[Laparoscopic Abdominoperineal Resection of the Rectum in a Case with Pagetoid Spread of Anal Canal Carcinoma].

The patient, a man in his 60s, first noticed an elevated lesion around the anus 3 years ago. The lesion failed to subside with the topical drug preparations prescribed at a local clinic, and the patient was referred to the Department of Dermatology of our hospital for further workup and treatment. The findings of biopsy from the lesion suggested skin infiltration of anal canal carcinoma, and the patient was referred to the Department of Surgery. Examination here revealed only induration of the anal canal, with no abnormality of the rectal mucosa even when the endoscope was reversed to visualize the rectum. Examination by various imaging modalities failed to reveal any metastases to the lymph nodes or distant organs, and the primary lesion remained unidentified. Laparoscopic abdominoperineal excision of the rectum was performed, beginning with anal manipulation. First, a 15-mm margin was set on the skin from the tumor edge, and the skin stump was divided into 4 equal portions. After confirming by rapid intraoperative frozen-section examination that the margin was negative along the full circumference, anal manipulation was performed, leaving a distance in the vertical direction immediately below the tumor. Upon completion of the anal manipulation, intraperitoneal manipulation was performed in a routine manner. The anal skin was relaxed subcutaneously, as done during mastectomy, and the subsequent suture closure could be done smoothly. The tumor was classified as pT1bN0M0, pStage Ⅰ. The experience with this case indicates that biopsy should be proactively employed for the diagnosis in such cases, and that proactive skin biopsy is useful when dealing with intractable anal skin lesions.

[A Case of Recurrent Gastric GIST Who Survived for Long after Laparoscopic Resection and Imatinib Therapy].

A man patient in his 70s underwent left nephrectomy and laparoscopic partial gastrectomy for the treatment of a left renal cell carcinoma and gastrointestinal stromal tumor(GIST)arising from the stomach. Histopathologically, both the renal cell carcinoma and GIST were kit-positive, CD34-positive, and S-100 protein-negative, and the Ki-67 index was about 40% as determined by the hot spot method, so that it was diagnosed as an intermediate-group GIST. After surgery, the patient was followed without adjuvant therapy, as he did not wish to receive postoperative chemotherapy. A computed tomography(CT)conducted 3 years after the surgery revealed tumorous shadows in the abdominal wall, inferior periesophageal region, and dorsal aspect of the pancreas. Positron emission tomography(PET)-CT showed fluorodeoxyglucose(FDG) accumulation in these lesions. Therefore, based on a suspicion of recurrent renal cell carcinoma or GIST, we carried out abdominal wall tumor resection for both exploratory and diagnostic purposes, which yielded histopathological diagnosis of GIST, with features similar to those observed at the time of the initial operation. Because the number of tumors remained unchanged during the subsequent follow-up period, the tumorous lesions in the periesophageal region and on the dorsal aspect of the pancreas were resected laparoscopically. Each of the resected tumors showed histological features consistent with GIST. The patient was started on oral imatinib therapy after this operation. To date(5 years after the surgery for the recurrent tumors and 8 years after the initial operation), the patient has remained free of recurrence. The pattern of tumor recurrence noted in the present case(ie, metastasis/dissemination to the skeletal muscles)is relatively rare, and few reports have been published concerning long-term survivors through multidisciplinary treatment (surgical treatment and others). We report this case with a review of the literature.

[A Case of Unresectable Advanced Gastric Cancer Successfully Treated with Conversion Surgery].

