Safety, efficacy, and operability of a newly developed absorbable adhesion barrier (GM142) in patients with primary rectal cancer scheduled for diverting ileostomy during laparoscopic surgery: Randomized controlled trial

Aim

The aim of this study was to compare the outcomes of GM142, a newly developed gelatin film with a concave and convex structure to a commercially available conventional film, hyaluronate‐carboxymethylcellulose.

Methods

Patients with primary rectal cancer who were scheduled for diverting ileostomy during laparoscopic surgery were eligible for this study. Patients were randomized before surgery and an antiadhesion film was applied under the umbilical incision. The primary outcome was the incidence of adhesion under the midline incision confirmed by second‐look surgery for diverting ileostomy closure. The secondary outcomes were the adhesion severity score, the extent of adhesion score, the presence of intestinal obstruction, and the success of all patching.

Results

A total of 146 patients were enrolled. A total of 123 patients were included in the full analysis set. The primary outcome of “no adhesion” was observed in 66.1% in the GM142 group and 55.7% in the conventional film group. The noninferiority of GM142 to conventional film was confirmed (P = .0005). The secondary outcomes were similar between the groups. For the safety evaluation, there were no safety concerns regarding allergic reactions to gelatin or increased gelatin‐specific IgE antibody titers.

Conclusions

The noninferiority of GM142 to conventional film was shown. GM142 showed no major safety issues. The clinical safety profiles of GM142 suggested certain physiological benefits of the gelatin film as an adhesion barrier.

Multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine: A case report

FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus bevacizumab is the preferred first-line treatment for right-sided metastatic colorectal cancer with RAS mutation. However, severe adverse events are common in Japanese patients. We report the successful management of multiple stage IV colorectal cancers in a patient who received multidisciplinary treatment, including chemotherapy and Japanese Kampo medicine. A 68-year-old man presented with epigastralgia and appetite loss and was diagnosed with multiple stage IV colorectal cancers. Colonoscopy identified type II tumors in the ascending colon, sigmoid colon, and upper rectum. Histopathological examination of a biopsy specimen revealed well- to moderately differentiated tubular adenocarcinoma. Enhanced computed tomography of the thorax and abdomen showed multiple pulmonary nodules and para-aortic lymph node swelling. Laparoscopic loop-ileostomy was performed to avoid bowel obstruction due to severe stenosis of ascending colon cancer. Intraoperative observation revealed two white nodules suggestive of metastasis in the lateral area of the liver. Therefore, we diagnosed multiple stage IV colorectal cancers with multiple metastases (lung, liver, and distant lymph nodes). His postoperative course was uneventful, and chemotherapy was started. Since the cancer cells harbored a RAS mutation, he received FOLFOXIRI plus bevacizumab. Japanese Kampo medicine consisting of Hangeshashinto and Juzen-taiho-to, to prevent diarrhea and fatigue, was administered daily. After 12 courses of chemotherapy, though circumferential stenosis still existed in the ascending colon, the tumors in the sigmoid colon and upper rectum were unclear. Enhanced computed tomography showed shrinkage of the pulmonary nodules and para-aortic lymph node; therefore, laparoscopic-assisted ileocecal resection was performed. The postoperative histopathological examination revealed moderately differentiated adenocarcinoma. The patient recovered uneventfully, and Kampo medicine consisting of Ninjin'yoeito was administered for postoperative weakness. Administration of adjuvant chemotherapy in this patient led to a near complete response that has been maintained without recurrence for 2 years and 8 months without reduced quality of life.

[A Case of Sarcoid‒Like Reaction with Multiple Lymphadenopathy by Rectal Cancer after an Operation]

We are reporting on a case of lymphadenopathy after surgery for rectal cancer. The case was a 66‒year‒old female. Laparoscopic high anterior resection(D3 dissection)was performed for rectal cancer(pT1bpN0M0, pStage Ⅰ)in April 2018, and she was followed up with on an outpatient basis. In July of the same year, a painless mass had formed in the right groin. An abdominal contrast‒enhanced CT showed lymph node swelling around the right groin and external iliac artery, but the tumor markers, CEA 2.3 ng/mL and CA19‒9 <2 U/mL, were within the standard values. An inguinal lymph node biopsy was performed during the same month. Pathological examination revealed no cancer cells and formation of epithelioid granuloma with giant cells. There was no suspicion of systemic sarcoidosis based on the test results and clinical findings. From the above, the patient was diagnosed with sarcoid reaction due to the tumor. Abdominal contrast‒enhanced CT scan 2 months after the biopsy showed lymph node shrinkage and there was no recurrence 2 years after the biopsy.

Transverse colonic volvulus due to mesenteric fibromatosis: a case report

BACKGROUND

Colonic volvulus, a condition in which a colonic segment partially twists around its base, is the third leading cause of large bowel obstruction after colonic neoplasms and diverticular disease. However, volvulus of the transverse colon is the rarest type of large intestinal volvulus. Moreover, the occurrence of transverse colonic volvulus secondary to a benign tumor originating from outside the intestine has never been reported. We hereby report a case of transverse colonic volvulus caused by mesenteric fibromatosis.

CASE PRESENTATION

A 53-year-old female with a history of rheumatoid arthritis and thyroid tumor presented with abdominal pain for 1 day. Abdominal computed tomography revealed intestinal torsion at the hepatic flexure. Twisted and obstructed mucosa of the transverse colon was observed during colonoscopy, but no tumor invasion of the mucosal surface was detected. A solid mass of a mesenteric origin with involvement of the transverse colon was observed during surgery. The mass was diagnosed surgically as transverse colonic volvulus induced by a mesenteric tumor. Hence, the patient underwent a right hemicolectomy. Histopathological results indicated mesenteric desmoid-type fibromatosis. The postoperative recovery was uneventful, and the patient was discharged 8 days after surgery.

CONCLUSIONS

Although mesenteric fibromatosis is rare, this disease should be considered when managing transverse colonic volvulus resulting from nonmucosal tumors.

[A Case of Obstructing Rectal Cancer with Obstructive Colitis Resected after Neoadjuvant Chemotherapy to Avoid Anastomotic Leakage]

A 61-year-old male was referred to our department after decompression of the transanal ileus tube due to a rectal cancer obstruction. Colonoscopy revealed a circumferential type 2 tumor, 4 cm from the anal verge. The tumor was diagnosed as rectal cancer tub1-2, Group 5 on biopsy analysis. Longitudinal ulcers descending to the sigmoid colon were present and obstructive colitis was suspected. Enhanced computed tomography showed wall thickness in the Ra, Rb rectum and swelling of the mesorectum lymph node, but distant metastases were not identified. We diagnosed the patient with Ra, Rb rectal cancer cT4aN1aM0, cStage Ⅲb. Because of the risk of anastomotic leakage with obstructive colitis, we planned neoadjuvant chemotherapy(SOX therapy)after laparoscopic transverse colostomy. After neoadjuvant chemotherapy, colonoscopy revealed improvements in the obstructive colitis. The tumor was reduced in size and the chemotherapy appeared effective. We performed laparoscopic rectal super low anterior resection with resection of the D3 lymph node. Histopathological examination revealed tub1, ypT3, ypN0, and the chemotherapeutic outcome was rated as Grade 1a. The final diagnosis was Ra, Rb rectal cancer with ypT3ypN0M0, ypStage Ⅱa.

