a better survival.

[Early prediction of treatment response by serum CRP levels in patients with advanced esophageal cancer who underwent definitive chemoradiotherapy]

Serum CRP has been shown to be associated with the progression of esophageal cancer. The purpose of this study was to examine the relationship between treatment response and serum CRP levels in time course during definitive chemoradiotherapy (CRT) in terms of early prediction of CRT response by serum CRP. The subjects of this study were 36 patients with cT3/cT4 esophageal squamous cell carcinoma who underwent definitive CRT in our hospital. Serum CRP levels during definitive CRT (pretreatment, 1W, 2W and 3W after CRT initiation) were compared between CR and non-CR group. In addition, partition model was constructed to discriminate CR with non-CR and the prediction accuracy was evaluated. The patients were consisted of 28 males and 8 females. At pretreatment diagnosis, tumors were categorized as T3 (n=21) and T4 (n=15). Thirty four patients received FP-based chemotherapy and 2 patients received docetaxel-based chemotherapy. Treatment responses were categorized as CR (n=8), PR (n=14), NC (n=2) and PD (n=12). Serum CRP levels at the time of 2W after CRT initiation (CRT2W) in CR group were low compared to those in non-CR group (p=0.071). The partition model was constructed based on CRP levels at CRT2W. The prediction accuracies to discriminate CR from non-CR by CRP≤0.1 were 50%, 82%, and 75% in sensitivity, specificity and accuracy, respectively. Serum CRP is a useful biomarker for an early prediction of CRT response.

Prognostic impact of histological blood vessel invasion in patients with ampullary adenocarcinoma

BACKGROUNDS/AIMS

Ampullary adenocarcinoma (AmpCA) has a greater overall survival (OS) rate than other periampullary cancers such as pancreatic cancer or bile duct cancer. Nevertheless, the OS of AmpCA is still poor. In the present study we evaluated the clinicopathologic features of AmpCA with respect to its impact on OS.

METHODOLOGY

Records of 28 patients with AmpCA undergoing pancreaticoduodenectomy from 1995 to 2009 in Kyoto Prefectural University of Medicine were reviewed retrospectively. The mean age was 65.6 and mean +/- S.D. tumor size was 2.08 +/- 1.13 cm. Of the 28 patients, nine (32%) were > or = T3 tumors and nine (32%) were pN1 stage. There were seven (25%) cases of pancreatic invasion (Panc-invasion) and 15 (54%) cases of duodenal invasion (Du-invasion). Further, 14 (50%) cases involved lymphatic vessel invasion (ly+) and five (18%) cases involved histological blood vessel invasion (v+). Eleven (39%) patients experienced recurrences, of which eight were liver metastases. The median OS was 37 months (range 0.6-139.6 months) and the five-year survival rate was 56.4%. The clinicopathologic features and prognoses of these patients were analyzed and the prognostic factors determined.

RESULTS

On log-rank testing, Du-invasion (p = 0.029), ly+ (p = 0.022), and v+ (p < 0.001) were significantly associated with worse survival. According to multivariate Cox's hazard analysis using these three factors by Backward Elimination of Stepwise method, blood vessel invasion was the only significant prognostic indicator for survival (p = 0.046; Hazard ratio, 4.40).

CONCLUSIONS

Blood vessel invasion was an independent prognostic indicator, while prevention of liver metastases was important for longer survival.