A man in his 70s consulted a local clinic with a chief complaint of difficulty eating. Upper gastrointestinal endoscopy revealed a type 4 tumor spreading irregularly from immediately below the esophageal cardia to the lower gastric body. The patient was referred to our hospital with a diagnosis of advanced gastric cancer(human epidermal growth factor receptor 2 [HER2]-positive moderately-differentiated adenocarcinoma)accompanied by lymph node enlargement. We planned an open total gastrectomy after staging laparoscopy to rule out dissemination because peritoneal dissemination could not be ruled out using computed tomography(CT). To perform a total gastrectomy, a celiotomy was done after staging laparoscopy results suggested that dissemination was unlikely. However, the border between the pericardial lymph nodes and the pancreas or peritoneal artery was not visible, forcing us to terminate the staging laparotomy based on a judgment of unresectable locally advanced gastric cancer. Therefore, the patient was administered 6 cycles of combined S-1/CDDP plus trastuzumab as the primary therapy. The response to therapy was favorable, and we scheduled a surgical resection. However, the scheduled surgery was rescheduled because of COVID-19 pneumonia, and R0 resection was finally performed after the 7th cycle of S-1/CDDP plus trastuzumab therapy. Histopathologically, the regional lymph node metastasis had disappeared, the viable tumor remained within the mucosal layer, and scarring was evident from the submucosal layer to the serosa. In recent years, conversion surgery for unresectable gastric cancer has been sporadically reported. However, we are unable to definitively opine on whether this kind of surgery may contribute to improving the prognosis, resection remains indispensable for radical treatment. We report this case along with a review of the literature.

[A Case of Triple Negative Breast Cancer with Successful Control of Recurrent Disease Activity for More than Ten Years].

A woman in her 70s underwent mastectomy plus axillary lymph node excision(Bt plus Ax)in December 2011 for left breast cancer classified as pT2N1M0, pStage ⅡB. The tumor was identified as an invasive ductal carcinoma(IDC), neural/ glial antigen 2(NG2), pT2(35 mm), INF γ, ly2, v0, g+, f+, s+, extensive intraductal component(EIC)-negative, ICT- positive, NCAT-positive, n(4/18), estrogen receptor(ER)-negative, progesterone receptor(PgR)-negative, human epidermal growth factor receptor 2(HER2)-negative, Ki-67 30-40%. Postoperative adjuvant fluorouracil plus epirubicin HCl plus cyclophosphamide(FEC)plus paclitaxel(PTX)therapy was administered. The patient refused to undergo postoperative radiation therapy. Two years after the surgery, she was diagnosed as having a lung metastasis and local disease recurrence. Biopsy of the local recurrent lesion revealed the same histopathological diagnosis as before. Capecitabine was selected for treatment of the recurrent lesion. After 2 years of capecitabine treatment, the response was rated as progressive disease (PD). At this time, eribulin mesylate was selected, along with intensity-modulated radiation therapy(IMRT). This resulted in disappearance of the tumor on imaging. However, considering that the histological findings did not suggest complete response(CR)and that the tumor was triple-negative(TN), we adopted a strategy of continuing the drug therapy at reduced dose level. With this strategy, the disease activity could be successfully controlled for 6.5 years. Subsequently, liver metastasis was detected, and the drug was switched to vinorelbine ditartrate(a drug with less non-hematological toxicity). Meanwhile, a breast cancer susceptibility gene(BRCA)analysis was performed in January 2021, which was negative. Subsequently, in September 2021, we obtained a positive result for PDL1-SP142 and negative result for 22C3. About half a year later, ie, in October 2021(11 years after the surgery), we detected an increase in the size of the liver metastasis and selected atezolizumab and nab-PTX for treatment. Applicable regimens of drug therapy are still available at present and drug therapy has been continued based on a discussion and mutual understanding of the adverse reactions, etc. with the patient. Few reports have been published concerning long-term survivors among TN breast cancer cases.

Usefulness of laparoscopic surgery and preoperative examinations for chronic recurrent small bowel obstruction.

