[A Case of a Patient with Multiple Liver Metastases of Colorectal Cancer with Relapse-Free, Long-Term Survival and Responding Completely to Chemotherapy after Primary Lesion Resection].

A 64-year-old man who suffered from colorectal cancer with multiple liver metastases underwent laparoscopic low anterior resection. He did not undergo partial liver resection. He was treated with mFOLFOX6 plus bevacizumab chemotherapy. The liver metastases had disappeared completely on Gd-EOB-DTPA(EOB)MRI after 6 courses of therapy with mFOLFOX6 plus bevacizumab. This chemotherapy was discontinued after 13 courses. At present, 86 months have passed since the laparoscopic low anterior resection. He is relapse-free and a long-term survivor.

[A Case of Laparoscopic Hartmann's Operation for Perforation of Rectal Cancer in Superior Elderly People].

We report a case where home discharge was possible after laparoscopic Hartmann's operation for superior elderly perforation of rectal cancer. The patient was 91-year-old, a woman. She was delivered to the emergency room complaining of weakness. We diagnosed rectal perforation and started emergency laparoscopic surgery. Rectal cancer perforation was observed during surgery and laparoscopic Hartmann's operation plus D2 lymph node dissection was performed. The operation time was 3 hours 21 minutes, the blood loss was 10 g. She resumed her meal intake from the postoperative day(POD)5 and became ready for discharge on POD 20 postoperatively. She moved to a comprehensive care ward and she was discharged to her house on POD 89. On POD 120, she visited the hospital complaining of anorexia and anal bleeding, and was diagnosed as local recurrence in the pelvis, multiple liver metastases, and cancerous peritonitis. She was admitted to palliative care unit on POD 132 and died on POD 141. It was suggested that laparoscopic surgery will be minimally invasive even at superior elderly patients and that they will be able to discharge from their homes.

Dinosaur Tail Sign: A Useful Spinal MRI Finding Indicative of Cerebrospinal Fluid Leakage.

OBJECTIVE: To evaluate the imaging characteristics and diagnostic utility of the "Dinosaur tail sign" in the diagnosis of cerebrospinal fluid (CSF) leakage. BACKGROUND: The authors propose the "Dinosaur tail sign," defined as a combination of the dorsal epidural hyperintensities, fat tissue, spinal cord, and cauda equine on lumbosacral sagittal fat-suppressed T2-weighted image (FST2WI), as a sensitive indicator for diagnosing CSF leakage. METHODS: Imaging characteristics of the "Dinosaur tail sign" was evaluated in seven spontaneous intracranial hypotension (SIH) and 23 iatrogenic CSF leakage (ICSFL) patients. Additionally, the diagnostic index was compared between the "Dinosaur tail sign" and other previously reported useful magnetic resonance imaging (MRI) and magnetic resonance myelography (MRM) findings. RESULTS: In contrast to other imaging findings including the epidural expansion, floating dural sac sign, and distension of the spinal epidural veins on MRI, and paraspinal fluid collections (PFC) on MRM, the "Dinosaur tail sign" was found equally in both SIH and ICSFL patients (6 SIH and 19 ICSFL; 83% of all patients with CSF leakage). The "Dinosaur tail sign" showed sufficient diagnostic utility (sensitivity 83%, specificity 94%, accuracy 89%) that was comparable to that of PFC. CONCLUSION: The "Dinosaur tail sign" is a useful imaging finding suggestive of CSF leakage. Evaluation of subtle interspinous arched hyperintensities on spinal MRI is mandatory for the diagnosis of SIH and ICSFL.

[Long-Term Survival of a Patient with Stage IV Breast Cancer and An Intrathoracic Space-Occupying Metastatic Lesion].

