Impact of Fluorine-18 2-Fluoro-2-Deoxy-D-Glucose Uptake on Preoperative Positron Emission Tomography/Computed Tomography in the Lymph Nodes of Patients with Primary Colorectal Cancer.

BACKGROUND/AIMS: Although the diagnostic value of fluorine-18 2-fluoro-2-deoxy-D-glucose (F-18-FDG) positron emission tomography/computed tomography (F-18-FDG-PET/CT) in patients with colorectal cancer (CRC) has been reported, the association between the F-18-FDG uptake in metastatic lymph nodes (FDGLN) and clinicopathological variables has not been fully investigated. We evaluated the diagnostic value of F-18-FDG-PET/CT in detecting LN metastasis from CRC, and the relationship between F-18-FDG-PET/CT-detecting LN metastasis and prognosis. METHODS: We retrospectively analyzed the medical records of 370 patients who underwent preoperative F-18-FDG-PET/CT, followed by surgical resection for CRC between January 2007 and December 2010. We analyzed the sensitivity, specificity, and accuracy of F-18-FDG-PET/CT and CT in diagnosing metastatic LNs. Survival was analyzed in 115 patients with stage III CRC. RESULTS: The sensitivity, specificity, and accuracy for detecting metastatic LNs using F-18-FDG-PET/CT were 56.8, 90.3, and 74.2%, and those for contrast-enhanced CT were 38.4, 95.5, and 65.0%, respectively. The accuracy of F-18-FDG-PET/CT was significantly associated with tumor depth and lymphatic involvement. In the survival analysis, cancer-specific survival and the disease-free survival were significantly shorter in patients with stage III CRC with FDGLN than in those without FDGLN. CONCLUSION: F-18-FDG-PET/CT had low sensitivity and high specificity for detecting metastatic LNs from CRC. FDGLN independently predicted poor prognosis in patients with stage III CRC.

Silk suture granuloma with false-positive findings on PET/CT accompanied by peritoneal metastasis after colon cancer surgery.

INTRODUCTION: Suture granuloma is a rare benign tumor caused by suture material, which usually appears several months or years after surgery. PRESENTATION OF CASE: A 71-year-old man underwent sigmoidectomy and partial hepatectomy (S6) for sigmoid colon cancer and synchronous liver metastasis at a previous hospital. At 4 postoperative months, surveillance computed tomography (CT) revealed a suspicious tumor at the hepatic resection stump. He was referred to our hospital for further examinations and treatments. Positron emission tomography/CT (PET/CT) revealed abnormal hepatic F-18 fluorodeoxyglucose (FDG) uptake below the diaphragm at the S5/S8 surface. Peritoneal metastasis was suspected and surgery was performed. White nodules were found in the Douglas pouch. A diagnosis of adenocarcinoma was confirmed by frozen section analysis of the nodules. He underwent a partial hepatectomy (S5/S8) and partial resection of the diaphragm. Pathological examination showed that the liver tumor was a foreign body granuloma that included silk suture material. DISCUSSION: Although postoperative PET/CT surveillance is useful following malignant tumor resection, it is important to note that PET/CT false-positive findings are possible. Furthermore, PET/CT cannot detect small peritoneal metastases, necessitating a thorough abdominal examination. CONCLUSION: In cases of malignancy, the possibility of postoperative suture granuloma should be considered. In addition, a thorough surgical examination of the abdomen should be performed in cases of suspected recurrence.

Excision of the urachal remnant using the abdominal wall-lift laparoscopy: A case report.

INTRODUCTION: Here, we report the surgical excision of the urachal remnant using the abdominal wall-lift laparoscopy with a camera port in the umbilicus, combined with a small Pfannenstiel incision to optimally treat the bladder apex. PRESENTATION OF CASE: A 21-year-old woman presented with periumbilical discharge and pain on urination. Contrast enhanced CT and MRI showed an abscess in the umbilical region that was connected to the bladder via a long tube-like structure. It was diagnosed as an infected urachal sinus. Partial excision of the umbilical fossa followed by dissection of the urachal remnant was easily performed using the abdominal wall-lift laparoscopy from the umbilicus down to the bladder without pneumoperitoneum or additional trocar placement. A Pfannenstiel incision was made above the pubis to get access to the junction between the urachal remnant and the bladder. Under direct vision, we succeeded in accurately dividing the remnant tract, and we adequately closed the bladder opening with absorbable sutures. This method has the advantage of easily closing peritoneal defects after excision of the urachal remnant with direct sutures under a laparoscopic view from the umbilicus. Cosmetic satisfaction was obtained postoperatively. DISCUSSION AND CONCLUSION: Urachal sinus excision using the abdominal wall-lift laparoscopy seems to surpass the previously reported methods in term of safety, cosmetics, and adequacy of surgical procedures.