[A case report--locally advanced pancreatic adenocarcinoma was resected after chemotherapy]

The case was a 36-year-old male whose chief complaints were anorexia and weight loss. Upper gastrointestinal endoscopy revealed circumferential stenosis in the fourth portion of the duodenum, while CT revealed a tumor with a diameter of 60 mm continuing as a single mass from the pancreatic body and tail to the fourth portion of the duodenum, and this was accompanied by findings that raised suspicions of circumferential invasion of the superior mesentric artery (SMA). Based on these results and biopsy, the patient was diagnosed with pancreatic and SMA invasion of duodenal cancer that was considered to be unresectable. After performing gastrojejunostomy, we administered DOC (40 mg/m2, day 1), CDDP (60 mg/m2, day 1), and S-1( 80 mg/m2, day 1-14) for 3 courses. The tumor response was PR and the images indicated the SMA invasion was disappeared. We judged that the tumor could be gone by a resection while preserving the SMA. In the surgical findings, the tumor continued as a single mass from the pancreatic body and tail to the third portion of the duodenum, and the surrounding area exhibited marked fibrosis. We performed a pancreatic tail resection along with combined resection of third and fourth portions of the duodenum, transverse colon and splenic flexure, and left adrenal gland. The case was diagnosed to be well-differentiated invasive ductal pancreatic cancer with duodenal invasion. Cancer invasion was not observed in any of the stripped surfaces surrounding the pancreas. The T3, N1, M0, fStage III antitumor effects were mildly effective. In this case, the treatment was initially started by considering the case as one of duodenal cancer, but the final results of a pathological diagnosis revealed that it was pancreatic cancer. However, either way, even though the case was unresectable before the chemotherapy performed for duodenal cancer was significantly effective for the pancreatic cancer. Therefore, a resection became possible, and an R0 resection was also effective.

[Usefulness of esophageal stenting by using a covered self-expandable metallic stent for esophagorespiratory fistula associated with esophageal carcinoma]

We report three cases of esophagorespiratory fistula associated with esophageal carcinoma successfully treated with esophageal stenting by using a covered self-expandable metallic stent (SEMS). All three cases had advanced esophageal carcinoma at middle thoracic esophagus with esophagorespiratory fistula at the level of esophageal carcinoma. Case 1 is a 58-year-old man who had lung abscess due to esophagopulmonary fistula caused after induction chemoradiotherapy. He underwent a surgical resection of the affected lung and intraoperative esophageal stenting with dietary intake starting on day 26 after stenting. Case 2 is a 60-year-old man with esophagopulmonary fistula caused after primary chemotherapy. He started to take an oral intake on day 3 after esophageal stenting. Case 3 is a 68-year-old man with esophagobronchial fistula detected at the first medical examination. He started to take an oral diet on day 7 after esophageal stenting. All three cases had a rapid improvement of respiratory symptoms, pneumonia and malnutrition by esophageal stenting leading to marked improvement of impaired general condition. Esophageal stenting is a useful method for palliation of esophageal carcinoma with respiratory fistula.

[A case of esophageal cancer with sigmoid colon tumor treated by laparoscopic surgery]

We performed a subtotal esophagectomy with gastric tube reconstruction by hand assisted laparoscopic surgery and laparoscopic sigmoidectomy simultaneously for the patient with middle thoracic esophageal cancer and lateral spreading tumor in the sigmoid colon. Upper abdominal and transumbilical incisions were made and Lap Discs (regular, mini) were set respectively. Two 12 mm ports were inserted in the right flank and lower quadrant, and two 5 mm ports were inserted in the left flank and lower quadrant. First, by using video-scope from upper Lap Disc, laparoscopic sigmoidectomy was performed. Anastomosis was performed via lower Lap Disc. For the gastric tube reconstruction, upper Lap Disc was used for hand assistance, and video-scope was inserted from lower Lap Disc. The patient was discharged at 26 days after surgery without complications. In conclusion, our surgical procedure provided a good surgical view and decreased a surgical stress.

