Dynamic ultrasound reveals the specific behavior of the medial meniscus extrusion in patients with knee osteoarthritis.

BACKGROUND: In the dynamic condition, knee osteoarthritis (OA) usually presents with pain. In the weight-bearing condition, a medial meniscus extrusion (MME) may cause severe symptoms and pathological progression. However, the correlation between a dynamic MME and pain has not been elucidated. Now, an MME can be evaluated under dynamic conditions and reflect the characteristics of symptomatic knee OA. This study investigated MMEs during walking and their correlation with knee pain. METHODS: Thirty-two symptomatic patients with knee OA (mean age, 60.5 ± 9.9 years) were enrolled in this study. The medial meniscus was evaluated using ultrasonograms during walking, and in the static supine and unipedal standing positions, as dynamic and static conditions, respectively. The ΔMME (the difference between the maximum and minimum MMEs) was obtained in each condition. The intensity of the knee pain during walking was measured by the visual analog scale (VAS). RESULTS: The ΔMME in the dynamic condition was significantly higher than that in the static condition (P < 0.01). There was a significant correlation between VAS and ΔMME only in the dynamic condition. CONCLUSIONS: The dynamic evaluation is a valid tool for understanding the mechanisms of knee pain and the behavior of the medial meniscus in symptomatic knee OA.

Tumor-to-Tumor Metastasis of Medullary Thyroid Carcinoma to Paraganglioma in a Multiple Endocrine Neoplasia Type 2B Patient: A Case Report and Literature Review.

Tumor-to-tumor metastasis is a rare phenomenon in which primary tumor cells metastasize to other tumors. Herein, we report an extremely rare case of tumor-to-tumor metastasis of medullary thyroid carcinoma to a paraganglioma in a patient with multiple endocrine neoplasia type 2B. Based on genetic examination, a 36-year-old woman was diagnosed with multiple endocrine neoplasia type 2B when she was 24 years old. She had a history of total thyroidectomy for medullary thyroid carcinoma and bilateral adrenalectomy for pheochromocytomas, which were performed when she was 15 years and 29 years old, respectively. Follow-up computed tomography demonstrated a retroperitoneal tumor of 30 mm in diameter beside the left kidney and a liver tumor of 16 mm in diameter located in segment 6. The retroperitoneal and liver tumors were surgically resected and examined by a pathologist. Histological examination revealed the classic Zellballen pattern in the retroperitoneal tumor, rendering the diagnosis of a paraganglioma recurrence. Inside the tumor, a white nodule positive for carcinoembryonic antigen, weakly positive for calcitonin, and negative for tyrosine hydroxylase, was identified and diagnosed as a metastatic medullary thyroid carcinoma with high malignant potential. The liver lesion was diagnosed as a metastasis of the medullary thyroid carcinoma. This is the first report of tumor-to-tumor metastasis of medullary thyroid carcinoma to paraganglioma in a patient with multiple endocrine neoplasia type 2B twenty years after total thyroidectomy.

Usefulness of Preoperative Controlling Nutritional Status in Predicting Prolonged Hospitalization and Incidence of Postoperative Delirium for Elderly Hepatectomy with Hepatocellular Carcinoma.

The number of elderly patients with hepatocellular carcinoma (HCC) has been increasing, but it remains unclear whether hepatectomy can be performed using the same criteria as in younger patients. Furthermore, the appropriate preoperative evaluation for hepatectomy in elderly patients is not yet clearly defined. Here, we investigated the applicability of preoperative assessment using the Controlling Nutritional Status (CONUT) score to help improve hepatectomy outcomes in elderly patients with HCC. This was a single-center retrospective analysis, and the study population comprised 64 consecutive patients who underwent hepatectomy for HCC between January 2012 and August 2016. We compared the preoperative assessment and perioperative outcomes between elderly (≥ 75 years old) and younger (< 75 years old) patients. A total of 61 patients were reviewed. Poor preoperative CONUT score was associated with a longer postoperative hospital stay in elderly patients undergoing hepatectomy for HCC. In addition, although elderly patients had similar perioperative outcomes to younger patients, the incidence of delirium was significantly higher, and univariate analysis confirmed that old age is a risk factor for delirium among the preoperative factors. Hepatectomy for HCC in the elderly can be safely performed with appropriate preoperative nutritional assessment using CONUT score and prevention of postoperative delirium. Preoperative nutritional assessment using the CONUT score was useful in predicting prolonged hospitalization for elderly hepatectomy with HCC.

[Indication of Palliative Gastrojejunostomy for Unresectable Advanced Gastric Cancer with Obstruction from the View Point of Preoperative Inflammatory Biomarkers].