Retrocecal hernia successfully treated with laparoscopic surgery: A case report and literature review of 15 cases in Japan.

INTRODUCTION: Retrocecal hernia is rare and involves strangulation ileus, and therefore, frequently requires emergency surgery following conservative therapy. PRESENTATION OF CASE: We report an interesting case of a retrocecal hernia in a 65-year-old man, with a history of diabetes mellitus. The patient was admitted to our hospital with severe periumbilical pain and nausea. Abdominal computed tomography revealed an intestinal obstruction at a pericecal site, and dilatation of the small bowel at the oral side of the obstruction. The patient was initially treated with conservative therapy using long intestinal tube placement. On the 12th hospital day, the patient's symptoms had not resolved, and laparoscopic surgery was performed. We diagnosed a retrocecal hernia based on laparoscopic findings and repaired it. The patient was discharged without complications on the 7th postoperative day. DISCUSSION AND CONCLUSION: Using laparoscopic exploration and suturing, we were able to perform a minimally invasive operation that may have promoted an earlier hospital discharge.

Chronic Ischemia Induced by Woven Coronary Artery Anomaly with Typical Atrial Flutter: Insights from Multiple Imaging Devices.

A 75-year-old man with a 120-bpm tachycardia and typical atrial flutter was admitted. Echocardiography showed a dilated left ventricle with anterior and apical wall akinesia. Tachycardia was terminated with cavotricuspid isthmus ablation. Multiple imaging findings revealed a woven coronary artery anomaly (WCAA) in the left anterior descending artery. Stress myocardial perfusion imaging was performed after ablation in the sinus rhythm and revealed stress-induced ischemia and a fixed low uptake in the WCAA territory. WCAA is generally regarded as a benign condition; however, compromised blood flow within the anomaly, caused by tachycardia-related diastolic shortening, may induce ischemia.

Isolated spontaneous dissection of the celiac artery: report of two cases.

Isolated spontaneous dissection of the celiac artery (DCA) is extremely rare and its therapeutic strategy is still not established. We report two cases of DCA, in which 58-year-old and 43-year-old male patients with right hypogastralgia and back pain, respectively, were diagnosed by enhanced computed tomography and treated conservatively with antihypertensive agents. They were doing well under circumspect medical management without recurrence of symptoms or progression of dissection after 3.5 years and 3 months, respectively, after detection of DCA. Conservative treatment with blood pressure control and careful surveillance is considered to be applicable in most cases of DCA.

Serum ghrelin levels partially recover with the recovery of appetite and food intake after total gastrectomy.

PURPOSE: Ghrelin may lead to weight gain by appetite stimulation. This prospective study investigated the association between weight loss and the ghrelin levels in patients after gastrectomy. METHODS: Thirty-three males and eight females were enrolled in the study. The average age was 66 years. Measurements of the serum ghrelin level and an appetite questionnaire were performed preoperatively and at one, three, six and 12 months postoperatively. RESULTS: The preoperative serum total ghrelin level was 51.6 ± 31.9 (fmol/ml ± SD), and that at one, three, six and 12 months postoperatively was 16.9 ± 9.0, 21.2 ± 16.0, 28.0 ± 19.1 and 29.6 ± 20.6 (fmol/ml ± SD), respectively. The appetite score was 2.02 ± 1.09 points at 1 month, and increased significantly to 2.61 ± 1.00 by 12 months. CONCLUSIONS: The ghrelin levels were reduced after gastrectomy and did not recover by 12 months postoperatively. Further studies are needed to evaluate these results as the basis of a therapeutic trial.

Clinical value of serum CA19-9 as a prognostic factor for the ampulla of Vater carcinoma.

