A multicenter, open-label, single-arm phase I trial of neoadjuvant nivolumab monotherapy for resectable gastric cancer.

BACKGROUND: Nivolumab monotherapy has demonstrated superior efficacy in advanced unresectable gastric cancer (GC), but its impact on resectable GC remains unknown. This phase I study aimed to evaluate safety, feasibility, and potential biomarkers of neoadjuvant nivolumab monotherapy in resectable GC. METHODS: Untreated, resectable, cT2 or more advanced gastric adenocarcinomas with clinical stage I, II, or III were treated with two doses of nivolumab before gastrectomy. Patients were excluded if their tumors may be applicable to neoadjuvant chemotherapy. The primary endpoint was the incidence of adverse event (AE) categories of special interest. RESULTS: All of the 31 enrolled patients completed 2 doses of nivolumab monotherapy. While 30 (97%) patients underwent surgery with curative intent, 1 patient discontinued before the planned surgical intervention because of a newly emerging liver metastasis. Seven patients (23%) had nivolumab treatment-related AEs, and one patient had a treatment-related AE of grade 3-4. The incidences of treatment-related AE categories of special interest ranged from 0 to 6%. Notable surgical complications included two cases of grade 3 anastomotic leakage and two cases of pancreatic fistula. The major pathologic response (MPR) assessed by the independent pathology review committee was achieved in five (16%) patients, of which one patient had a pathologic complete response. The MPR was mostly observed in patients with positive PD-L1 expression, high microsatellite instability, and/or high tumor mutation burden. CONCLUSIONS: Neoadjuvant nivolumab monotherapy is feasible with an acceptable safety profile and induces a MPR in certain patients with resectable GC. (Registration: clinicaltrials.jp, JapicCTI-183895).

A Case of Breast Cancer in a Patient with a Congenital Pectoralis Muscle Defect.

Congenital pectoral muscle defects are very rare, and when accompanied by limb defects, they are called Poland syndrome. A woman in her 70s, 4 years after partial mastectomy for breast cancer, underwent mastectomy for a local recurrence. During the operation, the pectoralis major and minor muscles were found to be defective. However, the patient did not have any limb defects. Although congenital pectoral muscle defects are very rare, it would be better to confirm defects of the pectoral muscle by preoperative diagnostic imaging such as CT because the postoperative treatment may be affected.

Thoracic esophageal injury due to a neck stab wound: a case report.

BACKGROUND: Traumatic esophageal injury leads to severe complications such as mediastinitis, pyothorax, and tracheoesophageal fistula. Although prompt diagnosis and treatment are required, there are no established protocols to guide diagnosis or treatment. In particular, thoracic esophageal injury tends to be diagnosed later than cervical esophageal injury because it has few specific symptoms. We report a case of thoracic esophageal injury caused by a cervical stab wound; the patient was stabbed with a sharp blade. CASE PRESENTATION: A 74-year-old woman was attacked with a knife while sleeping at home. The patient was taken to the emergency room with an injury localized to the left section of her neck. She was suspected of a left jugular vein and recurrent laryngeal nerve injury from cervical hematoma and hoarseness. On the day following the injury, computed tomography revealed a thoracic esophageal injury. Emergency surgery was performed for an esophageal perforation and mediastinal abscesses. Although delayed diagnosis resulted in suture failure, the patient was able to resume oral intake of food a month later following enteral feeding with a gastrostomy. Esophageal injuries due to sharp trauma are rare, and most are cervical esophageal injuries. There are very few reports on thoracic esophageal injuries. CONCLUSIONS: The possibility of thoracic esophageal injury should always be considered when dealing with neck stab wounds, particularly those caused by an attack.

Planned Versus On-Demand Relaparotomy Strategy in Initial Surgery for Non-occlusive Mesenteric Ischemia.