[A Case of Disseminated Carcinomatosis of the Bone Marrow with Carcinoma of the Rectum Diagnosed by Disseminated Intravascular Coagulation]

A 77-year-old man with rectal cancer was admitted to our hospital. After neoadjuvant chemotherapy, laparoscopic abdominoperineal resection of rectum with D3 dissection was performed. The pathological diagnosis was poorly differentiated carcinoma, pT3, N1a, M0, pStage Ⅲa. Adjuvant chemotherapy was not performed. Fifteen months after operation, his chief complaint was fatigue. Thrombocytopenia and elevation of tumor maker was detected by blood test and disseminated intravascular coagulation(DIC)was suspected. He was admitted to our hospital and we started anti DIC therapy immediately. Bone scintigraphy revealed multiple bone metastases, then we diagnosed disseminated carcinomatosis of the bone marrow. He died 10 days after hospitalization. Disseminated carcinomatosis of the bone marrow with colon cancer is rare and prognosis is very poor. It is important to diagnose and start treatment as early as possible.

[Hemorrhage of Peritoneal Dissemination of the Ascending Colon Cancer Successfully Controlled by Palliative Radiotherapy-A Case Report]

An 81-year-old man underwent laparoscopic right hemicolectomy for ascending colon cancer. The postoperative diagnosis was tub1>tub2, pT4apN1bM0, pStage Ⅲb, ascending colon cancer. At 1 year 4 months after operation, abdominal CT showed dissemination around anastomosis. The patient has been treated with first-line systematic chemotherapy(capecitabine, oxaliplatin and bevacizumab). Epigastralgia and grade 4 anemia were observed at 5 years 7 months after initiation of chemotherapy when he was treated with second-line chemotherapy(capecitabine, irinotecan and bevacizumab). As abdominal CT showed that the dissemination progressed rapidly in size 30 mm to 100 mm, we diagnosed tumor bleeding in the dissemination. Palliative radiotherapy(30 Gy/10 Fr)for the dissemination was performed. Hemostasis and tumor shrinkage were achieved, and epigastralgia improved after receiving the radiation therapy. The patient discharged our hospital on 31 days form admission. We believe that palliative radiotherapy is effective to recurrent colon cancer with tumor bleeding.

[Hyperammonemia with Disturbance of Consciousness during 5-FU plus Nedaplatin Therapy for Esophageal Cancer-A Case Report]

Hyperammonemia is a rare adverse event of 5-FU. Here, we report a case of hyperammonemia with disturbance of consciousness during 5-FU plus nedaplatin therapy for esophageal cancer and present a literature review. A 69-year-old man was diagnosed with cT2N2M0, cStage Ⅲ esophageal cancer. He was administered with DCF therapy as the first-line neoadjuvant chemotherapy. After the first course, he showed renal dysfunction. Therefore, as the second-line neoadjuvant chemotherapy, he was administered with 5-FU plus nedaplatin. He vomited on treatment day 5 and suddenly presented with disturbance of consciousness on treatment day 6. Blood tests showed hyperammonemia(114 μg/dL). He was treated with rehydration and branched-chain amino acid solutions, resulting in a gradual improvement of symptoms. Hyperammonemia has been reported in patients with colorectal cancer but rarely in patients with esophageal cancer. A case of hyperammonemia during the 5-FU plus nedaplatin therapy has never been reported in Japan. We should be aware that 5-FU may cause hyperammonemia and resultant disturbance of consciousness during chemotherapy with 5-FU.

[A Case of Intra-Abdominal Desmoid Tumors Occuring Four Years after Open Radical Prostatectomy]

Desmoid tumor is one kind of fibromatosis, and much occurs the abdominal wall and outside the abdominal wall. Intra- abdominal desmoid tumor is rare at about 8%. We experienced a case of intra-abdominal desmoid tumors occurring 4 years after open radical prostatectomy with some literature review. A 72-year-old man had undergone open radical prostatectomy for prostate cancer. Four years after that resection, multiple intra-abdominal tumors measuring 56 mm in maximum diameter was identified on follow-up computed tomography, and he was referred to our department for management. We performed laparotomy and investigation of the biopsy. Immunohistochemistry of the resected specimen indicated the tumor cells were positive for vimentin and β-catenin, and the diagnosis was desmoid. We performed partial resection of the small intestine and ileocecal resection. His postoperative course was uneventful and he was discharged on the 12th postoperative day. He has shown no sign of recurrence in the 4 months follow-up since surgery. In the past, an operation was the best treatment for intra-abdominal desmoid tumor. But it is reported that watchful waiting is also possible by the case which has no symptom and dysfunction in NCCN guidelines 2019. Further research is needed.

[Effective Palliative Radiation for Hemostasis of Recurrent Colon Cancer in the Lymph Node with Gastric Wall Invasion]

A 76-year-old man underwent laparoscopic left hemicolectomy D3(pStage Ⅱb)for sigmoid colon cancer in 2015. Later, partial transverse colectomy D2(pStage Ⅱb)was performed because transverse cancer was also detected. Recurrent peritoneal dissemination was found in 2018. In 2019, hematemesis/black stool, as well as prominent anemia(Hb 3.1 g/dL)and bleeding from recurrent gastric wall invasion of the lymph nodes on the lesser curvature side of the stomach, was observed. Although hemostasis was performed endoscopically, palliative irradiation(30 Gy in 10 fractions)was performed to control bleeding because the risk of rebleeding was high. After irradiation, endoscopy showed that the ulcer in the infiltrated area of the gastric wall had a tendency to improve. No bleeding or progression of anemia was observed, and oral intake became possible. However, the patient's general condition deteriorated, and he died 80 days after palliative irradiation. For palliative radiation therapy, alleviation of pain owing to bone metastasis, as well as alleviation of the narrowed airway and esophagus, is known. Palliative radiation therapy has recently been performed for symptom relief and prognosis extension against tumor bleeding. Palliative radiation therapy for controlling bleeding has limited hemostatic effect compared with surgical resection, and it takes some time before hemostasis is achieved, but it is less invasive and less adverse event and may be an effective treatment option.