BACKGROUND/AIMS: Ampulla of Vater carcinoma is a relatively rare digestive tract tumor; postoperative prognostic factors have been well studied. However, any indicator of preoperative prognosis remains poorly identified. This study aims to identify serum tumor markers as preoperative prognostic factors and other variables as postoperative prognostic factors for ampulla of Vater carcinoma. METHODOLOGY: This study retrospectively analyzed data from 26 patients undergoing pancreaticoduodenectomy (PD), including pylorus preserving PD for ampulla of Vater carcinoma between April 1993 and December 2006. The main outcome measures were survival rates of patients with and without high levels of CA19-9 and CEA. RESULTS: Patients with high levels of CA19-9 (n = 12) had significantly higher survival rates than those without (n = 14) (p = 0.0027). High levels of CEA did not influence cumulative survival rates (p = 0.4522). Histopathological classification was an independent predictor of poor survival rates; patients with well differentiated adenocarcinoma (n = 18) had significantly higher survival rates than those with moderate to poorly differentiated tumors (n = 12) (p = 0.0280). Other factors such as tumor size, lymph node metastasis (p = 0.4006), or invasion of pancreas (p = 0.1156), duodenum (p = 0.0.3723), vein (p = 0.4331), and lymph vessel (p = 0.8606), and perineural invasion (p = 0.0.8765) were not an independent indicators of poor survival rate. CONCLUSIONS: The results of our study indicated that high levels of CA19-9 and histopathological classification were significant independent predictors of poor survival rates for the ampulla of Vater carcinoma.

Impact of portal vein invasion and resection length in pancreatoduodenectomy on the survival rate of pancreatic head cancer.

BACKGROUND/AIMS: A positive surgical margin is a poor prognosis factor. Resection of the invaded portal vein (PV) may be necessary to achieve a negative surgical margin during pancreaticoduodenectomy (PD). This study clarifies the intraoperative and long-term survival of patients who received PD with PV resection compared to without. METHODOLOGY: Between July 1992 and March 2012, a retrospective analysis of 119 patients undergoing PD with or without PV resection for pancreatic head cancer was performed. Main outcome measures were perioperative mortality and survival rate of PD with and without PV resection. RESULTS: Perioperative mortality was not different between PD (1 of 51 cases: 2.0%) and PD with PV resection (3 of 68 cases: 4.4%) (p = 0.462). Patients without resection had a significantly better prognosis than patients with PV resection (p = 0.0052). Patients on whom >2.1 cm of the PV was resected (n = 34) had a worse cumulative survival rates than patients with a resection of <2.1 cm (n = 19) (p = 0.0380). Patients with no invasion of PV wall (n = 18) had a significantly higher survival rate than positive PV wall invasion (n = 49) (p =0.039). CONCLUSIONS: Patients with PV resection had a significantly worse prognosis than patients without PV resection. Some patients survived more than 5 years post-operation after PD with PV resection. PV resection contributes to attaining complete tumor resection.

Altered plasma apolipoprotein modifications in patients with pancreatic cancer: protein characterization and multi-institutional validation.

BACKGROUND: Among the more common human malignancies, invasive ductal carcinoma of the pancreas has the worst prognosis. The poor outcome seems to be attributable to difficulty in early detection. METHODS: We compared the plasma protein profiles of 112 pancreatic cancer patients with those of 103 sex- and age-matched healthy controls (Cohort 1) using a newly developed matrix-assisted laser desorption/ionization (oMALDI) QqTOF (quadrupole time-of-flight) mass spectrometry (MS) system. RESULTS: We found that hemi-truncated apolipoprotein AII dimer (ApoAII-2; 17252 m/z), unglycosylated apolipoprotein CIII (ApoCIII-0; 8766 m/z), and their summed value were significantly decreased in the pancreatic cancer patients [P = 1.36×10(-21), P = 4.35×10(-14), and P = 1.83×10(-24) (Mann-Whitney U-test); area-under-curve values of 0.877, 0.798, and 0.903, respectively]. The significance was further validated in a total of 1099 plasma/serum samples, consisting of 2 retrospective cohorts [Cohort 2 (n = 103) and Cohort 3 (n = 163)] and a prospective cohort [Cohort 4 (n = 833)] collected from 8 medical institutions in Japan and Germany. CONCLUSIONS: We have constructed a robust quantitative MS profiling system and used it to validate alterations of modified apolipoproteins in multiple cohorts of patients with pancreatic cancer.

Rupture of abdominal aortic aneurysm with shrinkage after endovascular repair.

An 85-year-old man, who had undergone endovascular abdominal aortic aneurysm repair 8½ years earlier, was transferred to the emergency department with chest pain and transient loss of consciousness. Computed tomography revealed a ruptured abdominal aortic aneurysm with a stent graft inside. His aneurysm was 62 mm in diameter at the endovascular repair, but 45 mm at the rupture site. He was rescued by emergency aneurysmectomy.