Palliative surgery for advanced gastric cancer with serious symptoms such as hemorrhage or obstruction may be meaningful in the point of improving quality of life(QOL). However, the meaning of palliative gastrojejunostomy for unresectable gastric cancer with obstruction is controversial. We retrospectively evaluated the effectiveness of gastrojejunostomy for unresectable gastric cancer with obstruction using preoperative inflammatory biomarkers. Blood lymphocyte monocyte ratio(LMR), neu- trophill ymphocyte ratio(NLR)and C-reactive protein/albumin ratio(CAR)were analyzed as inflammatory biomarkers in this study. The percentage of improvement in food intake, discharge from the hospitaland performance of chemotherapy were significantly higher in the patients without any preoperative inflammatory reaction compared to those with any inflammation. Moreover, the survival of the patients without any inflammatory change was significantly longer compared to those with any inflammation. In conclusion, preoperative status of inflammation may be a useful marker to predict the effect and outcome of palliative gastrojejunostomy for unresectable gastric cancer with obstruction. Especially when there is any inflammation, the surgical indication should be carefully judged.

[Three Cases of Advanced Gastric Cancer with Peritoneal Dissemination Successfully Treated with S-1 and Docetaxel Combination Chemotherapy].

Case 1: A 74-year-old man underwent total gastrectomy for gastric cancer, but peritoneal dissemination(P1c)was con- firmed intraoperatively in July 2011. Postoperatively, S-1/docetaxel(DTX)combination chemotherapy was administered; after 32 courses of treatment, S-1 was continued as monotherapy. However, in November 2013, CT scan showed a portal vein tumor. We modified the chemotherapy regimen, but he died 3 years and 7 months after the operation. Case 2: A 77-year-old man underwent distal gastrectomy for gastric cancer with peritoneal dissemination(P1b)in September 2013. He was treated with S-1/DTX/trastuzumab(Tmab)combination chemotherapy. After 5 courses of treatment, S-1was continued as monotherapy until October 2015. He has since survived without recurrence. Case 3: A 75-year-old woman was diagnosed with gastric cancer with peritoneal dissemination(P1c)by laparotomy in September 2014. She was treated with S-1/DTX combination chemotherapy. After 23 courses of treatment, chemotherapy was discontinued according to the patient's wish. She died 2 years and 6 months after the surgery. We suggest S-1/DTX combination chemotherapy as an option for advanced gastric cancer with peritoneal dissemination.

[Experience of Perioperative Status for Super Elderly Colorectal Patients in Our Facility].

We examined the perioperative situation according to estimation of physiologic ability and surgical stress(E-PASS)score of 35 colon cancer patients aged 85 years or older who underwent operation in our facility. The incidence of Grade 2 and Grade 3 complications according to Clavien-Dindo classifications increased with age. The preoperative risk score(PRS)also increased with age; however, the surgical stress score(SSS)did not. The comprehensive risk score(CRS)also increased with age. Because the PRS was already high in these elderly patients, since 2016, we implemented methods to lower the SSS to reduce patient risk, including decreasing the operative time and increasing the laparoscope rate. Compared to before these efforts, the SSS decreased, resulting in a reduced incidence of Grade 3 complications.

tRNA modifying enzymes, NSUN2 and METTL1, determine sensitivity to 5-fluorouracil in HeLa cells.

Nonessential tRNA modifications by methyltransferases are evolutionarily conserved and have been reported to stabilize mature tRNA molecules and prevent rapid tRNA decay (RTD). The tRNA modifying enzymes, NSUN2 and METTL1, are mammalian orthologs of yeast Trm4 and Trm8, which are required for protecting tRNA against RTD. A simultaneous overexpression of NSUN2 and METTL1 is widely observed among human cancers suggesting that targeting of both proteins provides a novel powerful strategy for cancer chemotherapy. Here, we show that combined knockdown of NSUN2 and METTL1 in HeLa cells drastically potentiate sensitivity of cells to 5-fluorouracil (5-FU) whereas heat stress of cells revealed no effects. Since NSUN2 and METTL1 are phosphorylated by Aurora-B and Akt, respectively, and their tRNA modifying activities are suppressed by phosphorylation, overexpression of constitutively dephosphorylated forms of both methyltransferases is able to suppress 5-FU sensitivity. Thus, NSUN2 and METTL1 are implicated in 5-FU sensitivity in HeLa cells. Interfering with methylation of tRNAs might provide a promising rationale to improve 5-FU chemotherapy of cancer.