BACKGROUND: There has been insufficient evidence regarding a treatment strategy for patients with non-occlusive mesenteric ischemia (NOMI) due to the lack of large-scale studies. We aimed to evaluate the clinical benefit of strategic planned relaparotomy in patients with NOMI using detailed perioperative information. METHODS: We conducted a multicenter retrospective cohort study that included NOMI patients who underwent laparotomy. In-hospital mortality, 28-day mortality, incidence of total adverse events, ventilator-free days, and intensive care unit (ICU)-free days were compared between groups experiencing the planned and on-demand relaparotomy strategies. Analyses were performed using a multivariate mixed effects model and a propensity score matching model after adjusting for pre-operative, intra-operative, and hospital-related confounders. RESULTS: A total of 181 patients from 17 hospitals were included, of whom 107 (59.1%) were treated using the planned relaparotomy strategy. The multivariate mixed effects regression model indicated no significant differences for in-hospital mortality (61 patients [57.0%] in the planned relaparotomy group vs. 28 patients [37.8%] in the on-demand relaparotomy group; adjusted odds ratio [95% confidence interval] = 1.94 [0.78-4.80]), as well as in 28-day mortality, adverse events, and ICU-free days. Significant reduction in ventilator-free days was observed in the planned relaparotomy group. Propensity score matching analysis of 61 matched pairs with comparable patient severity did not show superiority of the planned relaparotomy strategy. CONCLUSIONS: The planned relaparotomy strategy, compared with on-demand relaparotomy strategy, did not show clinical benefits after the initial surgery of patients with NOMI. Further studies estimating potential subpopulations who may benefit from this strategy are required.

Laparoscopic appendectomy during the second trimester of a twin pregnancy.

Acute appendicitis during pregnancy may lead to increased maternal and fetal risks. Laparoscopic appendectomy is commonly performed during pregnancy. Compared with open appendectomy in pregnant women, laparoscopic appendectomy has shown non-inferior safety for pregnancy outcomes and superior safety for surgical outcomes. Over the last few decades, the occurrence of twin pregnancy has been increasing. Performing an operation on a patient with a twin pregnancy is more difficult than with a singleton pregnancy. Only a few operations of this kind have been reported. Here, we present a case of a 20-week twin pregnant woman who presented with acute appendicitis. Laparoscopic appendectomy was performed, and no maternal complications occurred. This report contributes to discussions on the safety of the laparoscopic approach for appendicitis during twin pregnancies.

[A Case of Advanced Esophagogastric Junction Cancer Responding to Combined Modality Therapy].

The patient was a 75-year-old man with advanced esophagogastric junction cancer.He received 2 courses of neoadjuvant chemotherapy with DCS followed by lower esophagectomy and total gastrectomy via the left thoracoabdominal approach. Pathological examination revealed EGJ adenocarcinoma(pT3N4M0, pStage Ⅳa).He was followed up after the surgery and was diagnosed with pulmonary portal lymph node and No.1 07 node recurrences 4 years and 8 months after the surgery, respectively.He received 2 courses of TS-1 monotherapy and chemoradiotherapy, resulting in a complete response(CR).He has remained in CR until June 2019.

[Surgical Treatment for Synchronous Double Cancer of the Thoracic Esophagus and Lung].

We herein report 2 cases of radical operation for synchronous double cancer of the thoracic esophagus and each side of the lung. Case 1:A 71-year-old woman with synchronous double cancer of the thoracic esophagus (Mt, T3N2M0, Stage III) and right lung (M, T2aN0M0, Stage I B) underwent esophagectomy concomitantly with right middle lobectomy through right thoracotomy (single-stage operation) after 2 courses of systemic chemotherapy with docetaxel, cisplatin and 5-fluorouracil( DCF regimen). Case 2:A 72-year-old man with synchronous double cancer of the thoracic esophagus( MtLt, T3N2M0, Stage III) and left lung( U, T1aN0M0, Stage I A) underwent 2-stage operation after 2 courses of the DCF therapy. Esophagectomy through right thoracotomy was performed followed by left upper lobectomy through left thoracotomy 3 months later. Treatment strategy for synchronous double cancer of the thoracic esophagus and lung is discussed based on our experiences and previous reports.

Transcatheter arterial embolization for intercostal arterio-esophageal fistula in esophageal cancer.

