[A Case of Postoperative Pulmonary Metastasis of Breast Cancer with Complete Response by Abemaciclib plus Fulvestrant Therapy].

A 66-year-old woman underwent total mastectomy with level Ⅰ and Ⅱ axillary lymph node dissection for right breast cancer in July 2007. The pathology results indicated the presence of T2N0M0 invasive ductal carcinoma(tubule forming type), that was estrogen receptor-positive and human epidermal growth factor 2-negative. She received postoperative adjuvant therapy with oral anastrozole(ANA)for 5 years. Eleven years after surgery, at the age of 77 years, a chest X-ray examination during a routine health checkup identified a mass shadow in the right lung. Further investigation revealed bilateral multiple lung metastases due to breast cancer recurrence. Histological examination of a tissue obtained by computed tomography(CT)-guided lung biopsy confirmed that the histological type and subtype were identical to those found in the initial surgery. Hence, endocrine therapy with ANA plus CDK4/6 inhibitor was started in November 2018. However, the first CDK4/6 inhibitor, palbociclib, caused severe myelosuppression even when the dose was reduced by 2 levels. Therefore in January 2019, the patient was switched to abemaciclib, with the dose reduced by 1 level initially and then reduced by 2 levels from August 2019. In June 2019, new multiple lung metastases appeared, and the patient was switched from ANA to fulvestrant, after which complete response was achieved in 6 months. CT in June 2021 showed no recurrence, and the patient(now 80-year-old)continues to take abemaciclib plus fulvestrant therapy.

[Primary Peritoneal Carcinoma with Long Term Survival-A Case Report].

A 62-year-old woman underwent upper endoscopy in January 2009 to reveal the presence of an extrinsic compression measuring approximately 3 cm in the anterior wall of the gastric antrum. Further examinations suggested that it was caused by peritoneal cancer of an unknown origin; thus, staging laparoscopy was performed in May 2009. Multiple white nodules of varying sizes were found scattered throughout the right upper quadrant of the abdomen and the right abdomen. Based on a biopsy of the greater omentum, the patient was diagnosed with papillary serous adenocarcinoma. As no abnormalities were observed in the uterus and ovary, it was suspected that the patient had primary peritoneal cancer. Hence, in July 2009, the patient underwent resection of the greater omentum, gastric pylorus, gall bladder, and right hemicolon where the tumors were localized, as well as bilateral adnexectomy. Based on intraoperative findings and postoperative histology, the patient was diagnosed with high-grade primary peritoneal serous adenocarcinoma and received paclitaxel and carboplatin therapy. Subsequent follow-up examinations, including positron emission tomography-computed tomography(PET-CT), indicated repeated recurrences in the mesentery, the pelvic floor, and around the remnant stomach. After identifying these recurrences, the patient was treated with platinum-based drugs, experiencing repeated response and cessation cycles. Since September 2019, the patient has received olaparib therapy. PET-CT examination performed in September 2020 indicated that the patient remained in complete remission.

[A Case of Recurrent Breast Cancer with Complete Response to Eribulin Monotherapy after Bevacizumab plus Paclitaxel Combination Therapy].

A 65-year-old woman underwent mastectomy and dissection of a level I axillary lymph node in January 2002 for left breast cancer. The diagnosis was T1N0M0 scirrhous carcinoma that was estrogen receptor-positive, progesterone receptorpositive, and human epidermal growth factor receptor 2-negative. After 3 years 10 months, during which the patient underwent adjuvant therapy with oral aromatase inhibitors, she developed bilateral multiple lung metastases. These were treated with the anticancer agents anthracycline and taxane. Progressive disease(more and larger lung metastases)was diagnosed in April 2013, and bevacizumab plus paclitaxel combination therapy was started. After completion of 4 courses, a lung abscess appeared, which was conjectured to represent rapid tumor necrosis that had become infected. As several tumors remained solid even after the lung abscess improved, the patient received 18 courses of eribulin monotherapy. Computed tomography in April 2016 revealed only patches of linear or cord-like scarring in both lungs, with no metastatic or recurrent foci. In this case, a patient with recurrent breast cancer responded to the sequential administration of bevacizumab plus paclitaxel combination therapy followed by eribulin monotherapy.

[Total Gastrectomy for Advanced Gastric Cancer after Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery: Report of a Case].