Postoperative Adjuvant Chemotherapy Regimen of CAPOX Combined With Ninjin'yoeito in an Elderly Patient With Stage III Colon Cancer: A Case Report

We report the successful management of stage III colon cancer in an elderly patient who received an adjuvant chemotherapy regimen of capecitabine plus oxaliplatin (CAPOX) with the Japanese kampo medicine ninjin'yoeito (NYT). A 75-year-old woman with a medical history of hypertension presented at another institution with fecal occult blood, and a colonoscopy that showed a type II tumor in the sigmoid colon. She was referred to our hospital for tumor resection, where colonoscopy confirmed the location of the type II tumor in the sigmoid colon. Histopathology of the biopsy specimen indicated a moderately differentiated tubular adenocarcinoma. Enhanced computed tomography of the thorax and abdomen indicated thickening of the sigmoid colon wall. Regional lymph node metastasis was suspected, but distant metastasis was not indicated. A blood examination revealed an elevated carcinoembryonic antigen (CEA) concentration (32.7 ng/ml). Following a diagnosis of cancer of the sigmoid colon, clinical stage IIIb [cT4a, N1b, M0], a laparoscopic sigmoid colectomy was performed without complications. The postoperative histopathological examination revealed a moderately differentiated to mucinous adenocarcinoma. Three of 16 retrieved lymph nodes contained malignant cells. The final tumor classification was Stage IIIb [pT4a, pN1b, M0]. The patient recovered uneventfully, and was discharged 10 days after surgery with a recommendation for adjuvant chemotherapy with CAPOX starting 4 weeks after surgery. The patient also received 7.5 g of NYT daily throughout the adjuvant chemotherapy course. She did not report any loss of appetite, general fatigue, peripheral neuropathy, neutropenia, or febrile neutropenia. During a 1-year postoperative follow-up, she has not experienced any recurrence. We conclude that NYT might be useful for reducing the adverse effects of anticancer therapy, particularly in elderly patients.

[A Case in Which pCR Was Obtained by S-1 plus Oxaliplatin Therapy Administered as Neoadjuvant Chemotherapy for Advanced Gastric Cancer]

A 78-year-old man presented with anemia, with a hemoglobin level of 6.7 g/dL, during follow-up for angina pectoris and paroxysmal atrial fibrillation. Upper gastrointestinal endoscopy revealed type 2 advanced gastric cancer(por), and abdominal computed tomography(CT)showed multiple lymph node metastases. He was diagnosed with advanced gastric cancer, cStage Ⅲ(cT3N1M0). He received neoadjuvant chemotherapy in 3 courses of SOX(80mg/m / 2/day of S-1 on days 1-14 and 7 days of rest, and 100mg/m2 of oxaliplatin on day 1). Grade 1 thrombocytopenia was observed, but it resolved without any other major side effects. Upper gastrointestinal endoscopy revealed a marked reduction in the primary lesion, and abdominal CT showed a significant reduction in the metastatic lymph node. We performed laparoscopic distal gastrectomy(D2+No. 14v)for advanced gastric cancer ycT1N(+)M0, ycStage ⅡA. Histological assessment revealed no evidence of residual tumor cells in the primary tumor or lymph nodes, and the histologic response was classified as Grade 3, pathological complete response(pCR). We report a case in which pCR was obtained by SOX therapy administered as neoadjuvant chemotherapy for advanced gastric cancer.

[A Case of Metachronous Metastasis to the Pancreas from Ascending Colon Cancer after Subtotal Stomach-Preserving Pancreaticoduodenectomy(SSPPD)]

A67 -year-old man was diagnosed with ascending colon cancer and multiple liver metastases and underwent laparoscopic right hemicolectomy(D3 lymphadenectomy). Pathological examination indicated tubular adenocarcinoma(tub1, pT4apN2H2M1[HEP], pStage Ⅳ). After chemotherapy, he underwent hepatectomy. One year and 9 months after the first operation, obstructive jaundice appeared. Abdominal computed tomography revealed a tumor 2 cm in size in the head of the pancreas. After several detailed examinations, he was diagnosed with pancreatic metastasis of ascending colon cancer. After partial resection of the left lung metastasis, pancreaticoduodenectomy(SSPPD-Ⅱ A-1, D1 lymphadenectomy)and low anterior resection(LAR)for early rectal cancer were performed. The tumor was positive for CDX2(+), resulting in a diagnosis of pancreatic metastasis. There has been no indication of recurrence 8 months after the pancreatic surgery. Resectable pancreatic metastasis from colon cancer is rare, and there are no clear indications for resection. Some cases of long-term survival have been reported; however, further studies are needed in order to establish a consensus.

[Transanal Minimally Invasive Surgery for Rectal Neuroendocrine Tumor]

A 57-year-old woman was admitted to our hospital due to a suspected rectal tumor at previous doctor. Colonoscopy showed a submucosal tumor with 8mm yellowish protrusions and smooth surfaces in the rectum, 5 cm from the anal verge. Endoscopic ultrasonography showed the appearance of the internal portions of the tumor to be relatively uniform in low echoic imagery. The tumor was located in the second to third layer. Histopathological findings showed neuroendocrine tumor- G1. We performed transanal minimally invasive surgery with GelPOINT®Path. Under general anesthesia, complete fullthickness excision of the rectal lesion was performed. Primary closure was accomplished using a 3-0 braided absorbable suture. The operation duration was 24 min; blood loss was very little in this case. The patient recovered uneventfully and was discharged 2 days after the operation. There was no anorectal dysfunction and no local and distant recurrence during the postoperative follow-up of 1 year 3 months. Transanal minimally invasive surgery with GelPOINT®Path was an effective treatment for the safe removal of small rectal tumor indicated for local resection.

[A Case of Emergency Surgery for Intussusception Due to Cecal Cancer]

A 79-year-old woman was admitted to the hospital because of continuous right lower abdominal pain lasting for 1 day. There was tenderness with signs of peritoneal irritation at the right lower abdomen along with a palpable mass. With the diagnosis of intussusception of the ileocecal region by CT examination, an emergency surgery was performed under general anesthesia. By laparoscopic ileocecal resection with lymph node dissection, the ileocecal region was found invaginated into the transverse colon, although this was easily reduced by Hutchinson's procedure. The histological diagnosis of the tumor was highly differentiated adenocarcinoma in Stage Ⅲb. The postoperative course was uneventful and the patient remained in good health without any recurrence during a follow-up period of 12 months. When a patient has a sign of peritoneal irritation, such as in our case, and intestinal tract necrosis and perforation by intussusception cannot be excluded, it is necessary to perform an emergency surgery.