PURPOSE: The aim of this study was to investigate the usefulness of laparoscopic surgery for patients with postoperative abdominal symptoms, including chronic recurrent small-bowel obstruction (SBO), and preoperative examinations of barium follow-through and computed tomography (CT) to predict the postoperative outcomes of laparoscopic surgery. METHODS: Between 2016 and 2018, 49 patients with postoperative symptoms were treated by laparoscopic surgery at our institute. The data from two preoperative examinations were available for 42 patients. The patients were divided into 4 groups: CT-positive (CP, n = 18), barium follow-through-positive (BP, n = 1), both positive (AP [all positive] n = 13), and both negative (AN [all negative], n = 10). RESULTS: Among the 49 patients, 41 received pure laparoscopic surgery, 7 received laparoscopic-assisted surgery with mini-laparotomy, and 1 required conversion. Intra- and postoperative complications occurred in two and seven patients, respectively. Improvement of abdominal symptoms was observed in 40 patients. In terms of the medium-term outcomes, the rate of improvement of symptoms was poorer in the AN group than in the other three groups, but not to a significant degree. CONCLUSION: Laparoscopic surgery was safe and feasible for patients with chronic recurrent abdominal symptoms, including SBO. Furthermore, in patients with negative results on both preoperative examinations, laparoscopic surgery may yield only poor improvement of symptoms.

Short-term and midterm outcomes of single-incision laparoscopic surgery for right-sided colon cancer.

INTRODUCTION: The purpose of this study was to clarify the usefulness of SILS for right-sided colon cancer by evaluating the short-term and midterm outcomes. METHODS: Between 2012 and 2017, 65 selected patients with right-sided colon cancer underwent ileocecal resection, right hemicolectomy, or transverse colectomy; all were enrolled in the study. The same well-trained surgeon performed each procedure by using a multi-instrument access port with three channels, which was placed at the umbilicus via an approximately 3-cm skin incision. RESULTS: The pathological disease stage distribution was stage 0, 4 cases; stage I, 23 cases; stage II, 19 cases; stage III, 17 cases; and stage IV, 2 cases. The surgical procedures performed were ileocecal resection, 23 cases; right hemicolectomy, 35 cases; and transverse colectomy, 7 cases. The median operative time and intraoperative blood loss were 216 min and 10 mL, respectively. Although 18 cases needed additional ports, none required conversion to open surgery. The median number of harvested lymph nodes was 24. No major perioperative morbidities occurred in this patient series. The median postoperative hospital stay was 7 days. The median follow-up period was 30 months, and the 3-year relapse-free and overall survival rates were 100% and 100%, respectively, in the stage 0-I cases and 89% and 96% in the stage II-III cases, respectively. CONCLUSION: We concluded that SILS is as feasible as multiport laparoscopic surgery and a reliable surgical option in selected cases of right-sided colon cancer.

Vitamin D Supplementation and Survival of Patients with Non-small Cell Lung Cancer: A Randomized, Double-Blind, Placebo-Controlled Trial.

Purpose: Higher serum 25-hydroxyvitamin D (25(OH)D) levels are reportedly associated with better survival in early-stage non-small cell lung cancer (NSCLC). Therefore, whether vitamin D supplementation can improve the prognosis of patients with NSCLC was examined (UMIN000001869).Patients and Methods: A randomized, double-blind trial comparing vitamin D supplements (1,200 IU/day) with placebo for 1 year after operation was conducted. The primary and secondary outcomes were relapse-free survival (RFS) and overall survival (OS), respectively. Prespecified subgroup analyses were performed with stratification by stage (early vs. advanced), pathology (adenocarcinoma vs. others), and 25(OH)D levels (low, <20 ng/mL vs. high, ≥20 ng/mL). Polymorphisms of vitamin D receptor (VDR) and vitamin D-binding protein (DBP) and survival were also examined.Results: Patients with NSCLC (n = 155) were randomly assigned to receive vitamin D (n = 77) or placebo (n = 78) and followed for a median of 3.3 years. Relapse and death occurred in 40 (28%) and 24 (17%) patients, respectively. In the total study population, no significant difference in either RFS or OS was seen with vitamin D compared with the placebo group. However, by restricting the analysis to the subgroup with early-stage adenocarcinoma with low 25(OH)D, the vitamin D group showed significantly better 5-year RFS (86% vs. 50%, P = 0.04) and OS (91% vs. 48%, P = 0.02) than the placebo group. Among the examined polymorphisms, DBP1 (rs7041) TT and CDX2 (rs11568820) AA/AG genotypes were markers of better prognosis, even with multivariate adjustment.Conclusions: In patients with NSCLC, vitamin D supplementation may improve survival of patients with early-stage lung adenocarcinoma with lower 25(OH)D levels. Clin Cancer Res; 24(17); 4089-97. ©2018 AACR.