An 82-year-old man, who had undergone coronary artery bypass grafting(CABG) with the right gastroepiploic artery( RGEA) 13 years previously, suffered with abdominal pain after meal and tarry stools, and was diagnosed with advanced gastric cancer. Gastroscopy revealed an advanced Borrmann type 4 cancer at the lesser curvature of the gastric body to the pyloric ring. The gastrogram showed poor extension and stenosis at the same part. Abdominal computed tomography showed the tumor reached the subserosal layer and infrapyloric lymph nodes were swollen. Abdominal angiography showed the RGEA graft remained well patent. Total gastrectomy with D2 lymph nodes dissection and arterial reconstruction between the splenic artery and the RGEA graft was performed. He has been well without any sign of cancer recurrence since the operation. Recently, more patients with CABG using RGEA are found to have gastric cancer and require the resection of RGEA for lymph nodes dissection as this case. We consider this procedure one of the options for advanced gastric cancer after coronary bypass grafting using RGEA.

Modified simultaneous integrated boost radiotherapy for large retroperitoneal malignant tumor: A case report.

The current study reports the case of a large retroperitoneal tumor treated with modified simultaneous integrated boost (SIB) radiotherapy. A 45-year-old female presented to the emergency department complaining of left abdominal pain and fever. A computed tomography scan detected a retroperitoneal tumor of 12×16×16 cm, and a biopsy revealed a poorly-differentiated adenocarcinoma. The patient was diagnosed with a large adenocarcinoma originating from the left ureter, with no distant metastasis. Due to the patient's poor physical condition, surgery was not recommended, and the patient was referred to the Department of Radiation Oncology (Yamagata University Hospital, Yamagata, Japan). Modified SIB radiotherapy was administered following the acquisition of written consent from the patient. The total irradiation dose to the center of the tumor and to the surrounding healthy tissue was ∼96 Gy/33 fractions and <60 Gy/33 fractions, respectively. At the end of the radiotherapeutic course, the tumor volume was reduced by ≥80%, and the residual tumor was surgically resected. As a result of the resection, a complete pathological response was confirmed; the patient has been recurrence-free for >3 years with no complications. Modified SIB radiotherapy may be safely administered, with favorable outcomes. Complete recovery can be achieved with this technique, even in a patient with a large radioresistant tumor.

Pancreatic schwannoma: Case report and an updated 30-year review of the literature yielding 47 cases.

Pancreatic schwannomas are rare neoplasms. Authors briefly describe a 64-year-old female patient with cystic pancreatic schwannoma mimicking other cystic tumors and review the literature. Databases for PubMed were searched for English-language articles from 1980 to 2010 using a list of keywords, as well as references from review articles. Only 41 articles, including 47 cases, have been reported in the English literature. The mean age was 55.7 years (range 20-87 years), with 45% of patients being male. Mean tumor size was 6.2 cm (range 1-20 cm). Tumor location was the head (40%), head and body (6%), body (21%), body and tail (15%), tail (4%), and uncinate process (13%). Thirty-four percent of patients exhibited solid tumors and 60% of patients exhibited cystic tumors. Treatment included pancreaticoduodenectomy (32%), distal pancreatectomy (21%), enucleation (15%), unresectable (4%), refused operation (2%) and the detail of resection was not specified in 26% of patients. No patients died of disease with a mean follow-up of 15.7 mo (range 3-65 mo), although 5 (11%) patients had a malignancy. The tumor size was significantly related to malignant tumor (13.8 ± 6.2 cm for malignancy vs 5.5 ± 4.4 cm for benign, P = 0.001) and cystic formation (7.9 ± 5.9 cm for cystic tumor vs 3.9 ± 2.4 cm for solid tumor, P = 0.005). The preoperative diagnosis of pancreatic schwannoma remains difficult. Cystic pancreatic schwannomas should be considered in the differential diagnosis of cystic neoplasms and pseudocysts. In our case, intraoperative frozen section confirmed the diagnosis of a schwannoma. Simple enucleation may be adequate, if this is possible.

Expression of MUC1 and MUC2 in ampullary cancer.