[The role of adjuvant chemotherapy with S-1 for gastric cancer patients]

A randomized controlled trial of adjuvant chemotherapy with S-1 for gastric cancer (ACTS-GC) demonstrated that the chemotherapy with S-1 improved the relapse-free survival and overall survival rates of patients with locally advanced gastric cancer. We examined retrospectively 47 patients with locally advanced gastric cancer, who received adjuvant chemotherapy with S-1 after curative gastrectomy. Patients who received more than 50% of the total scheduled dose of S-1 during the first 1 year after starting the chemotherapy showed a tendency to favorable outcome in terms of relapse-free survival compared with patients who received less than 50% of the dose, although no statistical significance was detected. Age did not show a significant correlation with tolerability. The number of elderly people with gastric cancer will increase in the next decade. They should be candidates for adjuvant chemotherapy on the basis of a geriatric assessment.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a low-density lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab’s operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient’s postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.

Salvage surgery for uncontrollable hepatocellular carcinoma treated with repeated non-surgical therapies

BACKGROUND/AIMS

Some hepatocellular carcinoma (HCC) cases undergo surgery because tumor progression cannot be controlled by various non-surgical therapies. This retrospective study sought to clarify the clinicopathologic features of such HCC cases.

METHODOLOGY

Among cases with solitary small HCCs (< or = 3.0cm at the time of detection), the clinicopathologic features of 7 patients who had undergone hepatectomy after various non-surgical therapies (Salvage (S) group) were analyzed and compared with those of 30 patients who received hepatectomy as the initial treatment (Control (C) group).

RESULTS

In S group, the serum alpha-fetoprotein level was higher (p = 0.045) and macroscopic ductal invasion was more common (p = 0.028) at the time of the operation. Lobectomy was more commonly performed (p = 0.034) and curability B (No residual cancer, but Stage III or IV) was more frequent (p = 0.011). Other organ recurrence was more common (p = 0.0044). The survival time after the initial treatment (post-initial treatment survival) was worse (p = 0.028). Univariate analyses revealed that those with maximum tumor sizes of > 3.0 cm at the time of the operation were significantly worse compared with the other patients (p = 0.012).

CONCLUSIONS

The timing for changing from a non-surgical treatment to a surgical treatment is important.

RUNX3 promoter methylation in colorectal cancer: its relationship with microsatellite instability and its suitability as a novel serum tumor marker

BACKGROUND/AIM

RUNX3 is a novel gastric cancer tumor suppressor. RUNX3 promoter hypermethylation is associated with many types of cancer, including colorectal cancer. Furthermore, the RUNX3 promotor is one of the CpG island methylator phenotype (CIMP)-specific promotors. CIMP is a distinct phenotype associated with microsatellite instability (MSI) in colorectal cancer. In this study, the suitability of the quantitative analysis of RUNX3 promoter hypermethylation as a novel serum tumor marker was investigated. Moreover, we investigated the relationship between RUNX3 promoter methylation and MSI in colorectal cancer.

PATIENTS AND METHODS

A RUNX3 real-time quantitative methylation-specific PCR (RTQ-MSP) technique we developed was used to analyze the CpG sites in the RUNX3 promoter of 119 colorectal tumors and 344 sera from colorectal cancer patients. MSI analysis of 119 colorectal tumors was performed with five microsatellite markers (BAT25, BAT26, D5S346, D2S123, and D17S250).

RESULTS

Proximal colon tumors exhibited significantly higher RUNX3 methylation than their paired normal tissues (p=0.0438). Analysis of the clinicopathological parameters revealed that a proximal location (p=0.0054), lymphatic invasion (p<0.0001), and an advanced pathological stage (p=0.0018) were associated with significantly higher RUNX3 methylation. Assessment of the relationship between RUNX3 methylation and tumor MSI revealed 11 out of 13 tumors with high-frequency MSI (85%) were positive for RUNX3 hypermethylation, significantly more than the tumors with low-frequency MSI or which were microsatellite stable (34%, p=0.0070). In preoperative sera from 344 colorectal cancer patients, significantly higher RUNX3 methylation was associated with lymphatic invasion (p=0.0487) and an advanced pathological stage (p=0.0466). Post-operative follow-up data revealed that recurrence cases exhibited significantly higher preoperative serum RUNX3 methylation than non-recurrence cases (p=0.0003). Concomitant analysis of carcinoembryonic antigen (CEA) levels in the preoperative sera showed that 17.7% (61/344) were CEA-negative but RUNX3 methylation-positive, which means assessing both serum RUNX3 methylation and CEA should improve diagnosis of colorectal carcinoma.