[A Difficult Case of Invagination of the Protruding Colon Cancer].

A 88-year-old female suffered of ileus due to advanced transverse colon cancer. Pneumonia was observed and nutrient condition was bad. Operation was found to be difficult because of the bad condition with complication on this present time. Self-expandable metallic stent(SEMS)was inserted to extend obstruction. But SEMS dropped out next day and SEMS, thicker than previous one, was reinserted. Main tumor was huge protruding tumor and the reason of ileus was invagination of the cancer. The fixation of SEMS was not so good, but the generalcondition was improved while a week after reinsertion of SEMS. Laparoscopic colon partial resection was performed safely. Bridge to surgery with SEMS for the case of invagination of protruding colon cancer was thought to be useful.

[A Case of Surgical Treatment of Pulmonary Metastasis from Gastric Cancer].

An 87-year-old woman was diagnosed with advanced gastric cancer and primary lung cancer in November 2012. She underwent distal gastrectomy for the gastric cancer in December 2012, and right upper wedge resection for the primary lung cancer in February 2013. After surgery, the patient received S-1 chemotherapy. However, she subsequently experienced adverse effects, and so S-1 chemotherapy was stopped. In February 2016, a computed tomographic scan of the chest showed a nodular shadow at S8 in the left lung. Because the nodular shadow gradually increased in size, we suspected that the diagnosis would be either primary lung cancer or metastatic lung cancer arising from gastric cancer. In July 2016, we performed left lower wedge resection. Histopathological examination of the resected specimen resulted in a diagnosis of metastatic lung cancer arising from gastric cancer. After pulmonary resection, the patient had no recurrent tumor. It is thought that surgery is an effective treatment for solitary pulmonary metastasis arising from gastric cancer.

[Subtotal Esophagectomy for Mediastinal Lymph Node Oligo-Recurrence of ALK-Positive Lung Adenocarcinoma - A Case Report].

The patient was a 54-year-old woman with anaplastic lymphoma kinase-positive stage III B lung cancer. She received 4 courses of carboplatin(CBDCA)plus paclitaxel(PTX)plus bevacizumab(Bev)chemotherapy and crizotinib. Chemotherapy reduced the size of the primary site and mediastinal lymphadenopathy; however, the right supraclavicular and subcarinal lymph nodes were enlarged again during crizotinib treatment. Because it was an oligo-recurrence, we performed radiotherapy for these lymph nodes and changed systemic chemotherapy to alectinib. After 16 months, the patient exhibited esophageal stenosis due to subcarinal lymphadenopathy. We performed a subtotal esophagectomy, which improved the quality of life, and she was continued on an oral treatment of alectinib. Therefore, we suggest that an invasive surgical treatment is useful for oligo-recurrence cases.

[Liver Metastases from Pancreatic Neuroendocrine Tumor(P-NET)Treated with Surgery and Chemotherapy].

Pancreatic neuroendocrine tumor(P-NET)often involve liver metastases. We report a 52-year-old woman who underwent distal pancreatectomy for a pancreatic body tumor with a diameter of 8 cm. The pathological findings were P-NETG2 . After 1 year 6 months, a liver metastasis was detected. We performed partial hepatectomy. The pathological findings showed a Ki-67 index of 23%. After surgery, CPT-11 plus CDDP therapy and AMR therapy were administered. CONCLUSION: Multimodal therapies should be considered for P-NETliver metastases based on the Ki-67 index.

[A Case of Successful Treatment of Liver Metastases from Gastric Cancer with Chemotherapy].

A 69-year-old man was diagnosed with advanced gastric cancer accompanied by multiple liver metastases in April 2009. Because of worsening anemia due to bleeding from the primary tumor, we performed a distal gastrectomy. After gastrecto- my, he underwent S-1/CDDP combination chemotherapy. After 5 courses of chemotherapy, the size of the liver metastases was reduced. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy, but he developed grade 3 diarrhea, and the S-1/irinotecan combination chemotherapy was immediately stopped.Weekly paclitaxel chemother- apy was administered as third-line chemotherapy, and S-1/docetaxel combination chemotherapy was administered as fourth-line chemotherapy. After 11 courses of S-1/docetaxel combination chemotherapy, the liver metastases could not be detected by CT and PET-CT in October 2012, and it was concluded that a complete response(CR)had been obtained. He receive maintenance therapy with S-1 chemotherapy for 10 months. Now, he is alive without chemotherapy and has maintained a CR for 4 years 8 months after achieving a CR.

[Three Cases of Gastric Cancer with Rare Presentation of Oncologic Emergency].