BACKGROUND: Mucins are high-molecular-weight glycoproteins that play important roles in carcinogenesis or tumor invasion. The authors investigated the expression of mucins in ampullary cancer. METHODS: MUC1 and MUC2 expressions were examined using immunohistochemistry. Tissue samples were obtained from 32 patients with ampullary cancer who underwent resection at Yamagata University Hospital, Japan. The authors classified the cases with ampullary cancer into 2 subtypes--pancreatobiliary type (PB type) and intestinal type (I type)--using H&E, MUC1, and MUC2 staining. Then, the authors made a comparison of the clinicopathologic data of the 2 subtypes. RESULTS: Fourteen patients (44%) were classified as PB type and 18 patients (56%) as I type. The PB-type group had significantly worse histopathologic characteristics than the I-type group in nodal involvement (PB type 57% vs I type 22%; P = .04), perineural invasion (PB type 50% vs I type 17%; P = .04), duodenal invasion (PB type 100% vs I type 33%; P = .01), and pancreatic invasion (PB type 71% vs I type 33%; P = .03). The PB-type group had significantly worse outcome than the I-type group (5-year survival: PB type 40% vs I type 72%; P = .03). CONCLUSION: PB-type ampullary cancers were more aggressive than I-type carcinomas. MUC1 and MUC2 expression was useful for classification as PB or I type.

Post operative changes of rapid turnover proteins in elective gastrointestinal surgery.

BACKGROUND/AIMS: This study was performed to examine the changes in rapid turnover proteins (RTPs), such as retinol-binding protein, transthyretin and transferrin, which are known nutritional parameters, during the perioperative period for digestive system operations. METHODOLOGY: The study was performed with 62 subjects who underwent elective surgery of the digestive system. The RTP measurements were performed approx. seven times for each subject (approx. 20 times in total) from the preoperative period to the 14th postoperative day. For 20 subjects who exhibited no recurrence of a malignant tumor, additional measurements were performed 6 to 12 months after the operation. RTPs were measured more than 1,400 times in total for all subjects. RESULTS: The three types of RTPs all exhibited similar changes, but the largest change was observed for retinol-binding protein. The changes in RTPs were significantly larger than those for albumin. RTP levels were lowest on the 3rd postoperative day and gradually increased thereafter. The RTP levels recovered to approx. 80% of the preoperative values on the 14th postoperative day. In the measurements performed 6 to 12 months after the operation, the levels recovered to 90% or higher of the preoperative values. No significant differences were observed between the cases utilizing different operation methods. The administration of fresh frozen plasma had no impact on the postoperative changes. No correlation was observed between the calories obtained by oral intake during the period from the 5th to 10th postoperative days and the changes in RTPs. CONCLUSION: The study results suggested that changes in RTPs would not affected by the calories obtained by oral intake during the early postoperative days. In patients who returned to their daily life after an invasive surgery or reconstruction of the digestive tract, RTP levels were restored to the preoperative values 6 to 12 months after the operation.

Intrahepatic micrometastases around liver metastases from gastric cancer.

BACKGROUND/PURPOSE: We aimed to clarify the association between the presence of micrometastases around liver metastases from gastric cancer and the results of hepatic resection. In addition, we investigated the influence of E-cadherin and matrix metalloproteinase (MMP)-7 expression on the development of micrometastases. METHODS: Micrometastases around liver metastases were examined microscopically in 31 metastatic liver tumor specimens resected from 17 patients who had undergone hepatic resection for liver metastases from gastric cancer. E-cadherin and MMP-7 expression in the primary gastric tumor, the liver metastases, and the micrometastases were examined immunohistochemically. RESULTS: Hepatic micrometastases were present in around 48% of the liver metastases, accounting for 59% of the patients. The tumor recurrence rate in the remnant liver after hepatic resection was significantly higher, and survival significantly poorer, in patients with such micrometastases than in those without. Micrometastases tended to appear around the liver metastases that had reduced E-cadherin expression. Most of the micrometastases in the lymph ducts and sinusoids showed reduced E-cadherin expression. MMP-7 expression was not correlated with the presence of micrometastases. CONCLUSIONS: About half of the hepatic metastases from gastric cancer had seeded off micrometastases, and the presence of these micrometastases was associated with a poorer result of hepatic resection. Reduced E-cadherin expression in metastatic liver tumors may be associated with the development of micrometastases.

[Management of colorectal cancer in elderly patients over 80 years old].