CONCLUSION

RTQ-MSP-based quantification of serum RUNX3 methylation is useful for the detection and monitoring of colorectal cancer.

Production of 2-Keto-l-Gulonic Acid from d-Glucose by Two-Stage Fermentation

A practical method for the production of calcium 2-keto-l-gulonate (an intermediate in the Reichstein synthesis of l-ascorbic acid) from d-glucose has been established by using a two-stage fermentation system. d-Glucose was first converted to calcium 2,5-diketo-d-gluconate by a mutant strain of Erwinia sp. in a medium containing d-glucose, corn steep liquor, (NH(4))(2)HPO(4), and CaCO(3). After a 26-h cultivation, 328.6 mg of calcium 2,5-diketo-d-gluconate per ml was obtained, with a 94.5% yield from d-glucose. This broth was used directly for the next conversion without removal of cells by treatment with sodium dodecyl sulfate. The stereospecific reduction of calcium 2,5-diketo-d-gluconate to calcium 2-keto-l-gulonate was performed with a mutant strain of Corynebacterium sp. When the cell growth reached a maximum (about 16 h) in a medium containing d-glucose, corn steep liquor, NaNO(3), KH(2)PO(4), and trace elements, NaNO(3) was added to the culture, and then the calcium 2,5-diketo-d-gluconate broth was fed over a period of about 50 h. Since the mutant strain requires a hydrogen donor for reduction, the calcium 2,5-diketo-d-gluconate broth was mixed with d-glucose before being fed. The results of four two-stage fermentations in 10-m conventional fermentors showed that an average of 106.3 mg of calcium 2-keto-l-gulonate per ml was obtained, with a 84.6% yield from d-glucose, the starting material of calcium 2,5-diketo-d-gluconate production. Calcium 2-keto-l-gulonate was stable in the broth. Neither 2-keto-d-gluconic acid nor 5-keto-d-gluconic acid was detected in the final broth.

Application of polyethylene glycolic acid felt with fibrin sealant to prevent postoperative pancreatic fistula in pancreatic surgery

OBJECTIVE

The purpose of this nonrandomized retrospective study was to report our new procedures using polyethylene glycolic acid (PGA) felt with fibrin sealant to prevent severe pancreatic fistula in patients undergoing pancreatic surgery.

METHODS

From 2000 to 2008, 54 and 63 patients underwent pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), respectively. Of those patients, we applied PGA felt with fibrin sealant to 18 PD patients and 26 DP patients. In PD patients, the PGA felt was wrapped around the pancreatic suture site, while in DP patients, the PGA felt was wrapped around the predictive division site. The pancreaticojejunostomy site in PD patients and the cut stump in DP patients were coated with fibrin sealant. We compared the occurrence rates for severe postoperative pancreatic fistula (POPF) that occurred after PD or DP both with and without our new procedures.

RESULTS

Before introduction of our procedures, severe POPF developed in 14 of 36 PD patients (39%) and 10 of 37 DP patients (27%). In contrast, after introduction of our procedures, the incidence of POPF was only one in both of 18 PD (6%; P = 0.016) and 26 DP (4%; P = 0.017) patients.

CONCLUSION

In summary, our procedure using PGA felt with fibrin sealant may reduce the risk of severe POPF.