A 50-year old woman noticed left axillary lymph node swelling and presented at our hospital. CNB showed adenocarcinoma( pap-tub, ER+, PgR+, HER2 3+). CT revealed a right lung metastatic nodule and swollen lymph nodes above the left collarbone and left axilla. However, no breast tumor was found at that time. We diagnosed occult breast cancer, TxN3bM1 (lung), Stage IV . FEC(100), paclitaxel, letrozole, anastrozole, exemestane plus trastuzumab, tegafur/uracil plus trastuzumab, and lapatinib plus capecitabine were sequentially administered. Five years and 9 months after the treatment started, CT revealed a right intrathoracic lesion that had gradually increased in size. Subsequently, trastuzumab plus pertuzumab plus docetaxel, bevacizumab plus paclitaxel, trastuzumab emtansine, trastuzumab plus fulvestrant, and doxifluridine plus medroxyprogesterone acetate plus cyclophosphamide(DMpC therapy)were sequentially administered. At this time, 8 years after the treatment started, trastuzumab plus pertuzumab plus vinorelbine were also administered. An intrathoracic space-occupying lesion due to breast cancer is rare, and anti-HER2 chemotherapy was effective for this patient.

Lumbar puncture-related cerebrospinal fluid leakage on magnetic resonance myelography: is it a clinically significant finding?

BACKGROUND: Post-dural puncture headache (PDPH) due to excessive cerebrospinal fluid (CSF) leakage is a well-known complication of lumbar puncture. Although various factors, especially the type of spinal needle, have been demonstrated to be associated with PDPH, the clinical implications of CSF leakage detected on magnetic resonance myelography (MRM) images remain unclear. The objective of this case-control study was to evaluate the association between radiologically visualized CSF leakage and PDPH. METHODS: Clinical data including patients' age and gender, types of spinal needle, duration of bed rest, interval between lumbar puncture procedures and MRM studies, and incidence of PDPH were compared between patients who were radiologically-positive and -negative for CSF leakage. RESULTS: Of the 22 patients with definite CSF leakage on MRM images, most were asymptomatic (86%, 19/22). The remaining three patients, who were suffering from PDPH, only complained of headaches and were treated conservatively. In a review of patients' clinical data, there were no significant differences in any parameter including the incidence of PDPH between the 22 patients who were radiologically-positive for CSF leakage and the 31 radiologically-negative patients. CONCLUSION: The significance of radiologically visualized CSF leakage should not be overestimated, as most such incidents are not associated with PDPH and do not require any treatment.

Comparison of the radioisotope cisternography findings of spontaneous intracranial hypotension and iatrogenic cerebrospinal fluid leakage focusing on chronological changes.

BACKGROUND: Radioisotope cisternography (RICG) is useful for detecting cerebrospinal fluid (CSF) leakage in spontaneous intracranial hypotension (SIH) patients. However, RICG can cause iatrogenic CSF leakage (ICSFL) due to a lumbar puncture. OBJECTIVES: To compare the RICG findings of SIH and ICSFL. METHODS: The presence of direct findings suggesting CSF leakage and indirect findings including early visualization of the bladder and absence of radioactivity over the brain convexities were evaluated in seven SIH and six ICSFL patients. Radioisotope clearance was assessed semi-quantitatively. RESULTS: In contrast to the variety of anatomical levels at which direct findings were detected in the SIH patients, the ICSFL patients only displayed direct findings at the lumbosacral level. None of the ICSFL patients displayed direct findings at 1 hour after the tracer injection. Although early visualization of the bladder was depicted in all patients, no activity was visualized over the brain convexities in the SIH patients. In the semi-quantitative analysis, the tracer retention index at 24 hours was lower in the SIH patients than the ICSFL patients. CONCLUSIONS: The early appearance of direct findings above the lumbosacral level, the absence of radioactivity over the brain convexities and a low tracer retention index are suggestive of SIH.

[A case report of cholangiectasis with cholangiocarcinoma].

This is a case report of cholangiectasis with cholangiocarcinoma in a 37-year-old female. Both computed tomography (CT) and endoscopic retrograde cholangio-pancreatography (ERCP) demonstrated gallstone, and intrahepatic bile duct dilatation with the stone. The diagnosis was intrahepatic cholangiectasis without common bile duct-dilatation. Hepatectomy of segment 3 with resection of the extrahepatic bile duct and reconstruction of the biliary tract was performed. Upon pathological examination, an early stage of cholangiocarcinoma was pointed out within the small range of common bile duct without dilatation or stone. Cholangiocarcinoma with cholangiectasis has been reported to be induced by counter flow of pancreas and intestinal juice because of the pancreaticobiliary maljunction. So we usually choose a diversion operation as our tactics to get rid of the counter flow of those digestive juices. Despite the above-mentioned tendency, this is a very rare case of carcinogenesis in common bile duct without dilatation.

