Gluteal muscle metastasis with peritoneal dissemination from gastric cancer during postoperative adjuvant chemotherapy: a case report.

BACKGROUND: Skeletal muscle metastasis from gastric cancer is rare and has a poor prognosis. We reported a case of gluteal muscle metastasis with peritoneal dissemination from gastric cancer during postoperative adjuvant chemotherapy. CASE PRESENTATION: A 64-year-old man with gastric cancer underwent distal gastrectomy with D2 lymph node resection. The pathological diagnosis was poorly differentiated adenocarcinoma and signet cell carcinoma, T3N3bM0, Stage IIIC. Metastases were found in all regional lymph nodes, except 11p. The resection margin was negative. S-1 plus docetaxel therapy was administered as postoperative adjuvant chemotherapy. Six month post-operation, the patient presented with right gluteal muscle tenderness and abdominal distension. Computed tomography revealed a solid mass in the right gluteal muscle, a disseminated nodule on the abdominal wall, and massive ascites. Pathological examination of the gluteal muscle revealed signet cell carcinoma, similar to the resected gastric cancer. The tumor was diagnosed as gastric cancer metastases. Ascites cytology was class V. Thereafter, the patient underwent one course of capecitabine plus cisplatin combined with trastuzumab. Radiation therapy was also administered to relieve the pain of gluteal muscle metastasis. However, chemoradiotherapy was ineffective, and the patient died 2 months after the recurrence. CONCLUSIONS: Skeletal muscle metastasis and peritoneal dissemination during adjuvant chemotherapy indicated a poor prognosis.

Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy.

BACKGROUND: Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure. METHODS: This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy). RESULTS: Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups. CONCLUSIONS: Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.

[A Case of Severe Aortic Thrombosis during the First Chemotherapy Regimen of CapeOX plus Bevacizumab for Metastatic Colon Cancer].

A 61-year-old man underwent CapeOX plus bevacizumab chemotherapyafter right hemicolectomyfor metastatic ascending colon cancer. On the 7th dayafter the first administration, he had sudden abdominal pain and nausea. Contrast-enhanced computed tomographyrevealed aortic thrombosis and a superior mesenteric artery(SMA)embolism that was considered to be associated with bevacizumab. Bevacizumab was discontinued and anticoagulation therapyusing heparin and urokinase was performed. Brain infarction of the left middle cerebral arteryoccurred on the 15th dayafter the first administration and thrombectomywas performed. Anticoagulation therapyusing heparin, bayaspirin, and edoxaban tosilate hydrate was performed. The aortic thrombosis and SMA embolism resolved with treatment, but the patient died following an increase in peritoneal dissemination. It should be noted that unexpectedlysevere aortic thrombosis occurred during the first administration of CapeOX plus bevacizumab for metastatic colon cancer.

Impact of Recombinant Human Soluble Thrombomodulin for Disseminated Intravascular Coagulation.

BACKGROUND: Early treatment of disseminated intravascular coagulation (DIC) can be associated with improved early outcomes. We aimed to evaluate the effectiveness of recombinant human soluble thrombomodulin (rTM) administration in patients with peritonitis-induced DIC. PATIENTS AND METHODS: We treated 39 patients with DIC or pre-DIC caused by peritonitis at the Department of Surgery and Science, Kyushu University, and related facilities between January and December 2013. RESULTS: Patients surviving to 28 days after DIC treatment had significantly better platelet counts, DIC scores, and sequential organ failure assessment scores at 7 days than did those who died earlier than 28 days. Patients receiving rTM had significantly better overall survival rates at 28 days and the results of multivariate analysis showed that rTM administration for DIC treatment was a prognostic indicator of 28-day survival in patients with peritonitis. CONCLUSION: rTM administration for the treatment of DIC or pre-DIC complicated by peritonitis had acceptable early outcomes.

Carcinoma of the ampulla of Vater diagnosed after surgical treatment for Lemmel's syndrome.

Lemmel's syndrome encompasses a range of conditions in which a juxtapapillary duodenal diverticulum exerts mechanical and functional effects on the common bile and pancreatic ducts, leading to jaundice and pancreatitis. In this report, we describe a very rare case of carcinoma of the ampulla of Vater that was detected during postoperative follow-up in a patient who had undergone choledochojejunostomy following a diagnosis of Lemmel's syndrome. We present our clinical and pathological experiences with the diagnosis and treatment of this case as well as a review of the present literature concerning Lemmel's syndrome.