A case report of metastatic neuroendocrine carcinoma of the right adrenal gland successfully treated with chemotherapy and surgery

Poorly differentiated neuroendocrine carcinoma has a poor prognosis, especially when associated with distant metastasis. A 60-year-old man was admitted to a private hospital because of dyspnea at work in 2007. Computed tomography revealed lung infarction and a right adrenal tumor sized 12 cm in diameter that was tightly compressed against the inferior vena cava (IVC). Moreover, multiple lymph node metastases around the celiac axis and a solitary liver metastasis at the lateral segment were observed. Thus, we planned chemotherapy without surgery. We selected a combination therapy of irinotecan (CPT-11) and cisplatin (CDDP) (i.e., IP therapy): administration of CDDP [60 mg/m(2) body surface area (BSA)] on day 1 plus CPT-11 (80 mg/m(2)) BSA on days 1 and 8. Thereafter, this protocol was repeated at 3-week intervals. After 15 months of this chemotherapy strategy, the whole lesions showed a partial response by RECIST. The primary tumor had shrunk to 4.2 cm in diameter. In November 2008, we planned surgery to perform resection of the whole lesions. Histological diagnosis of the specimen was a poorly differentiated neuroendocrine carcinoma based on the immunostaining features, i.e., synaptophysin- and chromogranin positive. There were no viable tumor cells at the dissected lymph nodes or at the liver tumor. After surgery, CPT-11 administration was continued. The patient has remained well for 9 months without recurrence.

Gene transfer of NK4, an angiogenesis inhibitor, induces CT26 tumor regression via tumor-specific T lymphocyte activation

Hepatocyte growth factor (HGF) has been shown to be involved in malignant behaviors, such as invasion and metastasis, in different tumors. Hence, HGF could be a target molecule for control of the malignant potential of cancer. NK4 is a competitive antagonist for HGF and exerts an antitumor activity, not only by HGF antagonism but also by antiangiogenesis. Here, we studied the participation of cellular immunity in CT26 tumor regression by NK4 gene transfer. In vivo experiments showed that NK4-induced inhibition of subcutaneous tumor growth (as demonstrated in immunocompetent BALB/c mice) was weakened in T lymphocyte-deficient nude mice. In addition, the immunocompetent BALB/c mice that had shown complete regression of CT26-NK4 tumors generated an immune memory against repeated challenge with the same tumor antigen. Immunohistochemistry of tumor-infiltrating lymphocytes showed that the ratio of CD8/CD4 in CT26-NK4 tumors was significantly higher than that in control tumors. Also, the presence of tumor-specific cytotoxic T lymphocytes (CTL) was demonstrated by cytotoxicity assays. Depletion of CD8+ T lymphocytes markedly abrogated the antitumor activity of NK4. However, NK4 had no direct effect on the in vitro cellular immune system. Taken together, these data indicate that NK4 expression by gene transfer, at the tumor site, triggers tumor-specific CTL activation, resulting in complete CT26 tumor regression in vivo. This action was considered to be due to apoptosis induced by NK4's potent antiangiogenic and HGF antagonistic effects.

[PSK-mediated growth suppression and enhancement of 5-FU/docetaxel-induced cytotoxicity in human esophageal cancer cell lines]

PSK, a protein-bound polysaccharide, is widely used for treating cancer patients as an immunostimulant. However, its direct action on cancer cells is not fully understood. In the present study, we investigated direct effects of PSK alone or in combination with 5-FU, CDDP and docetaxel on tumor growth by using esophageal cancer cell lines, KYSE170 and TE13. Cells were incubated with different concentrations of PSK for 72 hour, and cell viability was determined by WST-8 assay, and cell cycle was analyzed by flow cytometry. As a result, PSK of 100 microg/mL induced growth suppression dose-dependently in the both cell lines, and flow cytometric analysis showed a PSK dose-dependent increase of sub-G1 cells indicating apoptotic cells. In addition, when cells were incubated with different concentrations of 5-FU and docetaxel in the presence of PSK at the dose of 5 microg/mL showing no growth suppression, cytotoxicity induced by 5-FU and docetaxel was significantly enhanced. These results indicate that PSK not only shows tumor growth suppression by apoptosis induction, but also enhances 5-FU and docetaxel-induced cytotoxicity.