[A Case of Apocrine Carcinoma of the Breast]

A 76-year-old postmenopausal woman presented with a bloody attachment on the left nipple. She had a 3 cm-sized tumor in her left breast. Mammography showed a spiculated irregular mass. Ultrasonography showed a 38 mm, low echoic mass with an irregular border. Core needle biopsy examination indicated apocrine carcinoma of the breast, ER(-), PgR(-), and HER2(-). An overall examination showed no distant metastasis. We diagnosed her with apocrine carcinoma of the breast(T2N0M0, cStageⅡA). We performed total mastectomy with sentinel lymph node biopsy. The postoperative histopathological examination revealed apocrine carcinoma without lymph node metastasis. The patient recovered uneventfully and was discharged 8 days after the surgery. She has not experienced any recurrence for 1 year and 7 months after the surgery.

[A Case of Sister Mary Joseph's Nodule from Transverse Colon Cancer Effectively Treated with SOX plus Bevacizumab Chemotherapy]

A 47-year-old woman presented with a hard umbilical nodule that appeared red and was painful. A biopsy of the umbilical nodule revealed adenocarcinoma. As a result of general examinations, the patient was diagnosed with umbilical, hepatic, and ovarian metastases from transverse colon cancer. She was treated with S-1 and oxaliplatin(SOX)plus bevacizumab chemotherapy. After 4 courses of chemotherapy, CT revealed that the primary lesion and umbilical and hepatic metastases had reduced in size. We considered this to be a partial response and thus administered 4 additional courses of SOX plus bevacizumab chemotherapy. Finally, she remained well for 22 months and achieved relatively good prognosis. An umbilical metastasis from an internal malignancy is known as a Sister Mary Joseph's nodule, and it has very poor prognosis. Most studies show that the survival period from the time of diagnosis is within 1 year. However, our case suggests that novel anti-cancer drugs or molecular-targeted agents may improve survival.

[A Retrospective Study of Preoperative Concurrent Chemoradiotherapy for Locally Advanced Resectable Rectal Cancer]

PURPOSE

To analyze chemoradiotherapy results for locally advanced rectal cancers at a single institution.

METHODS

The study cohort comprised 12 patients with clinically diagnosed T3/4, NX, M0 adenocarcinomas of the rectum who received preoperative chemoradiotherapy.

RESULT

Pathological complete response(pCR)were observed in 2/12(16.7%)patients and pathological downstaging in 5/12(41.7%)patients, with generally mild adverse events.

CONCLUSION

Preoperative che- moradiotherapy for clinical T3/4, NX rectal cancers significantly reduces local recurrences and improves prognoses.

[A Case of Sigmoid Colon Cancer It Was Found from Penetration of Sigmoid Diverticulum]

A 52-year-old woman presented with sudden left lower abdominal pain, fever, and vomiting. As the symptom got improved immediately she went home then. She consulted our hospital with chief complaint of the left lower abdominal mass. Abdominal computed tomography revealed sigmoid colon cancer with abscess. She was diagnosed with sigmoid colon cancer via colonoscopy. Sigmoidectomy including partial resection of the abdominal wall was performed(D3 lymphadenectomy). Surgical specimen showed penetration of diverticulum on mucous membrane of the lesion which had been thought of a abdominal wall permeation and a tumor of I sp type at anal side. Pathological examination showed diverticulitis with penetration and the tumor was tubular adenocarcinoma(tub1, pT1bpN0, pStage I ). We had doubted penetration of sigmoid colon cancer most, but the cause of penetration turned out to be diverticulitis. We experienced a case in which we could performed surgery of sigmoid colon cancer and penetration of diverticulum at the same time.

[Pneumatosis Cystoides Intestinalis after Hematopoietic Stem Cell Transplantation for Malignant Lymphoma - A Case Report]

A 47-year-old man underwent hematopoietic stem cell transplantation for malignant lymphoma. He developed acute skin graft versus host disease(GVHD)and pneumomycosis which were treated with steroids. One hundred and fifteen days later, the patient had a diagnosis of free gas images in the abdominal cavity and streakly air collections in the bowel wall from the ascending colon to the sigmoid colon in the CT scan. He was asymptomatic and his physical examination was unrevealing. We diagnosed his condition as pneumatosis cystoides intestinalis(PCI). He was managed conservatively with the high concentration oxygen administration. The CT scan performed 3 days later revealed the marked improvement of intramural gas and disappearance of free gas. We considered image in the abdominal cavity that the occurrence of PCI was related to the damage of the bowel mucosa due to long term corticosteroid administration. In patients demonstrating PCI with free air in the abdominal cavity, it is important to evaluate not only the diagnostic date based on the physical, laboratory, and imaging findings, but also their medical history. Furthermore, it is important to make a correct diagnosis to avoid unnecessary surgery.

[A Case of Early Colon Cancer Discovered by Granulomatous Inflammation of the Ileum Caused by Fish Bone]

A 63-year-old man presented with abdominal pain in the lower right quadrant and high fever. An abdominal CT scan on admission revealed ileocecal wall thickening and inflammation of the terminal ileum. No foreign body was observed on CT scan. He received antibiotic therapy, but no improvement was noticed. Colonoscopy showed a sporadic type 0- I s+ II c lesion in the sigmoid colon. Histological examination showed well differentiated adenocarcinoma. We diagnosed the patient as having inflammation of the terminal ileum and sigmoid colon cancer. Laparoscopic surgery was performed. Inflammation was present in the terminal ileum, and local resection and sigmoidectomy were performed. A foreign body that appeared to be a fish bone was present in the resected specimen, and this led to the diagnosis of granulomatous inflammation of the ileum caused by fish bone. In the sigmoid colon, the pathological diagnosis was pT1b(sm), pN0, ly1, v1, pDM0, pPM0, R0, pStage I . He was discharged without any complication and has not shown any evidence of recurrence more than 1 year after surgery.

[A Case of Curatively Resected Ascending Colon Cancer after Long-Term Chemotherapy Found in Abdominal Trauma]

A 46-year old man presented with lower right quadrant abdominal pain caused by abdominal trauma. Abscess drainage was performed after the diagnosis of retroperitoneal abscess in the ileocecal portion of the colon. Type 2 advanced cancer was found in the cecum and ascending colon. Surgery was performed after improvement of inflammation. Considering the difficulty of curative resection for retroperitoneal invasion, we first performed ileo-transverse colon anastomosis. After surgery, the patient received FOLFOX with panitumumab(Pmab)as neoadjuvant chemotherapy. After 6 courses of this regimen, contrast enhanced computed tomography revealed shrinkage of the tumor. We performed a second surgery but the tumor was unresectable because of retroperitoneal invasion. After 47 courses of chemotherapy(5-FU plus LV with Pmab), the tumor was stable and we observed no distant metastasis. A third surgery was performed, and we were able to perform ileocecal resection including the retroperitoneum. The pathological diagnosis was pT4b(SI), pN1, ly2, V2, pPM0, pDM0, R0, pStage III a. On histological examination, the efficacy of chemotherapy was evaluated as Grade 1a. The patient received adjuvant chemotherapy with capecitabine and remains healthy without any evidence of recurrence more than 10 months after surgery.