AIM: The incidence of colorectal cancer is increasing. Surgery and chemotherapy for elderly patients are also increasing. We evaluated the characteristics of elderly colorectal cancer to clarify issues related to surgical therapy for elderly patients. METHOD: We studied 67 patients (38 men, 29 women) over 80 years old on whom we operated for colorectal cancer from 1990 to 2004. We compared them with 130 patients aged from 70 to 74 who were operated on in the same period, examining clinicopathological factors, operative methods, preoperative morbidity, postoperative complications, chemotherapy and postoperative survival ratio. RESULTS: In the elderly patients aged over 80, the rate of Dukes' B was high, whereas the rate of Dukes' A was high in patients aged from 70 to 74. No significant differences were observed in operative methods for colon cancer but Hartmann's operation and transanal local excision were frequent for rectal cancer in patients aged over 80. The rate of lymph node dissection was low in patients aged over 80 with rectal cancer. A significant difference was observed in lymph node dissection of rectal cancer between patients aged over 80 and those aged from 70 to 74, but there was no significant difference in curative ratio. Preoperative morbidity were recognized in 76% of patients aged over 80. Postoperative complications occurred in 51% of patients aged over 80. There were many cases showing delirium, but no differences in other complications between patients aged over 80 and those aged from 70 to 74. There was no operative mortality in patients aged over 80. CONCLUSION: Even elderly patients can anticipate safe operations without postoperative complications or decreased quality of life, if the appropriate operative procedure is selected with regard to their general condition.

Prognostic role of angiogenesis and its correlations with thymidine phosphorylase and p53 expression in ductal adenocarcinoma of the pancreas.

BACKGROUND/AIMS: Currently, little information is available regarding the prognostic role of angiogenesis and its correlation with Thymidine phosphorylase (dThdPase) in ductal adenocarcinoma of the pancreas. In the present study, we aimed to evaluate whether tumor angiogenesis, dThdPase expression correlates with prognosis in patients after radical surgical treatment for ductal adenocarcinoma of the pancreas and to investigate the correlation between tumor angiogenesis and dThdPase expression. Furthermore, the role of p53 expression in tumor neovascularization was also examined in this study. METHODOLOGY: Tissue samples were taken from 32 patients with ductal adenocarcinoma of the pancreas after radical surgical treatment. Intratumoral microvessel density (IMVD) and dThdPase, p53 expression were examined immunohistochemically. RESULTS: Increased IMVD significantly correlated with the tumor size, lymph node metastasis and advanced TNM stage (p < 0.05, respectively). Furthermore, increased IMVD correlated withpoorer survival curve (p < 0.05). A significant correlation was present between IMVD and dThdPase expression (p < 0.001), while dThdPase expression did not correlate with prognosis. p53 expression correlated with prognosis, whereas no significant correlation was shown between p53 expression and IMVD in ductal adenocarcinoma of the pancreas. CONCLUSIONS: Tumor angiogenesis is associated with clinicopathological factors regarding tumor progression and may be an important prognostic factor in ductal adenocarcinoma of the pancreas. dThdPase plays an important role in tumor angiogenesis in ductal adenocarcinoma of the pancreas. Mutant p53 expression may not involve in tumor angiogenesis in ductal adenocarcinoma of the pancreas.

Twelve years survival with repeated hepatectomy and lung resection for metastasis from carcinoma of the papilla of Vater after pancreaticoduodenectomy.

We present a 60-year-old woman who underwent three times hepatectomy and lung resection for metastasis originating from a carcinoma of the papilla of Vater after pancreaticoduodenectomy with lymphadenectomy during 12 years. Pancreaticoduodenectomy was performed in 1980 and histological examination of original tumor revealed a stage IIA papillary adenocarcinoma (pT3, pN0, pM0). Repetitive hepatectomy underwent in 1986 (S7,8), 1988 (S2), 1991 (S4) and bilateral partial resection of lung (right S1, left S2.3) in 1990. She died from multiple skin, bone and lung metastases 12 years after pancreaticoduodenectomy. The current case is very rare, however, if patients with carcinoma of the papilla of Vater have localized liver metastases and no local recurrence, liver metastases should be resected to improve the chances for long-term survival.

Definition of MCN (mucinous cystic neoplasm of the pancreas) and a proposal for a new concept of MRN or MSN (mucinous round or spherical neoplasm).