Outcomes of total pelvic exenteration for colorectal cancer

BACKGROUND/AIMS

Pelvic recurrence occurs in 4-33% of patients who have undergone a curative resection of primary rectal cancer and is thus a serious problem. However, the best treatment for primary rectal cancer remains unclear. In the present study was assessed the outcomes of total pelvic exenteration for colorectal cancer retrospectively.

METHODOLOGY

In the present study was investigated the medical charts of 25 patients who underwent total pelvic exenteration for primary colorectal cancer (n = 12) or postoperative local recurrence of colorectal cancer (n = 13) at the Department of Surgery (Division of Digestive Surgery) of the Kyoto Prefectural University of Medicine between the years 1997-2005.

RESULTS

The mean disease-free time interval between the first operation for primary colorectal cancer and total pelvic exenteration for the recurrence was 919 days (range, 203-3460 days). Total pelvic exenteration required a mean operation time of 940 minutes (range, 540-1395 minutes). The mean carcinoembryonic antigen (CEA) value was 25.5 ng/ml (range, 1-171.8 ng/ml). Five-year survival was achieved in 9 patients (36%) and inhospital death occurred in 3 patients (12%). The patients with curative resection survived significantly longer than the patients with non-curative resection.

CONCLUSIONS

When curative resection is achieved, total pelvic exenteration for colorectal cancer can result in long-term survival.

[The IL-6 and COX-2 expression related to sensitivity of chemoradiotherapy and prognosis in esophageal carcinoma]

Chemoradiation therapy (CRT) for esophageal cancer induces inflammatory responses within tumor tissues. Inflammatory cells infiltrated into the tumor tissues may modulate the CRT responses via inflammation-related molecules such as IL-6 or COX-2. In the present study, we investigated a relationship between IL-6/COX-2 expression and CRT responses for esophageal cancer. A surgical resection following CRT was performed, and the specimens from the patients with cT3/T4 esophageal squamous cell examined for IL-6/COX-2 expression in both residual cancer and stromal cells by immunohistochemical staining. CRT responses were divided into responder group (Grade 1b and Grade 2) and non-responder group (Grade 1a). COX-2 in cancer cells and IL-6 in stromal cells were associated with non-responder and responder, respectively. In addition, IL-6 in stromal cells was significantly correlated with overall survival. Our data suggest that inflammatory responses concomitant with CRT responses could play a role in chemoradiation responses and prognosis.

[Radiofrequency ablation for postoperative recurrent of metastatic lesions of esophageal cancer]

Radiofrequency ablation (RFA) was performed for the postoperative recurrent of metastatic lesions of esophageal cancer in 6 patients. All patients were males, and the median age was 59. Surgical curativities were A (3 cases), B (2) and C (1). The recurrent sites were intramediastinal omentum of gastric tube (2 cases), rt lung (2), rt adrenal grand (1) and liver (1). Four cases had a single recurrent lesion and the two had multiple lesions consisted of a single lesion as RFA target, and the lesions in a different site that were simultaneously treated by other therapeutic modalities. The median time of recurrence was 12 months after esophagectomy. RFA was performed once in the 3 cases, and twice in the other 3 cases. Therapeutic effect evaluated by CT was CR (2 cases), PR (3) and SD (1). No serious complications associated with RFA procedure were observed. Three patients died due to cancer recurrence within 7 months after RFA. However, RFA-treated lesions were well controlled to the end. RFA are safe and minimally invasive, thus, can be repeatedly performed technique that can induce a good local control of the target lesion equivalent to surgical resection. RFA is applicable as an effective local therapy for the recurrent or metastatic lesions of esophageal cancer.