[A Case of Recurrent Stenosis after Metallic Stenting for Esophagogastric Junction Adenocarcinoma with Peritoneal Metastases]

A 65-year-old man presented with severe strictures from the esophagogastric junction to the body of the stomach and was histopathologically diagnosed with adenocarcinoma. Computed tomography showed multiple peritoneal metastases. A long, covered metallic stent was placed, and chemotherapy was started. Subsequent granulation from the oral side of the stent caused stricture formation, and a covered stent was also placed. After 8 months, granulation from the oral side of the stent caused recurrent stricture formation. We again placed a metallic stent. Successful chemotherapy for stomach cancer with long-term benefit is possible with new molecularly targeted drugs. Stenting may cause adverse events such as stenosis, but can enable oral intake and is minimally invasive. This report describes a case that required multiple stent placement and reviews the relevant literature.

[A Case of Huge Advanced Neuroendocrine Carcinoma of the Transverse Colon Resected Successfully]

The patient, 49-year-old woman, who was referred to our hospital in August 2016 because of left abdominal pain. The abdominal CT scan showed a large tumor, over 10 cm dimeter at splenic flexure of the transverse colon, and colonoscopy detected transvers colon cancer(por, cT4b, cN1, M0, cStage III A). There was no distant metastasis, although invasion to the retroperitoneum and the abdominal wall. Left hemicolectomy was successfully performed with D3 lymph node dissection. Pathological diagnosis was endocrine cell carcinoma, pT4a(SE), pN0, M0, pStage II . The Surgical margin was completely free of carcinoma(R0). The postoperative course was uneventful, and she has been in good health with no recurrence for 8 months after surgery. Neuroendocrine cell carcinoma is recommended for adjuvant treatment based on small cell lung cancer, but there are not effective clinical trials nor established treatment methods because it is rare disease.

[A Case of Small Intestinal Malignant Lymphoma Presenting with Perforated Peritonitis]

An 85-year-old man presented to the emergency department with vomiting. He had tenderness in the left abdomen and under the umbilicus. Laboratory data showed an increase in the inflammatory response. Enhanced abdominal computed tomography showed thickening ofthe small intestinal wall in the lower left abdomen with a small amount ofadjacent free air. The fat tissue around the small intestine also revealed a high density area suggestive of inflammation. A diagnosis of peritonitis caused by intestinal perforation was made and an emergency operation was performed. We resected part of the ileum about 90 cm from the ileum end. The resected specimen showed a 1 by 1 cm mass with an ulcer and perforation at the base of the tumor. Histopathological findings revealed densely increased numbers of monomorphic medium-sized lymphoma cells infiltrating into all layers ofthe intestine. Immunohistochemically, the lymphocytes were positive for CD3, CD20, CD30, and CD79a. We diagnosed diffuse large B-cell lymphoma. Two cycles ofchemotherapy were given post-operatively. A recurrence was not observed. After chemotherapy he was transferred to rehabilitation.

[Consideration of Safety of Implant-Based Breast Reconstruction with Postreconstruction Radiotherapy for Breast Cancer]

There is controversy as to whether immediate autologous breast reconstruction followed by postoperative radiotherapy has acceptable complications and aesthetic outcomes.

PURPOSE

To evaluate the interval between surgery and adjuvant chemotherapy and radiation in patients treated with mastectomy and immediate expander-implant reconstruction, and to evaluate locoregional and distant control and cosmesis in these patients.

METHODS AND MATERIALS

Between 2011 and 2015, 9 patients with breast cancer were treated at our institution with definitive mastectomy and axillary lymph node dissection followed by immediate tissue expander placement and postreconstruction radiotherapy. We reviewed the complications of implant-based breast reconstruction followed by postreconstruction radiotherapy.

RESULTS

The timing of irradiation was after implant insertion for 8 patients and after tissue expander insertion for 1 patient. The mean follow-up was 601 days. There were no unacceptable complications or local recurrences.

CONCLUSIONS

For the majority of patients, overall symmetry, aesthetic results, and patient satisfaction were high. Breast reconstruction using tissue expansion and implants is an acceptable option for the subset of patients who may undergo postreconstruction radiotherapy.

[A Case of Eosinophilic Enteritis Needed to Distinguish from a Tumor of the Small Intestine]

A 75-year-old woman was diagnosed with aplastic anemia 6 months ago and was under follow-up at our hospital. She had originallypresented to our hospital because of ongoing diarrhea and abdominal pain. Her blood tests showed a rise in inflammatorymarkers (WBC count was 6,900/mL[eosinophil was 1.3%]and CRP was 8.60mg/dL). Her abdominal computed tomography(CT)scan showed gastric wall and small intestine edema as well as ascites. There was no evidence of free air. We diagnosed her with generalized peritonitis and performed an emergencyoperation . Intra-operatively, moderate amounts of yellowish ascitic fluid were noted, as was a diffuse reddening of the small intestine. We performed a partial resection of the small intestine. Histopathological examination showed transmural infiltration of inflammatorycells mainly comprising eosinophilic leukocytes. Eosinophils were also present in the ascitic fluid. Post-operative blood tests confirmed eosinophilic, and we diagnosed her with eosinophilic enteritis. She was started on corticosteroids and her symptoms improved immediately. We report a rare case of eosinophilic enteritis with a review of the pertinent literature.

[Ovarian Cancer Rupture Causing Acute Abdomen That Required Emergency Surgery - A Case Report]

A 50-year-old post-menopausal woman with sudden lower abdominal pain was transported to hospital by ambulance. Abdominal symptoms and computed tomography(CT)suggested a diagnosis of acute pan-peritonitis due to gastrointestinal perforation, and emergency surgery was performed. The intraoperative findings led to a diagnosis of a ruptured cyst in the left ovary, a portion of which was observed to be partially solid, and therefore, ovarian cancer was suspected. Accordingly, a unilateral(left)salpingo-oophorectomy and intraperitoneal drainage were performed with assistance from a gynecologist. Following a diagnosis of ovarian clear cell adenocarcinoma based on histopathological examination, the patient underwent further debulking surgery at a later date, followed by postoperative chemotherapy. In acute pan-peritonitis associated with a large quantity of ascites in women, the rupture of ovarian tumors should be considered as a possible etiology. The therapeutic strategy for ovarian cancer is determined according to post-operative staging, even during emergency surgery. It is therefore important not only to repair the rupture, but also, if possible, to perform a diagnosticbiopsy or resection.