Laparoscope-assisted superlow anterior resection combined with inter sphincteric rectal dissection for very low advanced rectal cancers combined with preoperative chemotherapy.

Transanal intersphincteric resection (ISR) has been increasingly used as a surgical treatment for extremely low rectal cancer. We hypothesized that high quality less invasive surgery could be achieved if ISR and laparoscopic surgery were combined. The patient was a 46-year-old male with advanced rectal cancer on the lower rectum adjacent to the dentate line. The patient refused abdomino-perineal resection (APR), so we performed laparoscope-assisted ISR after preoperative chemotherapy. Previous dissection of this patient facilitated the muscle layer-oriented curative dissection, and more importantly, made the subsequent laparoscopic rectal excision effortless. This patient showed favorable recovery including postoperative anal function with no complications or recurrent disease. This procedure is feasible and has favorable short-term results for the radical treatment of very low rectal disease, while preserving anal function. This operative procedure may be appropriate for locally advanced rectal cancers to avoid a permanent colostomy.

Outcomes of total pelvic exenteration for colorectal cancer.

BACKGROUND/AIMS: Pelvic recurrence occurs in 4-33% of patients who have undergone a curative resection of primary rectal cancer and is thus a serious problem. However, the best treatment for primary rectal cancer remains unclear. In the present study was assessed the outcomes of total pelvic exenteration for colorectal cancer retrospectively. METHODOLOGY: In the present study was investigated the medical charts of 25 patients who underwent total pelvic exenteration for primary colorectal cancer (n = 12) or postoperative local recurrence of colorectal cancer (n = 13) at the Department of Surgery (Division of Digestive Surgery) of the Kyoto Prefectural University of Medicine between the years 1997-2005. RESULTS: The mean disease-free time interval between the first operation for primary colorectal cancer and total pelvic exenteration for the recurrence was 919 days (range, 203-3460 days). Total pelvic exenteration required a mean operation time of 940 minutes (range, 540-1395 minutes). The mean carcinoembryonic antigen (CEA) value was 25.5 ng/ml (range, 1-171.8 ng/ml). Five-year survival was achieved in 9 patients (36%) and inhospital death occurred in 3 patients (12%). The patients with curative resection survived significantly longer than the patients with non-curative resection. CONCLUSIONS: When curative resection is achieved, total pelvic exenteration for colorectal cancer can result in long-term survival.

[A case of huge advanced rectal cancer invaded into the surrounding organs resected successfully after preoperative chemotherapy with mFOLFOX6].

In the recent improvement in chemotherapy for advanced rectal cancer, a treatment for rectal cancer involving the surrounding organs has been well thought out. In this report, we described a case of advanced rectal cancer invaded into the surrounding organs was resected successfully after preoperative chemotherapy with mFOLFOX6. The case was a 74-year-old man with advanced rectal cancer (type 3). A close examination of the patient revealed a bowel movement disturbance. Bowel obstruction was treated with transverse colostomy. Then chemotherapy (mFOLFOX6) was performed six times. It was judged at first to be a huge tumor of 15 cm in diameter, which was unresectable due to invasion into the urinary bladder and sacrum. However, after mFOLFOX6 was enforced, the tumor was shrunk to about 5 cm in diameter (effect judgment PR). Then the tumor was successfully resected. A pathologic histology inspection of the tumor, judged to be Grade 2 prior to resection, revealed a differentiation type glandular carcinoma and a highly lymphocytic infiltration. These results suggested that an appropriate preoperative chemotherapy was useful for huge rectal cancers involving the surrounding organs such as urinary bladder and sacrum.

Utility of Laparoscopic Subtotal Cholecystectomy with or without Cystic Duct Ligation for Severe Cholecystitis.