[Surgically resected local recurrence after endoscopic submucosal dissection of esophageal cancer--a case report]

We report a case of surgically resected esophageal cancer which was locally recurred after endoscopic submucosal dissection. A 66-year-old man was admitted to our hospital because of further examination and a treatment of superficial esophageal cancer. A type 0-IIb+IIa cancer occupying the whole circumference of the lumen of the middle to lower esophagus was revealed. The depth of the invasion was judged to be T1a-EP or LPM by endoscopic ultrasonography, and no metastasis to other organs or lymph nodes was detected. Endoscopic submucosal dissection (ESD) was performed. However, macroscopic residual cancer didn't seem to exist. Pathological diagnosis was squamous cell carcinoma, moderately differentiated, the depth of tumor invasion was T1a-LPM. The presence of the residual cancer of the horizontal cut margin could not be judged because en bloc resection could not be achieved. After that, endoscopic balloon dilatation of the esophageal stenosis was performed repeatedly for about one year. Then, he was diagnosed as the local recurrence of the squamous cell carcinoma of the esophagus. Thoraco-abdominal esophagectomy reconstructed by stomach tube via a retrosternal route was undergone. The final stage of the lesion was judged T3N1M0 (Stage III, UICC) by the histological examination from the resected specimen. After the operation, he is receiving adjuvant chemotherapy and alive without recurrence. When endoscopic resection of the esophageal cancer is performed to the lesion, which relatively indicated to endoscopic resection or outside the guideline criteria for endoscopic resection, it is important that we choose the appropriate treatment protocol obtaining an informed consent from the patient sufficiently.

Management of Acute Superior Mesenteric Artery Occlusion by Thrombolytic Therapy

Acute occlusion of the superior mesenteric artery (SMA) causes extensive bowel necrosis, resulting in a poor prognosis with an extremely high mortality rate. An 82-year-old woman was admitted to our hospital with the complaint of abdominal pain. She was diagnosed as having acute SMA occlusion by enhanced CT. Five hours from onset, the first thrombolytic therapy with urokinase was performed, but failed to complete thrombolysis and recanalization of peripheral blood flow. An exploratory laparotomy following the first thrombolytic therapy showed a mild ischemic change in the affected intestine and mesentery, but no sign of necrosis. After the laparotomy, local thrombolytic therapy with angiographic evaluation of blood flow at 24, 36 and 48 h from the first thrombolysis was performed. As a result, the residual thrombus disappeared and all branches of the SMA became well visualized. The patient was discharged well without a second-look operation or major bowel resection. Sequential intermittent thrombolytic therapy with meticulous angiographic evaluation of blood flow is effective for early-stage acute SMA occlusion.

[A case of multiple hepatic metastases of gastric cancer that showed complete regression by systemic chemotherapy using paclitaxel and UFT-E]

We report a case of gastric cancer with simultaneous multiple liver metastasis that was successfully treated by paclitaxel and UFT-E. A 54-year-old man with gastric cancer was admitted to our hospital for further examination and treatment. A type III gastric cancer was located in the lower to middle part of the gastric body. Abdominal CT revealed multiple liver metastases and lymph node metastases. Then, we performed distal gastrectomy and cholecystectomy. Postoperative pathological diagnosis was stage IV(a type 3 tumor( 78x65 mm), pT3, por 2, INF g, ly3, v0, pN2(+)(26/ 28), H1(bilobular multiple metastases), CY0, P0). Postoperatively, he was treated with S-1 po at 100 mg/body/day as first-line chemotherapy. Thirteen days after S-1 initiation, he was readmitted due to grade 3 diarrhea, and S-1 was immediately stopped. After his general condition was improved, paclitaxel was administered biweekly at a dose of 80 mg/m2. He was discharged after twice administration, and the regimen was continued at an outpatient clinic. Four months after the operation, abdominal computed tomography(CT)showed a remarkable reduction of the multiple liver metastases, and the serum levels of tumor markers(CEA, CA19-9)were reduced. Five months after the operation, the serum levels of tumor markers elevated again. Then, additional administration of UFT-E po(300 mg/body daily) was started. Seven months after the operation, abdominal CT showed a complete regression of the multiple liver metastasis, and the serum levels of tumor markers were also reduced within the normal range. During chemotherapy at an outpatient clinic, critical adverse effects did not appear. Paclitaxel or paclitaxel combined with UFT-E might be an effective regimen as second- or third-line chemotherapy for the liver metastases of gastric cancer.