[Two Cases of Metastatic Rectal Cancer Patients Who Received Chemotherapy with FOLFOXIRI plus Bevacizumab]

We report 2 cases of metastatic rectal cancer patients who received chemotherapy with FOLFOXIRI plus bevacizumab(Bev). Case 1: A 54-year-old woman diagnosed with advanced rectal cancer with synchronous liver metastasis underwent a laparoscopic low anterior resection. After the operation, she received FOLFOXIRI plus Bev treatment, and experienced Grade 4 adverse events, including dyspnea and ventricular fibrillation(Vf). After chemotherapy, no other metastasis was detected except a liver metastasis, and partial resection of the liver was performed. Histopathological evaluation revealed that the effect of the chemotherapy was Grade 1a. After liver resection, FOLFOXIRI plus Bev was administered, and a recurrence of the rectal cancer was not detected. Case 2: A 44-year-old woman was diagnosed with advanced rectal cancer with synchronous liver metastasis, distant lymph nodes metastasis, and vaginal invasion. First a colostomy was performed and FOLFOXIRI plus Bev treatment was administered. Grade 3 adverse events, including tremor, neuralgia, and anemia occurred, and chemotherapy was stopped for 3 months. Her adverse events were not under control when progression of the disease was detected, and her treatment was changed to another chemotherapy regimen.

[Examination of Distal Gastrectomy in Our Hospital - Comparison of the Contents of Lymphadenectomy]

It has now been more than 20 years since laparoscopic gastrectomy was introduced in Japan, and the 2014 guidelines recommend laparoscopic distal gastrectomy as a treatment for cStage I gastric cancers. This operation facilitates minute lymphadenectomy via the option of enlarging the image, but there are some difficulties associated with limited range of motion. A hallmark of gastrectomy for gastric cancer is the widespread dissection of lymph nodes, and the limits imposed by laparoscopic forceps can complicate the operation. In this study, we subdivided regional lymph nodes, examined distal gastrectomy cases in our hospital, and compared the contents of lymphadenectomy.

[An Autopsy Case of an Elderly Patient with Signet-Ring Cell Carcinoma of the Breast Derived from Lobular Carcinoma]

A 90-year-old woman was referred to our hospital because of abdominal distension and pretibial edema. No tumors were palpable in either breast. Her abdomen was distended and palpitation was noticed. Laboratory examination revealed hypercalcemia and elevated levels of tumor markers(PIVKA- II , CEA, CA19-9, SCC). Contrast-enhanced computed tomography(CT) showed pleural effusion and ascites, an approximately 17-mm high-contrast mass in the D area of the left breast, and osteolysis of the dorsal lumber spine. We initiated treatment for pleural effusion, ascites, and hypercalcemia. However, on her 11th day in the hospital, hematemesis was observed and the patient died. We suspected metastasis of a malignant tumor, but a primary lesion had not been identified; therefore, an autopsy was performed. Autopsy showed a 17-mm mass in the D area of the left breast. Histopathological examination showed the growth of a signet-ring cell tumor that was immunohistochemically ER-positive, PgR-positive, and E-cadherin-negative. The patient was diagnosed with primary signet-ring cell carcinoma of the breast derived from lobular carcinoma. We reported a rare case of primary signet-ring cell carcinoma of the breast with a review of literature.

[A Case of HER2-Positive Breast Cancer Treated with Nipple-Sparing Mastectomywith Immediate Reconstruction Using a Tissue Expander after Nab-Paclitaxel Combined with Chemotherapy]

A 59-year-old woman presented to our hospital with a mass in her left breast. Mammography and ultrasound showed a 9 ×11×12mm mass in her left breast, and left axillary lymph adenopathy. Core needle biopsy and pathological examination confirmed the diagnosis of ER-negative, PgR-negative, HER2-positive invasive ductal carcinoma with axillary lymph metastasis. Dynamic computed tomography(CT)and bone scintigraphy showed no metastasis. A diagnosis ofbreast cancer with stage II A(T1N1M0)was made, and we started neoadjuvant chemotherapy. After 4 cycles of chemotherapy with 5-fluorouracil/ epirubicin/cyclophosphamide in 3-weekly cycles, we administered combination chemotherapy ofnab -paclitaxel and trastuzumab in 3-weekly cycles. After 7 months, the tumor disappeared and the axillary lymph node got significantly smaller. We performed nipple-sparing mastectomy/axillary lymph nodes dissection/tissue-expander placement. The pathological examination ofthe resected tumor confirmed a pathological complete response(pCR). The patient was treated with implant reconstruction and adjuvant therapy. One year has passed after the surgery, and no significant problem has been observed.

[A Case of Advanced Rectal Cancer Resected Successfully after Induction Chemotherapy with Modified FOLFOX6 plus Panitumumab]

We report a case of advanced colon cancer that was effectively treated with mFOLFOX6 plus panitumumab combination chemotherapy. The patient was a 54-year-old man who had type 2 colon cancer of the rectum. An abdominal CT scan demonstrated rectal cancer with bulky lymph node metastasis and 1 hepatic node (rectal cancer SI [bladder retroperitoneum], N2M0H1P0, cStage IV). He was treated with mFOLFOX6 plus panitumumab as neoadjuvant chemotherapy. After 4 courses of chemotherapy, CT revealed that the primary lesion and regional metastatic lymph nodes had reduced in size (rectal cancer A, N1H1P0M0, cStage IV). Anterior rectal resection with D3 nodal dissection and left lateral segmentectomy of the liver was performed. The histological diagnosis was tubular adenocarcinoma (tub2-1), int, INF a, pMP, ly0, v0, pDM0, pPM0, R0. He was treated with 4 courses of mFOLFOX6 after surgery. The patient has been in good health without a recurrence for 2 years and 5 months after surgery. This case suggests that induction chemotherapy with mFOLFOX6 plus panitumumab is a potentially effective regimen for advanced colon cancer.

Internal Hernias in the Era of Multidetector CT: Correlation of Imaging and Surgical Findings

Clinical diagnosis of internal hernias is challenging because of their nonspecific signs and symptoms. Many types of internal hernias have been defined: paraduodenal, small bowel mesentery-related, greater omentum-related, lesser sac, transverse mesocolon-related, pericecal, sigmoid mesocolon-related, falciform ligament, pelvic internal, and Roux-en-Y anastomosis-related. An internal hernia is a surgical emergency that can develop into intestinal strangulation and ischemia. Accurate preoperative diagnosis is crucial for appropriate management. Multidetector computed tomography (CT), with its thin-section axial images, high-quality multiplanar reformations, and three-dimensional images, currently plays an essential role in preoperative diagnosis of internal hernias. The diagnostic approach to internal hernias at multidetector CT includes detecting an intestinal closed loop, identifying the hernia orifice, and analyzing abnormal displacement of surrounding structures and key vessels around the hernia orifice and hernia sac. At each step, multidetector CT can depict pathognomonic findings. A saclike appearance suggests an intestinal closed loop in several types of internal hernias. Convergence, engorgement, and twisting of mesenteric vessels in the hernia orifice can be seen clearly at multidetector CT, especially with use of multiplanar reformations. For definitive diagnosis of an internal hernia, analysis of displacement of anatomic landmarks around the hernia orifice is particularly important, and thin-section images provide the required information. Detailed knowledge of the anatomy, etiology, and imaging landmarks of the various hernia types is also necessary. Familiarity with the appearances of internal hernias at multidetector CT allows accurate and specific preoperative diagnosis. (©)RSNA, 2015.