BACKGROUND: While esophageal fistula formation in the adjacent organs is associated with high rates of morbidity and mortality, the management of non-aortic arterio-esophageal fistula has not been frequently reported. CASE PRESENTATION: A 69-year-old Japanese man who had undergone definitive chemoradiotherapy for esophageal cancer was admitted to our hospital with hematemesis. He was diagnosed with mediastinal abscess caused by esophageal perforation, and esophageal bypass surgery was performed. After 3 days, he presented with fatal hemoptysis. As angiography revealed an intercostal artery pseudoaneurysm, transcatheter arterial embolization was performed. CONCLUSIONS: When patients with esophageal cancer, especially those with a history of radiotherapy and/or mediastinitis, present with hematemesis and/or hemoptysis, the possibility of non-aortic arterio-esophageal fistula should be considered. Transcatheter arterial embolization is an effective treatment for non-aortic arterio-esophageal fistula.

[Long-Term Survivor of a Barrett's Esophageal Adenocarcinoma, Who Underwent Three Times Surgical Resection and MultidisciplinaryTherapyfor Lymph Node Recurrences - Report of a Case].

We report a case of a 42-year-old man who underwent 3 times surgical resection for lymph nodes recurrence and multidisciplinary therapy for Stage IV b Barrett's esophageal adenocarcinoma, and was well 6 years and 3 months after the first resection. The prognosis of the recurrence cases after radical recection of the esophageal cancer is extremely poor. Long-term prognosis may be obtained in few patients, but the cases are squamous cell carcinoma in most of the reported cases. The number of Barrett's esophageal adenocarcinoma patients is increasing, but it is not many. There is little reports, and there is no fixed treatment policy.

[A Case of Rapidly Advancing G-CSF Producing Pleomorphic Carcinoma of the Breast Appearing as an Inflammatory Breast Cancer].

We report a rare case of pleomorphic carcinoma of the breast, suspected of being a granulocyte-colony stimulating factor (G-CSF)producing tumor, in a 75-year-old woman. She presented with a red and swollen breast, 3 weeks after undergoing core needle biopsy(CNB). Her leukocyte counts and C-reactive protein(CRP)levels were markedly high. At first, she was suspected to have an abscess and was initiated on a course of antibiotics. However, her condition rapidly deteriorated; therefore, she underwent an emergency mastectomy. Despite undergoing postoperative radiation therapy, 2 months after the operation, multiple metastatic foci were found in the lungs and liver, and she died of the disease 3 months after her first visit. After the operation, her leukocyte count had quickly returned to normal, but it increased as the disease progressed. These findings support the conclusion that this carcinoma was producing G-CSF. The final pathological diagnosis was G-CSF producing pleomorphic carcinoma of the breast.

[A Patient with Stage IV Gastric Cancer Who Survived More Than Five Years after Gastrectomy].

The prognosis of patients with Stage IV gastric cancer is generally poor. The 5-year overall survival rate is less than 10%. The patient was a 73-year-old man with Stage IV gastric cancer. Before chemotherapy, peritoneal dissemination was observed using staging laparoscopy. The patient received first-line chemotherapy with TS-1 plus CDDP. Renal function worsened and consequently the therapy was stopped. He received 3 courses of chemotherapy with weekly PTX. The peritoneal dissemination had disappeared by the second staging laparoscopy and he underwent distal gastrectomy. The final diagnosis was pT4a, ly2, v1, pN2(4/16),M0, fStage III B. The patient received adjuvant chemotherapy of TS-1 for 4 years and 8months after gastrectomy. More than 5 year after gastrectomy, the patient is alive without recurrence.

Spleen preservation versus splenectomy in laparoscopic total gastrectomy with D2 lymphadenectomy for gastric cancer: A comparison of short-term outcomes.