We use open cholecystectomy (OC) to treat severe cholecystitis in cases in which we are worried that inflammation might cause anatomical changes in Calot's triangle. Furthermore, in cases of severe cholecystitis in which marked inflammation leads to fibrosis, we perform subtotal cholecystectomy (SC), i.e., incomplete gallbladder resection. Laparoscopic SC (LSC) without cystic duct dissection is considered to be effective at reducing the incidence of serious complications in patients with severe cholecystitis. The cases of 246 patients who underwent cholecystectomy for benign gallbladder disease between January 2011 and May 2015 were evaluated retrospectively. Of these patients, 14 were treated with LSC, and 19 underwent OC. Moreover, three patients in the LSC group underwent LSC without cystic duct ligation because it was considered that it would be difficult to dissect and ligate the cystic duct. The LSC group suffered significantly less intraoperative blood loss than the OC group. However, the operative times of the two groups were similar. Moreover, the duration of the postoperative hospitalization period was significantly shorter in the LSC group than in the OC group. Next, we compared the long-term outcomes of the SC and total cholecystectomy groups, regardless of the surgical method. No cases of cholecystitis or gallbladder cancer were encountered in either group. It is suggested that LSC is safe, effective, and helps to prevent serious complications in cases of severe cholecystitis that require conversion to OC, regardless of whether cystic duct ligation is performed.

Pneumatosis intestinalis leading to perioperative hypovolemic shock: Case report.

Pneumatosis intestinalis (PI) is an uncommon disorder defined as multiple foci of gas within the intestinal wall. Despite recognition of an increasing number of cases of PI, the optimal management strategy, whether through surgical or other means, remains controversial. The present report describes the case of a patient with PI who underwent exploratory laparotomy without specific findings and who ultimately died due to extensive intestinal hemorrhage that was possibly triggered by surgery.

Expression of cancer stem cell markers CD133 and CD44 in locoregional recurrence of rectal cancer.

BACKGROUND: Recent findings suggest that cells with surface CD markers include cancer stem cells (CSCs) which can produce a cancer cluster, and that the presence of CSCs may be linked with prognosis. CD133 and CD44 are among the most useful markers for identification of colorectal CSCs. MATERIALS AND METHODS: An immunohistological analysis of CD133 and CD44 was performed using tissue from cases shown to be locoregionally recurrent or non-recurrent clinico-pathologically. RESULTS: The CD133-positive rates were 38.7% and 59.23% in non-recurrent and recurrent cases, respectively, and the CD44-positive rates were 35.5% and 44.4%, respectively. Expression of the CD markers had no correlation with other clinicopathological factors. The prognosis of patients who were positive for both markers was significantly worse than that of other patients. CONCLUSION: These results suggest that detection of CD133 and CD44 can provide useful information for selection of treatment and performance of intensive follow-up of colorectal cancer.

Gastrointestinal Stromal Tumor in a Patient with Neurofibromatosis: Abscess Formation in the Tumor Leading to Bacteremia and Seizure.

A 66-year-old woman with neurofibromatosis type 1 (NF1) was brought to the emergency room with seizures and high-grade fever. Seizure in adult NF1 patients raises concern for intracranial lesions. However, neurological examination and central nervous system imaging failed to detect any causative intracranial lesions for her seizure. Gram-positive cocci, Streptococcus anginosus, were detected by blood cultures. Abdominal computed tomography revealed a well-defined round mass 7 cm in diameter, which was found to be a small intestinal gastrointestinal stromal tumor (GIST) containing an abscess. There was fistula formation between the intestinal lumen and the abscess, in which there were numerous Gram-positive cocci. The seizure may have been caused by hypoosmolality (hyponatremia and hypoproteinemia), which may result from decreased food intake associated with high-grade fever and general malaise. In this case GIST originating from the small intestine was invaded by S. anginosus through a fistula, leading to abscess formation, bacteremia, high-grade fever, and seizure, which was the first clinical manifestation.

RUNX3 promoter methylation in colorectal cancer: its relationship with microsatellite instability and its suitability as a novel serum tumor marker.