[Effectiveness of Intraoperative Histologic Assessment of Surgical Margins for Breast-Conserving Surgery]

BACKGROUND

The effectiveness of intraoperative histologic assessment of surgical margins for breast-conserving surgery is unclear. In this study, we investigated the effectiveness of intraoperative histologic assessment of surgical margins for breast-conserving surgery.

METHODS

Sixty-six patients who underwent breast-conserving surgery for breast cancer at our hospital between January 2007 and December 2013 were retrospectively examined for an association between the surgical margin status and locoregional recurrence. The surgical margins were then evaluated by intraoperative histologic assessment.

RESULTS

The median observation period was 52 months. Positive margins were found in 14 patients (21%). A total mastectomy was performed in 9 patients, and additional resection in 5 patients. In the permanent tissue sample, the intraoperative assessment was found to be false negative in 2 patients (3.8%), who received boost irradiation postoperatively. No locoregional recurrence was observed in all patients who underwent additional resection or total mastectomy due to positive margins. The rate of margin positivity was significantly higher in invasive lobular carcinomas and in cancers with intraductal extension.

CONCLUSIONS

Intraoperative histologic assessment of the surgical margin was useful for reducing the rate of local recurrence.

[A Case of Locally Advanced Breast Cancer Treated with Modified Radical Mastectomy with Immediate Reconstruction Using a Tissue Expander after Endocrine Therapy]

We experienced a case of locally advanced breast cancer treated with modified radical mastectomy with immediate reconstruction using a tissue expander after endocrine therapy. A 64-year-old postmenopausal woman had a 50 mm tumor in her right breast with extensive reddening of the skin. She had axillary lymph node metastasis. Core needle biopsy showed invasive ductal carcinoma with positive hormone receptor (ER+, PgR+) and negative HER2 status. The patient was diagnosed with locally-advanced breast cancer (cT4bN1M0, stage ⅢB). She was treated with anastrozole at a dose of 1 mg per day. The tumor decreased in size gradually and became operable after 7 months of anastrozole monotherapy. She underwent modified radical mastectomy with immediate reconstruction using a tissue expander. The resected specimen was a 30 mm tumor; adverse effects due to endocrine therapy were of Grade 1a severity. Seven months after adjuvant chemotherapy (FEC→DTX), the tissue expander was removed, and the right breast was reconstructed using an implant. No complications were noted, and the patient was treated with radiation therapy. Ten months have passed since surgery, and no local recurrence or distant metastasis has been noted.

[A case of laparoscopic surgery for a rectal carcinoid after ALTA therapy for an internal hemorrhoid]

We report a case of laparoscopic surgery for a rectal carcinoid after aluminum potassium and tannic acid (ALTA) therapy for an internal hemorrhoid. A 66-year-old man was admitted to our hospital because of bleeding during defecation. He was diagnosed via anoscopy with Goligher grade II internal hemorrhoids. Examination via colonoscopy revealed 2 yellowish submucosal tumors in the lower rectum that were 5mm and 10mm in diameter. A rectal carcinoid tumor was diagnosed based on histopathology. Abdominal computed tomography demonstrated no metastases to the liver or lymph nodes. First, we performed ALTA therapy for the internal hemorrhoids. Two weeks later, we performed laparoscopic-assisted low anterior resection (D2) for the rectal carcinoid. The patient was discharged without complications and has not experienced recurrence during the 2 years of follow-up care.

[A case of emergency resection of a giant gastrointestinal stromal tumor of the stomach associated with hemorrhagic shock]

We report a case of emergency resection of a giant gastrointestinal stromal tumor of the stomach associated with hemorrhagic shock. A 79-year-old woman was admitted to our hospital because of massive hematemesis. Laboratory analysis revealed a hemoglobin level of 6.5 g/dL. Abdominal computed tomography (CT) and upper gastrointestinal endoscopy revealed a submucosal tumor, 12 cm in diameter, in the fornix of the stomach. As a Dieulafoy-like lesion was present, we attempted coagulation hemostasis in the exposed blood vessels. Endoscopic hemostasis was not successful. The patient went into hemorrhagic shock. Emergency surgery was performed: total gastrectomy with distal pancreatosplenectomy. The resected specimen measured 10×12×7 cm and was hard. Immunohistologically, the tumor was positive for c-kit and CD34 and negative for alpha smooth muscle actin (αSMA), desmin, and S-100. Histological examination revealed that the patient had a high-risk gastrointestinal stromal tumor of the stomach with no nodal metastasis. The postoperative course was uneventful and the patient has remained alive without recurrence for 4 years.

Retrospective analysis of capecitabine and oxaliplatin (XELOX) plus bevacizumab as a first-line treatment for Japanese patients with metastatic colorectal cancer

XELOX plus bevacizumab is an effective treatment strategy and has a manageable tolerability profile when administered to Japanese patients with metastatic colorectal cancer (mCRC). In this study, we retrospectively reviewed cases in which XELOX plus bevacizumab were administered in order to evaluate its efficacy and safety in clinical practice. In total, 40 patients with mCRC who presented at Fuchu Hospital received XELOX plus bevacizumab as a first-line treatment between September, 2009 and April, 2012. Eligible patients had histologically confirmed mCRC. XELOX consisted of a 2-h intravenous infusion of oxaliplatin 130 mg/m² on day 1 plus oral capecitabine 1,000 mg/m² twice daily for 2 weeks of a 3-week cycle. Overall survival (OS) and survival benefit were analyzed when patients continued with XELOX plus bevacizumab beyond disease progression. The median progression-free survival (PFS) was 290 days [95% confidence interval (CI): 222-409 days] and the median OS was 816 days (95% CI: 490 days-not calculated). The response rate (RR; complete plus partial response) was 67.5%, and the disease control rate (RR plus stable disease) was 90%. The most common adverse events observed following administration of XELOX plus bevacizumab were neurosensory toxicity (82.5%), anorexia (50%), hypertension (45%) and a decrease in the platelet count (40%). The most common grade 3/4 adverse events were neurosensory toxicity (15%) and fatigue (15%). In conclusion, XELOX plus bevacizumab may be considered a routine first-line treatment option for patients with mCRC. Notably, the combination of capecitabine and bevacizumab was safe with an acceptable toxicity profile and induced a significant rate of disease control.