INTRODUCTION: Splenic hilar lymph node dissection via a splenectomy for advanced proximal gastric cancer remains controversial. Recently, a laparoscopic spleen-preserving hilar lymph node dissection procedure was described in several publications. To assess the feasibility and safety of spleen-preserving laparoscopic total gastrectomy with D2 lymphadenectomy (LTG-D2), the present retrospective study compared the short-term surgical outcomes between spleen preservation and splenectomy during laparoscopic D2 total gastrectomy (LTG-D2S). METHOD: This study included 59 patients who underwent LTG-D2 and 19 patients who underwent LTG-D2S. RESULTS: The mean operation time did not significantly differ between the LTG-D2 and LTG-D2S groups (339.4 ± 56.8 vs 356.8 ± 46.0 min). The mean blood loss tended to be smaller in the LTG-D2 group than in the LTG-D2S group (105.9 ± 89.7 vs 210.0 ± 149.5 mL). The mean number of retrieved lymph nodes did not significantly differ between the LTG-D2 and LTG-D2S groups (39.9 ± 17.0 vs 40.6 ± 14.9), and the mean number of retrieved lymph nodes at the splenic hilum also did not significantly differ between the LTG-D2 and LTG-D2S groups (1.3 ± 1.7 vs 2.4 ± 2.6). Mild pancreatic fistula occurred in three cases (5%) in the LTG-D2 group and in three cases (15.8%) in the LTG-D2S group. CONCLUSION: A LTG-D2 is feasible in terms of the short-term outcomes. However, the indications for this complicated procedure should be considered carefully.

[A case of advanced esophagogastric junction cancer responding to pre-operative combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab].

We have no consensus on surgical treatment and chemotherapy for esophagogastric junction cancer in Japan. A 51-yearold man reporting dysphagia was examined, and through upper gastrointestinal endoscopy was found to have a tumor at the esophagogastric junction. Histologically, biopsy specimens indicated adenocarcinoma with genetic amplification of human epidermal growth factor receptor type 2(HER2). Positron emission tomography showed swelling of several abdominal lymph nodes with accumulation of fluorodeoxyglucose. He was treated with esophagogastorectomy with left thoracotomy after combination chemotherapy of docetaxel, cisplatin, S-1, and trastuzumab. He had no complication from the operation and had no adverse effect from the combination chemotherapy. Histopathological examination of the resected specimen showed a minute residual cancer nest at the muscularis propria of the esophagus, but no lymph node metastasis. This regimen could be useful for advanced junctional cancer with HER2 amplification as preoperative chemotherapy.

[A case of multiple distant lymph node metastases from advanced gastric cancer treated with adjuvant chemotherapy after total gastrectomy].

A 70-year-old woman with advanced gastric cancer (U, type 3, por, pT3, ly3, v2, pN3a [10/92, No. 1, 3], Stage IIIB) underwent total gastrectomy and D2 dissection followed by adjuvant chemotherapy with S-1. Eight months later, computed tomography (CT) showed multiple distant lymph node metastases, including metastases in the para-aortic and supraclavicular( Virchow's nodes) lymph nodes. Chemotherapy with cisplatin( CDDP) and irinotecan( CPT-11) was administered with concurrent radiation therapy for the para-aortic nodes. After 2 courses, the para-aortic lymph nodes showed complete response( CR), but Virchow's nodes showed partial response( PR). Dissection of Virchow's nodes was performed. Histopathological examination revealed a chemotherapeutic effect on the dissected node, and therefore, 2 more courses of chemotherapy were administered after the operation. Adverse events such as grade 3 neutropenia and grade 4 hyponatremia were observed. At present, the patient is well without recurrence, and chemotherapy is not being administered. Local therapy for distant metastasis followed by systemic chemotherapy may have been effective in this case.

[Successful treatment of aortoesophageal fistula due to a thoracic aortic aneurysm].

A 78-year-old female presented at a nearby hospital with hemorrhage and loss of consciousness. After examination by computed tomography (CT) scan, she was referred to our hospital on suspicion of an impending rupture of the descending thoracic aorta aneurysm. She underwent a 2 stage operation. At the 1st operation, graft replacement of the descending aorta and closing of the aneurysmal wall over the aortoesophageal fistula were performed. On the 2nd postoperative day, intrathoracic esophagogastrostomy was performed by the gastric tube interposition technique. On the 54th postoperative day, she was discharged to a rehabilitation hospital.

[A case of recurrent breast carcinoma metastasis successfully treated with S-1 and zoledronic acid therapy].