We report 3 cases of gastric cancer with rare presentations of oncologic emergency. Case 1 involved cardiac tamponade caused by mediastinitis-induced pericarditis. Metastatic lymph nodes became enlarged after total gastrectomy and invaded the esophagojejunal anastomotic region. Then, a fistula to the mediastinum occurred, resulting in mediastinitis. The drainage was efficacious, but the patient died of cancer 1 month after admission. Case 2 involved cardiac tamponade caused by invasion of metastatic peritoneal tumor into the pericardium. The drainage was successful, but the patient died of cancer 2 weeks after drainage. Case 3 involved perforation of the stomach during the third course of chemotherapy. A total gastrectomy was urgently performed. Thereafter, chemotherapy was continued. However, the patient died of cancer 6 months later. These oncologic emergencies should be considered, although they are rare.

[A Case of Successful Treatment of Metachronous Liver Metastasis from Gastric Cancer with Hepatectomy].

A 77-year-old man was found to have advanced gastric cancer and underwent total gastrectomy (pT4aN2H0P0M0, Stage ⅢB). Two years after gastrectomy, we found an elevated tumor marker level, and a liver metastasis appeared in segment 5 (20 mm in diameter). He was treated with S-1/CDDP combination chemotherapy. After 2 courses of chemotherapy, the tumor marker level kept rising and a CT scan detected a progressive tumor. S-1/irinotecan combination chemotherapy was administered as second-line chemotherapy. After 6 courses of chemotherapy, the size of the liver metastasis was reduced and the tumor marker level normalized. Because lymph node metastasis or peritoneal recurrence was observed, a partial resection of the liver (S5) was performed. After the operation, he was treated with S-1 chemotherapy again for 1 year and has had no recurrence.

Prognostic information derived from RT-PCR analysis of peritoneal fluid in gastric cancer patients: results from a prospective multicenter clinical trial.

OBJECTIVE: The purpose of this study is to define the clinical significance of the molecular analysis of peritoneal lavage fluid in patients with gastric cancer in a multicenter prospective trial. METHODS: Quantitative RT-PCR with CEA and CK-20 mRNA as target markers was introduced for peritoneal lavage diagnosis in 141 patients with clinically advanced gastric cancer from 9 different institutes. We then evaluated the prognostic factors in patients and also evaluated predictive markers for peritoneal recurrence in 124 patients without peritoneal metastasis at surgery RESULTS: Out of the 141 cases, 140 patients were successfully analyzed by RT-PCR of peritoneal lavage fluids. According to multivariate analysis, the combined results of RT-PCR (CEA and CK-20) and CK-20 alone in addition to pathological N (pN)-stage were significantly correlated with overall survival. Multivariate analysis showed that the RT-PCR (CEA and CK-20) and CEA alone in addition to pathological T-stage, pN-stage, and histological grade were significantly correlated with peritoneal recurrence after surgery. CONCLUSION: This is the first multicenter prospective study to show that RT-PCR analysis of peritoneal lavage fluid with the combination of CEA and CK-20 markers was useful for predicting overall survival and peritoneal recurrence in patients with clinically advanced gastric cancer.

Biosurfactant-and-bioemulsifier produced by a promising Cunninghamella echinulata isolated from Caatinga soil in the northeast of Brazil.

A Mucoralean fungus was isolated from Caatinga soil of Pernambuco, Northeast of Brazil, and was identified as Cunninghamella echinulata by morphological, physiological, and biochemical tests. This strain was evaluated for biosurfactant/bioemulsifier production using soybean oil waste (SOW) and corn steep liquor (CSL) as substrates, added to basic saline solution, by measuring surface tension and emulsifier index and activity. The best results showed the surface water tension was reduced from 72 to 36 mN/m, and an emulsification index (E24) of 80% was obtained using engine oil and burnt engine oil, respectively. A new molecule of biosurfactant showed an anionic charge and a polymeric chemical composition consisting of lipids (40.0% w/w), carbohydrates (35.2% w/w) and protein (20.3% w/w). In addition, the biosurfactant solution (1%) demonstrated its ability for an oil displacement area (ODA) of 37.36 cm², which is quite similar to that for Triton X-100 (38.46 cm²). The stability of the reduction in the surface water tension as well as of the emulsifier index proved to be stable over a wide range of temperatures, in pH, and in salt concentration (4%-6% w/v). The biosurfactant showed an ability to reduce and increase the viscosity of hydrophobic substrates and their molecules, suggesting that it is a suitable candidate for mediated enhanced oil recovery. At the same time, these studies indicate that renewable, relatively inexpensive and easily available resources can be used for important biotechnological processes.