Depressed type of intramucosal differentiated-type gastric cancer has high cell proliferation and reduced apoptosis compared with the elevated type.

BACKGROUND: The depressed type of early gastric cancer, in comparison to the elevated type, tends to invade the submucosal layer and metastasize to the lymph nodes. This study compared the differences in tumor cell proliferation and apoptosis between the elevated and depressed types of intramucosal differentiated gastric cancer. METHODS: A total of 57 intramucosal differentiated gastric cancers were studied. Twenty samples were the elevated type and 37 were the depressed type. The tumor cells were analyzed by immunohistochemistry for Ki-67, Bcl-2, and Bax, and terminal deoxynucleotidyl transferase 2´-deoxyuridine, 5´-triphosphate (dUTP)-biotin nick end labeling was carried out to detect apoptotic cells. RESULTS: (1) The Ki-67 labeling index (KI) was higher in the depressed type (median: 38.6) than in the elevated type (median: 21.2). (2) Immunopositivity for Bax and the apoptosis index (AI) were lower in the depressed type (median AI: 0.20) than the elevated type (median AI: 1.05). (3) The AI/KI was lower in the depressed type (median: 0.17) than in the elevated type (median: 5.57). (4) The AI in the tumors with a Bcl-2-negative and Bax-positive pattern (median: 2.0) was higher than that in the tumors with a Bcl-2-positive and Bax-negative pattern (median: 0.2). CONCLUSION: These results show that, regarding cell proliferation and apoptosis, the depressed type of intramucosal differentiated-type gastric cancer has high malignant potential in comparison to the elevated type.

Lamivudine treatment enabling right hepatectomy for hepatocellular carcinoma in decompensated cirrhosis.

A 69-year-old man was admitted to our hospital in October 2003, for further examination of two liver tumors. He was diagnosed with hepatocellular carcinoma (HCC) arising from decompensated hepatitis B virus (HBV)-related cirrhosis. Long-term lamivudine administration improved liver function dramatically despite repeated treatment for HCC. His Child-Pugh score was 9 points at start of lamivudine treatment, improving to 5 points after 1 year. His indocyanine green at 15 min after injection test score was 48% before lamivudine treatment, improving to 22% after 2 years and to 5% after 4 years. Radiofrequency ablation controlled the HCC foci and maintained his liver function. In April 2009, abdominal computed tomography revealed a tumor thrombus in the right portal vein. Since his indocyanine green test results had improved to less than 10%, we performed a right hepatectomy, which was successful. To our knowledge, there have been no documented reports of patients undergoing successful right hepatectomy for HCC arising from decompensated cirrhosis. The findings observed in our patient indicate the importance of nucleoside analogs for treating HBV-related HCC.

Serum matrix-metalloproteinase-1 is a bona fide prognostic marker for colorectal cancer.

BACKGROUND: Matrix metalloproteinases (MMPs) are involved in the degradation of extracellular matrix components and are associated with invasion and metastasis. MMP proteins could be serum tumor markers or molecular targets in the treatment of malignancy. The purpose of the current study was to identify a prognostic serum marker in cases of colorectal cancer (CRC) prior to surgical intervention. MATERIALS AND METHODS: Laser microdissection and microarray analysis were used to characterize gene expression in 73 cases of CRC. We then focused on expression of MMP-1. We examined serum MMP-1 activity before resection in another subset of 75 cases of CRC to validate the clinical significance of MMP-1 as a prognostic marker in CRC after surgically curative operation. RESULTS: Disease-free survival was 51% in the MMP-1 high expression group and 81% in the low-expression group (P < .05). Survival was 52% in the MMP-1 high expression group and 90% in the low group (P < .05). In multivariate analysis for disease-free survival, MMP-1 and lymph node metastasis were significant independent prognostic indicators. In multivariate analysis of overall survival, serum MMP-1 level was the only significant independent indicator among factors. CONCLUSIONS: Within the MMP family of proteins, MMP-1 is not a cancer-specific protease. However, MMP-1 activity does predict the future course of progression of malignant cells. Thus, MMP-1, which is activated at the primary lesion and is found in serum, assists in the clinical diagnosis of CRC. It is also an important molecule for understanding the underlying mechanism of invasion and metastasis of CRC.

[A case of inoperable gastric small cell carcinoma effectively treated by chemotherapy and radiotherapy].