[A case of anastomotic recurrence of gastric cancer who underwent esophagojejunostomy, treated with S-1 monotherapy leading to complete response (CR)]

A 67-year-old male with an anastomotic recurrence of gastric cancer who underwent esophagojejunostomy, was treated with S-1 monotherapy leading to a complete response (CR). The patient was diagnosed with gastric cardia cancer and underwent a total gastrectomy with lymph node dissection. Two years and 2 months after surgery, the patient was administered S-1 100 mg/day (4-week administration and 2-week rest) because anastomotic recurrence was confirmed. The patient was unable to take anything by mouth, but this chemotherapy could be orally administered after one course. After six courses, tumor tissue completely disappeared and he had a CR. Administration of S-1 was continued for eight courses and then discontinued. There was no relapse for two years after discontinuation.

[Clinical experience of chemotherapy with S-1/CDDP for highly-advanced gastric cancer]

BACKGROUND

We evaluated the efficacy and safety of chemotherapy with S-1/CDDP for advanced and recurrent gastric cancer at Fuchu Hospital.

METHODS

The participants were 24 patients treated at our hospital. S-1 was given orally at 80 mg/m/2 for days 1-21, and 60 mg/m2 of CDDP was administered on day 8, followed by a 2-week rest period, within a 5-week course.

RESULTS

Results were rated as a partial response in 12 cases and a stable response in 4 cases. The response rate was 50% (12/24), and median survival time was 273 days. The total incidence of grade 3 or greater adverse reactions including leucopenia, neutropenia, anemia, general fatigue, and eruption, was 25% (6/24).

CONCLUSION

The combination of S-1/CDDP therapy appears to be highly efficacious and safe and showed promise as a useful treatment strategy, even in an outpatient clinic.

Action of antiproteases on pancreatic cancer cells

Tumor-associated trypsinogen, urokinase-type plasminogen activator, matrix metalloprotease-2 (MMP-2), and MMP-9 each play a dominant role in the degradation of the extracellular matrix (ECM) during the invasion process of pancreatic cancer. Transforming growth factor beta1 (TGF-beta1) is a multifunctional polypeptide that regulates cell growth and differentiation, extracellular matrix deposition, cellular adhesion properties, angiogenesis and also immune functions. The protease-activated receptor-2 (PAR-2) is a G protein-coupled receptor which is cleaved and activated by trypsin and tryptase. PAR-2 activated by trypsin plays an important role in promoting the proliferation of pancreatic cancer. We previously reported that TGF-beta1 up-regulated vascular endothelial growth factor (VEGF) production, and the protease production of both MMP-2 and urokinase-type plasminogen activator in the highly metastatic pancreatic cancer cell lines SW1990 and CAPAN-2. We had examined the inhibitor effects of a protease inhibitor, gabexate mesilate, on cell invasion, cell proliferation, growth factor production, and ECM degradation. We also examined the effect of gabexate mesilate on the production of growth factor and ECM degradation by these cell proteases and enzymatic activities. Gabexate mesilate down-regulated the invasiveness, the proliferation and liver metastasis potential of SW1990 and CAPAN-2 cells. Gabexate mesilate inhibited not only the enzymatic activities of tumor-associated trypsinogen and urokinase-type plasminogen activator but also the production of MMP-2, all of which have been known to be secondarily up-regulated by TGF-beta1. These findings suggested that gabexate mesilate is potentially useful in the treatment against invasion, proliferation, and metastasis of pancreatic cancer.

Plasminogen activator inhibitor-1 (PAI-1) gene transfection inhibits the liver metastasis of pancreatic cancer by preventing angiogenesis

Plasminogen activator inhibitor-1 (PAI-1) is a unique type of serine protease inhibitor and one of the key regulators of tumor invasion and metastasis. The purpose of this study was to elucidate the effect of PAI-1 gene transfection on liver metastasis and its mechanism by using the human high liver metastasis pancreatic cancer cell line, SW1990. PAI-1-transfected SW1990 (SW/PAI-1) produced a significantly higher level of PAI-1 in supernatant than parental cells. While no difference was observed for the production of u-PA and u-PA activity in the supernatant, cell proliferation of SW/PAI-1 was slightly suppressed on the 7th day of incubation compared to parental cells. Cellular invasion, in vivo tumorigenesis in xenograft and liver metastasis were significantly suppressed in SW/PAI-1 cells compared to parental cells. The angiogenesis of xenograft by detecting microvascular density and the production of metastasis-related factors, such as VEGF and TGF-beta1, were also decreased in SW/PAI-1 cells. These findings suggested that PAI-1 gene transfection might have the ability to prevent the liver metastasis of pancreatic cancer by modulating angiogenesis.

[A case of multiple bone metastasis from gastric carcinoma given chemotherapy with TS-1 combined with cisplatin]

We experienced a case of bone metastatic recurrence from gastric carcinoma that responded to TS-1 combined with low-dose cisplatin (CDDP) therapy. A 63-year-old male patient presented with multiple bone metastases 5 years after radical surgery for advanced gastric carcinoma. The titer of serum CEA showed extremely high levels of 18,000 ng/ml. The uptake area was found at all vertebrae, ribs, and pelvis by scintigraphy 99mTc-HMDP. The chemotherapy regimen, performed in the outpatient clinic, comprised daily oral administration of 80 mg/m2 of TS-1 for 14 days and CDDP 20 mg/m2 infusion (day 1). This regimen was repeated every 3 weeks for 9 months. After that, severe pain diminished and the titer of serum showed CEA had improved to 599 ng/ml. The uptake at the multiple bone metastasis was found to have decreased by scintigraphy. The patient was able to resume his full social activities. TS-1/low-dose CDDP therapy seems to be applicable for the treatment of gastric carcinoma with bone metastasis.

Dieulafoy's vascular malformation of the jejunum: first case report of laparoscopic treatment

A case of Dieulafoy's vascular malformation of the jejunum treated by laparoscopic surgery is described. The patient was a 31-year-old-woman who had complained of melena and had severe anemia needing blood transfusion. Angiography revealed microaneurysms and hypervascularity of the jejunum in the area between the first and second jejunal arterial fields. Laparoscopic partial resection of the jejunum was performed. The resected specimen was histologically diagnosed as Dieulafoy's vascular malformation. Since the operation, the patient has been free of melena and anemia. Small-intestinal Dieulafoy's vascular malformation is rare, as only 41 cases have been reported during the past three decades. Almost two-thirds of the patients were under 40 years old. Most of the patients complained of melena. The lesion was preoperatively identified in 14 of the 41 patients, while angiography was useful to define the lesion. Thirty-six of 37 patients for whom treatment methods were reported were surgically treated. While there are various treatment methods for intestinal bleeding, a surgical operation is often needed. When the disease location is obvious, treatment with laparoscopic surgery can reliably produce good results, in terms of its rate of cure, minimal invasiveness, and better cosmetic effect.