The differential diagnosis of IPMN and MCN is very important for clinicians. MCN is reported to develop in middle-aged females (mean age 48 years) and in the body and tail of the pancreas. Some doctors insist that ovarian-like stroma is absolutely necessary for the definition of MCN. Prompt resection of MCN after diagnosis is desirable. In contrast, about 60% of cases with branch-type IPMN do not require an operation. Therefore, one of the important goals in the differential diagnosis of MCN and branch-type IPMN is to determine the surgical indications before the operation. We believe that MCN and IPMN should be defined by imaging procedures before the operation. We suggest that a neoplasm with an appearance similar to an orange should be diagnosed as MCN, while that with an appearance similar to a bunch of grapes in MRCP should be diagnosed as branch-type IPMN. Proposal of a new concept: If the term MCN is restricted to neoplasms that exhibit ovarian-like stroma, we propose that lesions which are surrounded by a very thick capsule, and which show an orange-like appearance by imaging procedures without histological ovarian-like stroma should be called MRN (mucinous round neoplasm) or MSN (mucinous spherical neoplasm).

Neuroendocrine carcinoma of the stomach with peripancreatic lymph node metastases successfully treated with pancreaticoduodenectomy.

Neuroendocrine carcinoma of the stomach is an uncommon tumor, usually associated with highly malignant biological behavior and extremely poor prognosis. In this report, we described a case of advanced neuroendocrine carcinoma of the stomach with the peripancreatic lymph node metastases which was treated with pancreaticoduodenectomy with extended lymphadenectomy. The patient was admitted to our hospital for anemia. An upper gastrointestinal endoscopy revealed a 4x4-cm fungating tumor with its fundus locating mainly in the duodenal bulbus and extending to the gastric antrum, and tumor biopsy revealed the histological findings of adenocarcinoma. Computed tomography (CT) showed a large mass in the duodenal bulbus with regional lymph node metastases. The patient's disease was diagnosed as primary duodenal cancer with regional lymph node metastases preoperatively. During the operation, an obviously swollen lymph node on the anterior surface of the head of the pancreas 4.0 x 3.5 cm in size was found growing into the parenchyma of the pancreas head and could not be separated from the pancreas, and the swollen lymph node along the superior mesenteric vein was also hard and suspected to be a metastatic node. A pancreaticoduodenectomy with extended lymphadenectomy was performed to achieve a radical resection. Histopathologically, the origin of the primary tumor was considered as a gastric origin, and the tumor was composed of diffused small cells with a moderate mitotic index and occasional rosette formation. Immunohistochemical investigations of the neoplastic cells confirmed the tumor to be neuroendocrine carcinoma. The obvious swollen lymph node on the anterior surface of the head of the pancreas and the swollen lymph node along the superior mesenteric vein were also identified as metastatic lymph nodes. Adjuvant chemotherapy with TS-1 was administered on an out-patient basis 6 weeks after the operation. The patient is well and has now been free of symptoms of recurrence and metastasis for 8 months.

Nodal involvement as an indicator of postoperative liver metastasis in carcinoma of the papilla of Vater.

BACKGROUND/PURPOSE: Although lymph node metastatic involvement is one of the most important prognostic factors for carcinoma of the papilla of Vater, a detailed analysis of this factor in relation to prognosis has not been conducted. METHODS: From 1985 to 2003, 29 patients with carcinoma of the papilla of Vater underwent pancreaticoduodenectomy and dissection of regional lymph nodes at Yamagata University Hospital. We analyzed clinicopathologic variables in relation to prognosis and precisely evaluated nodal involvement in each patient to determine lymphatic flow. Furthermore, the relationship between recurrent site and nodal involvement was investigated. RESULTS: The overall survival rate was 55% at 5 years. The significant prognostic factors were morphological ulcer formation (P = 0.04), histological type (P = 0.03), nodal involvement (P = 0.002), and lymphatic invasion (P = 0.03). Multivariate analysis indicated no independent factor, but nodal involvement may be the strongest prognostic factor. The overall rate of nodal involvement was 41.4% (12 of 29 patients). The metastatic rates in the superior posterior pancreaticoduodenal lymph nodes, the inferior posterior pancreaticoduodenal lymph nodes, the superior mesenteric lymph nodes, and paraaortic lymph nodes were high (31.0%, 20.7%, 17.2%, and 13.8%, respectively). Patients with nodal involvement had a significantly higher rate of liver metastasis after surgery than those without it (P = 0.02). Ulcer formation and histological type were significantly correlated with nodal involvement (P = 0.05 and P = 0.002, respectively). CONCLUSIONS: Nodal involvement is the most important prognostic factor in patients with carcinoma of the papilla of Vater. Patients with nodal involvement are at high risk of liver metastasis; therefore, adjuvant therapy may be necessary for the control of liver metastasis. Preoperative ulcer formation and histological type in the biopsy specimen are good indicators for extended lymph node dissection and adjuvant therapy, because these variables are correlated with nodal involvement. However, our data revealed only the sites of the positive nodes, without addressing the effect of extended lymph node dissection and adjuvant chemotherapy. To date, there has been reporting of extended lymph node dissection and adjuvant chemotherapy in patients with carcinoma of the papilla of Vater. Further studies will be necessary to resolve these problems.