We herein report a case of advanced gastric small cell carcinoma treated by chemotherapy and radiotherapy. A 69-year-old man was admitted to our hospital presenting with appetite loss and body weight loss. He was diagnosed to have an inoperable gastric small cell carcinoma with severe lymph node metastases and left adrenal gland metastasis. Chemotherapy with TS-1/paclitaxel, cisplatin/irinotecan and cisplatin/etoposide was sequentially performed. Primary and metastatic foci had obviously diminished. Eighteen months after the initial therapy, he had dysarthrosis and multiple brain metastases were found. Metastatic foci were decreased and his symptom was improved by successful radiotherapy. We conclude that chemotherapy and radiotherapy are effective for primary and metastatic lesions of gastric small cell carcinoma.

Choledochal cyst diagnosed and conservatively treated during pregnancy.

We report herein a rare case of choledochal cyst diagnosed at 14 weeks gestation and treated with percutaneous transhepatic drainage until postpartum. A 26-year-old primigravid woman at 14 weeks gestation presented with epigastric pain, slight fever, and nausea of 3 days duration. Abdominal ultrasonography revealed a 6-cm-diameter cystic mass between the porta hepatis and the pancreas head, which was diagnosed as a type I choledochal cyst. At 18 weeks of gestation, her upper abdominal pain became severe, and the size of the choledochal cyst increased to 12 cm in diameter. Laboratory data revealed a biliary obstruction. Percutaneous transhepatic drainage was performed immediately. She delivered a healthy male baby by elective cesarean section at 37 weeks of gestation. At 6 weeks postpartum, the patient underwent surgical excision of the choledochal cyst, cholecystectomy, and formation of a Roux-en-Y hepaticojejunostomy. Although choledochal cysts are rare during pregnancy, obstetricians should be familiar with the condition to ensure prompt diagnosis and adequate definitive management, given that the implications of missed or delayed diagnosis may be detrimental to both mother and fetus.

The benefit of laparoscopy-assisted distal gastrectomy compared with conventional open distal gastrectomy: a case-matched control study.

BACKGROUND/AIMS: Laparoscopy-assisted distal gastrectomy is a surgical procedure which is safe, useful, and technically feasible for patients with early gastric cancer. The aim of this study is to determine whether laparoscopy-assisted distal gastrectomy is also superior to conventional open distal gastrectomy. METHODOLOGY: The study comprised 27 consecutive patients with early gastric cancer who were admitted to our hospital from 1997 to 2000 and underwent distal gastrectomy. Ten patients underwent laparoscopy-assisted distal gastrectomy; and 17 conventional open distal gastrectomy. RESULTS: Estimated blood loss was 17.7 +/- 12.1 g during laparoscopy-assisted distal gastrectomy, and 250.0 +/- 160.8 g during conventional open distal gastrectomy. The difference was statistically significant (p < 0.001). The day of ambulation (2.7 +/- 0.7 vs. 1.0 +/- 0.0), and start of liquid diet (6.9 +/- 1.2 vs. 4.3 +/- 0.5) were significantly delayed in conventional open distal gastrectomy compared with laparoscopy-assisted distal gastrectomy (p < 0.001, p < 0.05). At the 3rd postoperative day, the serum C-reactive protein level in laparoscopy-assisted distal gastrectomy decreased significantly more than that in conventional open distal gastrectomy (4.2 +/- 1.7 vs. 9.4 +/- 2.5: p < 0.05). No postoperative complication was found in laparaoscopy-assisted distal gastrectomy. CONCLUSIONS: Laparoscopy-assisted distal gastrectomy is a safe and useful operation for most early gastric cancers. Laparoscopy-assisted distal gastrectomy has been superior to conventional open distal gastrectomy.

Incarceration of small bowel herniation through a defect of the broad ligament of the uterus: report of a case.

Intestinal herniation through a defect in the broad ligament of the uterus is uncommon among internal herniations. We herein report a 59-year-old woman with intestinal obstruction, who had no previous history of surgical treatment except for an appendectomy. The laparotomy revealed an incarceration of the small bowel herniation through the defect of the right broad ligament. This possibility should therefore be considered in the differential diagnosis for female patients presenting with an intestinal obstruction without any history of a prior laparotomy.

Laparoscopy-assisted replacement of percutaneous endoscopic gastrostomy.

Laparoscopy-assisted percutaneous endoscopic gastrostomy was successfully performed to replace gastrostomy tubes that had been inadvertently withdrawn. With this less-invasive surgical technique, gastrostomy tubes in elderly patients can be replaced safely and definitely without laparotomy. We suggest that this technique be performed when indicated.