[A case of sigmoid colon cancer liver metastasis accompanied by multiple liver abscesses].

We describe the case of a patient with sigmoid colon cancer liver metastasis accompanied by multiple liver abscesses. The 59-year-old female patient presented with a fever at a body temperature of 39.0°C. On abdominal computed tomography (CT), multiple liver abscesses were detected, and percutaneous transhepatic abscess drainage (PTAD) was performed. The day after the PTAD, the patient's fever subsided and her inflammatory response abated. A lower gastrointestinal examination, performed to identify the origin of her symptoms, revealed a type 1 tumor in the sigmoid colon. A biopsy indicated a moderately differentiated adenocarcinoma. Prior to surgery, a second abdominal CT scan was performed, and a single liver metastasis was detected. Laparoscopic sigmoidectomy and partial liver resection were simultaneously performed. The histopathological diagnosis of the colon cancer was tub2, pN1, pH1, P0, ly1, v1, stage IV. To date, the patient remains free from hepatic abscess and colon cancer recurrence. Gastrointestinal examinations should be performed as early as possible to identify the cause of hepatic abscesses. Moreover, therapeutic decisions should only be made after imaging and examinations have been performed, which will be sufficient to identify the presence of liver metastases.

[A case of surgery for stenosis of the colon from recurrent gastric cancer].

In June 2010, a 67-year-old man presented with advanced gastric cancer. He underwent 2 courses of combination chemo- therapy with S-1/CDDP. After chemotherapy, total gastrectomy was performed (pT4aN3aM0, Stage IIIC). Although he underwent S-1 chemotherapy, colon tumors recurred 22 months after the operation. Colonoscopy revealed the presence of type 2 advanced cancer in the ascending colon, and type IIa early cancer in the transverse colon, which were diagnosed as either primary colon cancers or recurrent gastric cancers upon pathological examination. In October 2012, resection of the right side of the colon was performed in order to prevent malignant bowel obstruction. Pathological examination of the resected specimen identified recurrent gastric cancers. After the surgery, he is currently undergoing S-1 chemotherapy and has no sign of recurrent tumors.

[A case of locoregional recurrence after gastric cancer surgery, which was treated with XPT regimen chemotherapy].

Based on the results of the trastuzumab for gastric cancer (ToGA) trial, the regimen of Xeloda/5-FU+CDDP+trastuzu- mab (XPT/FPT) has become the standard of care for treatment of HER2-positive unresectable or recurrent gastric cancers. In our hospital, the percentage of HER2-positive gastric cancer patients is 16.7%; we present a case of recurrence 26 months after gastric cancer surgery. A 67-year-old man presented with locoregional lymph node recurrence, with swelling in a paraaortic lymph node. ¹8F-fluorodeoxy glucose positron emission tomography (FDG-PET) examination revealed abnormal accumulation in these lymph nodes. He was treated with a regimen of XPT chemotherapy because of the HER2-positive status of his gastric cancer. After 8 courses, the lymph nodes had shrunk and FDG-PET examination revealed no abnormal accumulation. Imaging revealed the presence of interstitial pneumonia, and the adverse events of venous thromboembolism, and grade 3 hand-foot syndrome were detected; as a result, chemotherapy was suspended. The XPT regimen may be an effective treatment for HER2-positive unresectable or recurrent gastric cancers. HER2 status should be the key determinant in the strategy for the treatment of unresectable and recurrent gastric cancers in the future.

[A case of gastric cancer with portal vein tumor thrombosis].

We present a case of gastric cancer with portal vein tumor thrombosis. A 77-year-old man visited our hospital because of epigastric pain. Esophagogastroduodenoscopy and computed tomography (CT) revealed advanced gastric cancer. Total gastrectomy was performed. During surgery, peritoneal dissemination was found. Histopathological diagnosis was Stage IV gastric cancer (por2, T4aN3M1) with massive vascular invasion. He was treated with a chemotherapy regimen of S-1 plus docetaxel for approximately 2 years after which the regimen was changed to S-1 monotherapy. Six months later, CT revealed portal vein tumor thrombosis (PVTT) without progression of peritoneal dissemination. The metastatic route of PVTT was believed to be hematogenous because neither liver nor lymph node metastasis was detected. The regimen was shifted to CPT- 11 plus cisplatin therapy since the effects of the treatment was evaluated as progressive. The patient was alive with stable disease after 5 courses of chemotherapy. PVTT should be taken into consideration as a possible type of recurrence when the tumor is associated with massive vascular invasion, although gastric cancer with PVTT is rare.