Identification of adipophilin as a potential plasma biomarker for colorectal cancer using label-free quantitative mass spectrometry and protein microarray.

BACKGROUND: The aim of this study was to identify a new plasma biomarker for use in early detection of colorectal cancer. METHODS: Using the combination of hollow fiber membrane (HFM)-based low-molecular weight protein enrichment and two-dimensional image converted analysis of liquid chromatography and mass spectrometry (2DICAL), we compared the plasma proteome of 22 colorectal cancer patients with those of 21 healthy controls. An identified biomarker candidate was then validated in two larger cohorts [validation-1 (n = 210) and validation-2 (n = 113)] using a high-density reverse-phase protein microarray. RESULTS: From a total of 53,009 mass peaks, we identified 103 with an area under curve (AUC) value of 0.80 or higher that could distinguish cancer patients from healthy controls. A peak that increased in colorectal cancer patients, with an AUC of 0.81 and P value of 0.0004 (Mann-Whitney U test), was identified as a product of the PLIN2 gene [also known as perilipin-2, adipose differentiation-related protein (ADRP), or adipophilin]. An increase in plasma adipophilin was consistently observed in colorectal cancer patients, including those with stage I or stage II disease (P < 0.0001, Welch's t test). Immunohistochemical analysis revealed that adipophilin is expressed primarily in the basal sides of colorectal cancer cells forming polarized tubular structures, and that it is absent from adjacent normal intestinal mucosae. CONCLUSIONS: Adipophilin is a plasma biomarker potentially useful for the detection of early-stage colorectal cancer. IMPACT: The combination of HFM and 2DICAL enables the comprehensive analysis of plasma proteins and is ideal for use in all biomarker discovery studies.

Postoperative weight loss does not resolve after esophagectomy despite normal serum ghrelin levels.

BACKGROUND: Esophagectomy after gastric reconstruction leads to significant weight loss. Ghrelin is known to stimulate appetite and cause weight increase. The objective of this study is to examine the relationship of serum ghrelin levels and weight loss in patients after esophagectomy for cancer. METHODS: Twenty-two patients underwent esophagectomy including gastric reconstruction. Serum ghrelin levels and weight were measured preoperatively and then postoperatively for 12 months in all patients. A questionnaire assessed appetite, amount of food eaten, satisfaction, and frequency of eating. RESULTS: Preoperatively, the mean serum ghrelin level was 67.9 ± 42.6 (fmol/mL ± SD), and at 1, 3, 6, and 12 months after surgery were 43.4 ± 28.1, 51.5 ± 32.2, 67.1 ± 50.9, and 84.9 ± 43.1, respectively. Compared with preoperative values, the mean body mass index decreased by 1.9 ± 1.5, 2.3 ± 1.8, 2.1 ± 2.3, 2.4 ± 2.7 at 1, 3, 6, and 12 months after surgery. While appetite score showed a decrease at 1 month (1.6 ± 0.92), appetite increased by 12 months postoperatively (2.7 ± 1.0) and showed a strong positive correlation (r = 0.743) with serum ghrelin levels. There were no significant differences in ghrelin levels when patients were stratified by disease stage, recurrence, or administration of adjuvant chemotherapy. CONCLUSIONS: Esophagectomy resulted in temporary reduction of ghrelin levels, but while levels returned to normal 3 months later, weight loss persisted at 12 months. Further study is needed to elucidate the mechanisms of persistent weight loss and design therapeutic interventions to recover the weight lost.

Plasma biomarker discovery and validation for colorectal cancer by quantitative shotgun mass spectrometry and protein microarray.

The development of a new plasma biomarker for early detection would be necessary to improve the overall outcome of colorectal cancer. Here we report the identification and validation of the ninth component of complement (C9) as a novel plasma biomarker for colorectal cancer by cutting-edge proteomic technologies. Plasma proteins were enzymatically digested into a large array of peptides, and the relative quantity of a total of 94,803 peptide peaks was compared between 31 colorectal cancer patients and 59 age/sex-matched healthy controls using 2D image-converted analysis of liquid chromatography and mass spectrometry. The selected biomarker candidates were validated in 345 subjects (115 colorectal cancer patients and 230 age/sex-matched healthy controls) using high-density reverse-phase protein microarrays. Plasma levels of Apo AI and C9 in colorectal cancer patients significantly differed from healthy controls with P values of 7.94×10(-4) and 1.43×10(-12) (Student's t-test), respectively. In particular, C9 was elevated in patients with colorectal cancer, including those with stage-I and -II diseases (P=3.01×10(-3) and P=1.13×10(-5) , respectively). Although the significance of the present study must be validated in an independent clinical study, the increment of plasma C9 may be applicable to the early detection of colorectal cancer.