Surgical management for metastatic liver tumors.

BACKGROUND/AIMS: This study investigated the results of hepatectomy for multiple liver metastases and repeated hepatectomy for recurrent hepatic metastases. A proposed treatment strategy for liver metastases is discussed. METHODOLOGY: Fifty-seven consecutive cases of liver metastases were studied. The metastases originated from colon cancer (24 cases), rectal cancer (11 cases), gastric cancer (14 cases), or gastrointestinal stromal tumors (two cases). The other cases included one each of gastric carcinoid, carcinoma of the papilla of Vater, cystic duct cancer, esophageal cancer, choriocarcinoma and breast cancer. RESULTS: The overall 5-year survival rate for the 57 cases was 45.4%; there was no significant difference between patients with colon cancer (56.3%), rectal cancer (45.5%), or gastric cancer (41.6%). The cumulative 5-year survival rates for synchronous and metachronous metastases were 38.3% and 50.8%, respectively (difference not statistically significant; NS). The survival rates for single and multiple metastases were 56.0% and 31.3% (NS), and those for monolobar and bilobar metastases were 48.5% and 40.9% (NS), respectively. Concerning the operative procedure, the survival rates for partial resection and hemi-hepatectomy were 49.5% and 26.9%, respectively (NS). The survival rates for surgical margins <4mm and >5mm were 45.9% and 45.4%, respectively (NS), and those for single and repeat hepatectomy were 40.5% and 58.2% (NS). Preoperative portal embolization was performed in seven cases because of multiple metastases or a tumor located in a deeper site in the liver. There was no hospital death among the 57 cases. CONCLUSIONS: These results show that hepatectomy may offer longer survival, even in patients with multiple or bilobar metastases. Neither the operative procedure nor the size of the surgical margin had any influence on survival after hepatectomy. The prognosis was improved not only for metastases from colorectal cancer, but also for gastric cancer. An increased survival benefit was obtained by repeat hepatectomy for recurrent hepatic metastases. Preoperative portal embolization extended the indication for hepatectomy and provided postoperative safety.

Evaluation of inferior right hepatic vein-preserving hepatectomy with resection of the superior right hepatic vein.

BACKGROUND/AIMS: If the superior right hepatic vein (SRHV) is resected, segment 6 will be drained by the inferior right hepatic vein (IRHV) and congestion will not occur. However, early postoperative liver function and long-term regeneration of segment 6 after IRHV-preserving hepatectomy remains unclear. METHODOLOGY: Three patients undergoing IRHV-preserving hepatectomy were examined. One (case 1) had liver metastasis from sigmoid colon cancer and two (cases 2 and 3) had hepatocellular carcinoma. Resection of segments 7 and 8 along with the SRHV was performed in cases 1 and 2. Anterior sectionectomy and resection of segment 4a along with the SRHV and middle hepatic vein (MHV) was performed in case 3. The volume of each sector was calculated by summation of each CT area. RESULTS: The warm ischemic time of the three cases was 50-78 min, operative blood loss was 496-914 g, and operating time was 4-7 h. There was no significant change in diameter of the IRHV and MHV before and after surgery. Intraoperative color Doppler ultrasonography was a useful technique for evaluating intrahepatic venous communication. Part of segment 6 had previously been resected in case 1, and at outpatient follow-up this segment was found to have become atrophic. In cases 2 and 3, the remnant posterior sector became hypertrophic. CONCLUSIONS: IRHV-preserving hepatectomy can retain a greater proportion of liver parenchyma than right hepatectomy. Postoperative liver function was well maintained in our patients and there were no serious complications. Long-term follow-up showed hypertrophy of the remnant posterior sector except in one case. To minimize surgical damage, for example in patients with poor liver function or preoperative complications, IRHV-preserving hepatectomy should be considered.