We experienced a case of triple-negative recurrent breast carcinoma achieving a significant improvement by oral S- 1, a fluoropyrimidine-class anticancer drug and zoledronic acid(ZOL), a third generation bisphosphonate(BP). / Against metastases to orbital foramen, chest wall and bone, the oral treatment with S-1 was started at 80 mg/day everyday for 4 weeks, followed by a 2-week rest interval as 1 cycle, and ZOL was injected at 4 mg every 4 weeks. After 2 cycles of treatment, the level of tumor markers and tumor sizes became reduced. Twelve cycles after the initiation of the therapy, recrudescence of the metastatic lesions was not recognized, and no other metastases were recognized in any organ. In the course of the treatment, no adverse drug reactions to S-1 occurred in the patient. For treatment of recurrent breast carcinoma, S-1 is considered to be a useful and tolerable anticancer drug, and combination treatment of S-1 and ZOL is thought to be effective.

The simple "Rectum Catcher" device is a useful tool for laparoscopic-assisted high and lower rectal surgery.

BACKGROUND: This report describes our experience in 13 patients with rectal cancer along with a general overview of the use of the simple "Rectum Catcher" device in high and lower rectal surgery. MATERIALS AND METHODS: The Rectum Catcher is made of stainless steel (length 40 cm, caliber 7 mm), with a circle of diameter 6 mm punched out at a distance of 5 mm from the top and covered with a short-cut T-tube (length 1 cm, caliber 6 mm) (SILKOLATEX T-tube, 8 mm; Willy Rusch AG, Germany). A vessel tape (width 9 mm, length 120 cm; Kawano Seisakusho, Chiba, Japan) is inserted into the stainless steel and the short-cut T-tube. The Rectum Catcher is inserted into the abdominal cavity through the 12-mm trocar (Ethicon Endo Surgery) and a vessel tape is circled the rectum and pulled to catch it. Thirteen patients with rectal cancer were operated laparoscopically using the Rectum Catcher at our hospital. RESULTS: From January 2007 to the present, this study included 13 patients (5 men and 8 women) undergoing laparoscopic-assisted high anterior resection (Lap-HAR, five patients), low anterior resection (Lap-LAR: six patients), and abdominoperineal resection (Lap-APR: two patients) for rectal cancer, using the Rectum Catcher. Using the Rectum Catcher, easy maneuverability of the rectum and irrigation of rectal lumen can be easily performed to safely cut the bowel being occluded, in the narrow laparoscopic view of the pelvic cavity. CONCLUSION: In our experience, the simple Rectum Catcher device is safe and useful for performing laparoscopic assisted high and lower rectal surgery.

Surgical-site infection with toxin A-nonproducing and toxin B-producing Clostridium difficile.

To date, few cases of extraintestinal infection with Clostridium difficile have been reported. We describe a case of surgical-site infection with C. difficile following a colonic operation. Administration of metronidazole was considered to be effective for treatment of the infection. The isolate was a toxin A-nonproducing and toxin B-producing strain.

Prognostic significance of gastric cancer metastasis in second-tier lymph nodes detected on reverse transcriptase-polymerase chain reaction and immunohistochemistry.

To determine the prognostic significance of the methods used to determine the presence of metastasis in second-tier lymph nodes of patients with gastric cancer, the authors studied lymph nodes surgically removed from 100 patients with gastric cancer (55 with early cancer, 45 with progressive). The results of HE staining were compared with those of immunohistochemistry using the anticytokeratin (CK) antibody and reverse transcriptase-polymerase chain reaction (RT-PCR) assays. Lymph node 7 or 8a was obtained intraoperatively, then mRNA was extracted using an immunobeads method, and RT-PCR with CK19 mRNA was performed. The P for Cox regression analysis for metastasis detected by HE staining, CK staining, and RT-PCR of all 100 cases was 0.312, 0.426, and 0.021, respectively, while for second-tier lymph nodes it was 0.154, 0.013, and 0.006, respectively. In conclusion, RT-PCR and CK staining for detection of metastasis in second-tier lymph nodes were more reliable prognostic indicators than conventional HE staining.

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument "Endo-PSI (II)" and circular stapler.

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the "Endo-PSI (II)", and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.