Reduced plasma level of CXC chemokine ligand 7 in patients with pancreatic cancer.

BACKGROUND: Early detection is essential to improve the outcome of patients with pancreatic cancer. A noninvasive and cost-effective diagnostic test using plasma/serum biomarkers would facilitate the detection of pancreatic cancer at the early stage. METHODS: Using a novel combination of hollow fiber membrane-based low-molecular-weight protein enrichment and LC-MS-based quantitative shotgun proteomics, we compared the plasma proteome between 24 patients with pancreatic cancer and 21 healthy controls (training cohort). An identified biomarker candidate was then subjected to a large blinded independent validation (n = 237, validation cohort) using a high-density reverse-phase protein microarray. RESULTS: Among a total of 53,009 MS peaks, we identified a peptide derived from CXC chemokine ligand 7 (CXCL7) that was significantly reduced in pancreatic cancer patients, showing an area under curve (AUC) value of 0.84 and a P value of 0.00005 (Mann-Whitney U test). Reduction of the CXCL7 protein was consistently observed in pancreatic cancer patients including those with stage I and II disease in the validation cohort (P < 0.0001). The plasma level of CXCL7 was independent from that of CA19-9 (Pearson's r = 0.289), and combination with CXCL7 significantly improved the AUC value of CA19-9 to 0.961 (P = 0.002). CONCLUSIONS: We identified a significant decrease of the plasma CXCL7 level in patients with pancreatic cancer, and combination of CA19-9 with CXCL7 improved the discriminatory power of the former for pancreatic cancer. IMPACT: The present findings may provide a new diagnostic option for pancreatic cancer and facilitate early detection of the disease.

Depot-specific expression of lipolytic genes in human adipose tissues--association among CES1 expression, triglyceride lipase activity and adiposity.

AIM: Adipocyte lipolysis is mediated by a family of triglyceride (TG) lipases consisting of hormone-sensitive lipase (LIPE), adipose triglyceride lipase (PNPLA2) and carboxylesterase 1 (CES1); however, little is known about the relationship between the expression of each gene in different depots and TG lipase activity or obesity. METHOD: We measured both mRNA expression levels of the lipolytic enzymes (LIPE, PNPLA2 and CES1) and TG lipase activities of biopsy samples obtained from subcutaneous, omental and mesenteric adipose tissues of 34 patients who underwent abdominal surgery. The results were correlated with clinical parameters: adiposity measures, parameters for insulin resistance and plasma lipid levels. RESULTS: PNPLA2 mRNA levels were slightly higher in omental fat than subcutaneous fat. Cytosolic TG lipase activities were positively correlated with the mRNA levels of CES1 in subcutaneous fat and mesenteric fat, while they were correlated with those of PNPLA2 in omental fat. The mRNA levels of LIPE were negatively correlated with various measures of adiposity in subcutaneous fat. The mRNA levels of CES1 were positively correlated with various measures of adiposity, particularly those estimated by CT in the three depots; they were also positively correlated with plasma LDL-cholesterol levels in omental fat. In contrast, the mRNA levels of PNPLA2 were not significantly associated with adiposity. CONCLUSIONS: The positive correlations of the expression of CES1 with cytosolic TG lipase activities as well as with adiposity suggest that CES1 is involved in lipolysis, thereby contributing to the development of obesity-associated phenotypes. On the other hand, the expression of LIPE is negatively correlated with adiposity. These distinct regulatory patterns of lipolytic genes may underlie the complex phenotypes associated with human obesity.

F-18 FDG accumulation in mucinous cystic neoplasm of pancreas.

We report a case of mucinous cystic neoplasm which showed FDG accumulation in its cyst wall. MRI revealed that this tumor had repeated intracystic hemorrhage. Inhomogeneous FDG accumulation was found in the cyst wall. The epithelium was focally denuded and ovarian-like stroma with macrophage migration, which phagocytosed red blood cells, and fibrosis were recognized on histopathological examination. These histopathological findings suggested that FDG accumulates not in the monolayer epithelium but in ovarian-like stroma with macrophage migration and fibrosis. Macrophage migration and fibrosis were considered to have contributed to FDG accumulation in this mucinous cystic neoplasm.