Anatomy of right recurrent nerve node: why does early metastasis of esophageal cancer occur in it?

Early, distant and/or skip metastasis of squamous-cell thoracic esophageal cancer frequently occurs in the right recurrent nerve node (recR). However, the specific lymphatic route without a nodal relay, such as the submucosal ascending route, was not known for the recR afferent. Using 20 donated cadavers, macroscopic, and histological observations were performed on the recR and its surrounding lymphatics, especially afferent routes from the esophagus to the recR. Most afferent vessels of the recR originated from the right paratracheal node. However, the recR often (12/20) received a major submucosal lymphatic drainage route ascending along the thoracic esophagus. The submucosal vessel came out of the esophagus and ran in a longitudinal connective tissue mass along the right tracheo-esophageal groove. A direct drainage route was often (13/20) seen from the recR to the venous system. Moreover, because of the specific histology, collaterals seemed to be present around the recR. In the regional nodes of the intrathoracic esophagus, the recR histology was characterized by the high proportion of lymphocyte accumulating areas or the cortex. From the midthoracic level, metastatic cancer cells seemed to reach the recR via esophageal submucosal vessels in the early stage. Large lymphocyte accumulating areas of the recR suggested higher filtration capacity than other distal nodes. However, the collateral of the recR and its direct drainage to the venous system suggested that the recR involvement often corresponds to a systemic disease.

[Participation of the clinical laboratory in the nutrition support team].

Recently, organization of the nutrition support team (NST) is progressing steadily in many hospitals in Japan. In our Yamagata University Hospital, NST services were started in March, 2004. As is well known, NST is a multidisciplinary team comprised of physicians, nurses, dietitians, pharmacists, social workers and medical technologists. Here, we report the participation of medical technologists and physicians belonging to our Clinical laboratory in NST activities. From our laboratory, two medical technologists and two physicians participate in the NST and provide the following services. Firstly, nutritional assessment of proteins in serum i.e. albumin, retinol binding protein (RBP) and transthyretin (TTR) is carried out, measured as part of routine work, and, especially, the data of RBP and TTR are applied to the assessment of nutrition status around the digestive surgical operations. They are also useful to assess the effect of dietary meal, immunonutrition "Impact", which improves the malnutrition status of the pre operative patient. Secondly, a weekly "malnutrition report", including numbers of patients with malnutrition in every ward, serial graphs, and detailed comments on their movements, is reported by e-mail to NST associated departments. This report is conveniently indicates the nutritional situation of inpatients in the hospital and aids consideration of countermeasures for malnutrition in the NST meeting. Thirdly, we medical technologists also participate in making rounds, where we state our opinions on a patient's data, and, if necessary, propose to the chief physician to request additional laboratory tests. We believe that these current activities of our laboratory as part of the NST will contribute to the development of our University NST, raising the quality of nutrition support services, and resulting in improvements of malnutrition and the quality of life of patients.

Anatomy and histology of Virchow's node.

A regional lymphatic system is composed of the first, second, third and even fourth or much more intercalated nodes along the lymptatic route from the periphery to the venous angle or the thoracic duct. The third or fourth node is usually termed the last-intercalated node or end node along the route. Similarly, one of the supraclavicular nodes is known to correspond to the end node along the thoracic duct. It is generally called 'Virchow's node', in which the famous 'Virchow's metastasis' of advanced gastric cancer occurs. The histology of this node has not been investigated, although region-specific differences in histology are evident in human lymph nodes. We found macroscopically the end node in five of 30 donated cadavers. Serial sections were prepared for these five nodes and sections stained with hematoxylin and eosin. Histological investigation revealed that, on the inferior or distal side of the end node, the thoracic duct divided into three to 10 collateral ducts and these ducts surrounded the node. The node communicated with the thoracic duct and its collaterals at multiple sites in two to three hilus-like portions, as well as along the subcapsular sinus. Thus, the end node was aligned parallel to the thoracic duct. Moreover, the superficial and deep cortex areas of the end node were fragmented to make an island-like arrangement, which may cause the short-cut intranodal shunt. Consequenly, the filtration function of most of Virchow's node seemed to be quite limited.