BACKGROUND/AIM: RUNX3 is a novel gastric cancer tumor suppressor. RUNX3 promoter hypermethylation is associated with many types of cancer, including colorectal cancer. Furthermore, the RUNX3 promotor is one of the CpG island methylator phenotype (CIMP)-specific promotors. CIMP is a distinct phenotype associated with microsatellite instability (MSI) in colorectal cancer. In this study, the suitability of the quantitative analysis of RUNX3 promoter hypermethylation as a novel serum tumor marker was investigated. Moreover, we investigated the relationship between RUNX3 promoter methylation and MSI in colorectal cancer. PATIENTS AND METHODS: A RUNX3 real-time quantitative methylation-specific PCR (RTQ-MSP) technique we developed was used to analyze the CpG sites in the RUNX3 promoter of 119 colorectal tumors and 344 sera from colorectal cancer patients. MSI analysis of 119 colorectal tumors was performed with five microsatellite markers (BAT25, BAT26, D5S346, D2S123, and D17S250). RESULTS: Proximal colon tumors exhibited significantly higher RUNX3 methylation than their paired normal tissues (p=0.0438). Analysis of the clinicopathological parameters revealed that a proximal location (p=0.0054), lymphatic invasion (p<0.0001), and an advanced pathological stage (p=0.0018) were associated with significantly higher RUNX3 methylation. Assessment of the relationship between RUNX3 methylation and tumor MSI revealed 11 out of 13 tumors with high-frequency MSI (85%) were positive for RUNX3 hypermethylation, significantly more than the tumors with low-frequency MSI or which were microsatellite stable (34%, p=0.0070). In preoperative sera from 344 colorectal cancer patients, significantly higher RUNX3 methylation was associated with lymphatic invasion (p=0.0487) and an advanced pathological stage (p=0.0466). Post-operative follow-up data revealed that recurrence cases exhibited significantly higher preoperative serum RUNX3 methylation than non-recurrence cases (p=0.0003). Concomitant analysis of carcinoembryonic antigen (CEA) levels in the preoperative sera showed that 17.7% (61/344) were CEA-negative but RUNX3 methylation-positive, which means assessing both serum RUNX3 methylation and CEA should improve diagnosis of colorectal carcinoma. CONCLUSION: RTQ-MSP-based quantification of serum RUNX3 methylation is useful for the detection and monitoring of colorectal cancer.

Quantitative analysis of tumor-derived methylated RUNX3 sequences in the serum of gastric cancer patients.

PURPOSE AND EXPERIMENTAL DESIGN: Using real-time quantitative methylation-specific PCR (RTQ-MSP), methylated RUNX3 sequences were quantified and the fractional concentrations of circulating tumor DNA in serum were determined, along with peripheral blood cells collected preoperatively, intraoperatively and postoperatively from 65 patients with gastric cancer. RESULTS: RTQ-MSP was sufficiently sensitive to detect RUNX3 methylation. Quantitative MSP data were expressed in terms of the methylation index, which was defined as the relative amount of methylated RUNX3 sequences divided by the concentration of methylated actin. High levels of methylated RUNX3 sequences were detected in the peripheral circulation of 29% (19 of 65) of the gastric cancer patients. The RUNX3 methylation index was concordant with cancer stage, histology, lymphatic and vascular invasion, and was more sensitive than carcinoembryonic antigen (CEA) as a biomarker. Twenty-nine percent (19 out of 65) of preoperative serum samples had methylated RUNX3 sequences, ranging from 5.2 to 1625955 (median quantity=43 m-index, sensitivity 95.5%, specificity 62.5%, AUC 0.8651). After surgical resection, the median RUNX3 methylation index in serum significantly decreased. These results demonstrate the clinical usefulness and effectiveness of peripheral blood RTQ-MSP for detecting and monitoring gastric cancer after treatment. Furthermore, 5 out of the 30 preoperative control samples of benign disease (cases of panperitonitis due to acute appendicitis or cholecystitis) showed transient RUNX3 methylation which decreased after the operation in accordance with recovery. CONCLUSION: Quantification of epigenetic changes in serum RUNX3 methylation using RTQ-MSP is useful for the detection and monitoring of gastric cancer.