Latrunculin a has a strong anticancer effect in a peritoneal dissemination model of human gastric cancer in mice

Peritoneal dissemination of gastric cancer is a refractory disease. This paper focuses on the efficacy of actin-binding marine macrolide latrunculin A, which quickly inhibits actin polymerization and disrupts the function of the actin cytoskeleton. The effects of latrunculin A on cell viability in vitro were evaluated by treatment of MKN45 or NUGC-4 cell cultures. An in vitro viability assay demonstrated an anticancer effect of latrunculin A in a dose-dependent manner. Latrunculin A induced acute cell injury and programmed cell death through activating the caspase-3/7 pathway. In vivo, MKN45 or NUGC-4 cells were intraperitoneally inoculated into nude mice, as a model of peritoneal dissemination. Intraperitoneal (i.p.) injection of latrunculin A significantly improved survival rate in mice without any major side-effects. Data indicated that latrunculin A has strong anticancer effects, and it may be a new candidate i.p. drug against peritoneal dissemination of gastric cancer in humans.

Long-term complete response of multiple hepatic metastases from carcinoma of the papilla of Vater using intrahepatic infusion of 5-FU with low-dose cisplatin following pancreaticoduodenectomy

Of all distant metastases from carcinoma of the papilla of Vater (CPV), the liver is the most frequent site (more than 60%) and should be specifically targeted in the effort to improve the prognosis. However, the optimal chemotherapy regimen for nonresectable liver metastasis has not been clearly established. In this preliminary report, we note a patient with multiple hepatic metastases from CPV successfully treated using intrahepatic infusion of 5-fluorouracil (FU) with low-dose cisplatin. A 62-year-old woman underwent curative pylorus-preserving pancreaticoduodenectomy for CPV. Four months after surgery, followup computed tomography (CT) demonstrated multiple liver metastases. Weekly intrahepatic arterial infusion chemotherapy of 5-FU, 350 mg/m(2), with low-dose cisplatin (7 mg/m(2)) was started. Ten months after starting chemotherapy, a complete response was obtained. To date, the patient continues to receive this weekly hepatic arterial infusion chemotherapy without any side effects, and she has successfully maintained a long-term complete response for 20 months. The patient remains well and was able to proceed with daily activity at the last follow up 30 months after starting this chemotherapy regimen. This regimen is safe and effective and is recommended as one of the treatment choices for liver metastases from CPV.

[A case of huge advanced rectal cancer invaded into the surrounding organs resected successfully after preoperative chemotherapy with mFOLFOX6]

In the recent improvement in chemotherapy for advanced rectal cancer, a treatment for rectal cancer involving the surrounding organs has been well thought out. In this report, we described a case of advanced rectal cancer invaded into the surrounding organs was resected successfully after preoperative chemotherapy with mFOLFOX6. The case was a 74-year-old man with advanced rectal cancer (type 3). A close examination of the patient revealed a bowel movement disturbance. Bowel obstruction was treated with transverse colostomy. Then chemotherapy (mFOLFOX6) was performed six times. It was judged at first to be a huge tumor of 15 cm in diameter, which was unresectable due to invasion into the urinary bladder and sacrum. However, after mFOLFOX6 was enforced, the tumor was shrunk to about 5 cm in diameter (effect judgment PR). Then the tumor was successfully resected. A pathologic histology inspection of the tumor, judged to be Grade 2 prior to resection, revealed a differentiation type glandular carcinoma and a highly lymphocytic infiltration. These results suggested that an appropriate preoperative chemotherapy was useful for huge rectal cancers involving the surrounding organs such as urinary bladder and sacrum.