[A Case of Glycogen-Rich Clear Cell Carcinoma of the Breast with Extensive Intraductal Components and Micrometastases to the Axillary Lymph Node].

A 48-year-old woman had a left breast mass identified during routine breast cancer screening. The mammogram showed pleomorphic-segmental microcalcifications in the mediolateral-oblique view of the left breast. Ultrasonography showed a hypoechoic mass approximately 3.7 cm in diameter with multiple calcifications. Contrast-enhanced magnetic resonance imaging of the breast showed non-mass like enhancement of approximately 4 cm in diameter in the C area of the left breast. She was diagnosed with glycogen-rich clear cell carcinoma (GRCC) by ultrasound-guided vacuum-assisted biopsy. Nipplesparing mastectomy was performed along with sentinel lymph node biopsy. The intraoperative consultation suggested sentinel lymph node metastasis and we therefore performed axillary lymph node dissection. Pathological examination reported microinvasive carcinomas, 0.4 cm in maximum diameter, and extensive intraductal components, 5 cm in size. The tumor cells were stained on PAS staining, but the stains were digested with diastase. The cells were negative for adipophilin. GRCC was first reported by Hull et al. This is a rare type of breast carcinoma. There is no standard therapy for this disease or any data on the prognosis of breast cancer patients with GRCC.

Autophagy induction by SIRT6 through attenuation of insulin-like growth factor signaling is involved in the regulation of human bronchial epithelial cell senescence.

Cigarette smoke (CS)-induced cellular senescence has been implicated in the pathogenesis of chronic obstructive pulmonary disease, and SIRT6, a histone deacetylase, antagonizes this senescence, presumably through the attenuation of insulin-like growth factor (IGF)-Akt signaling. Autophagy controls cellular senescence by eliminating damaged cellular components and is negatively regulated by IGF-Akt signaling through the mammalian target of rapamycin (mTOR). SIRT1, a representative sirtuin family, has been demonstrated to activate autophagy, but a role for SIRT6 in autophagy activation has not been shown. Therefore, we sought to investigate the regulatory role for SIRT6 in autophagy activation during CS-induced cellular senescence. SIRT6 expression levels were modulated by cDNA and small interfering RNA transfection in human bronchial epithelial cells (HBECs). Senescence-associated ß-galactosidase staining and Western blotting of p21 were performed to evaluate senescence. We demonstrated that SIRT6 expression levels were decreased in lung homogenates from chronic obstructive pulmonary disease patients, and SIRT6 expression levels correlated significantly with the percentage of forced expiratory volume in 1 s/forced vital capacity. CS extract (CSE) suppressed SIRT6 expression in HBECs. CSE-induced HBEC senescence was inhibited by SIRT6 overexpression, whereas SIRT6 knockdown and mutant SIRT6 (H133Y) without histone deacetylase activity enhanced HBEC senescence. SIRT6 overexpression induced autophagy via attenuation of IGF-Akt-mTOR signaling. Conversely, SIRT6 knockdown and overexpression of a mutant SIRT6 (H133Y) inhibited autophagy. Autophagy inhibition by knockdown of ATG5 and LC3B attenuated the antisenescent effect of SIRT6 overexpression. These results suggest that SIRT6 is involved in CSE-induced HBEC senescence via autophagy regulation, which can be attributed to attenuation of IGF-Akt-mTOR signaling.

Mitochondrial fragmentation in cigarette smoke-induced bronchial epithelial cell senescence.

Mitochondria are dynamic organelles that continuously change their shape through fission and fusion. Disruption of mitochondrial dynamics is involved in disease pathology through excessive reactive oxygen species (ROS) production. Accelerated cellular senescence resulting from cigarette smoke exposure with excessive ROS production has been implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). Hence, we investigated the involvement of mitochondrial dynamics and ROS production in terms of cigarette smoke extract (CSE)-induced cellular senescence in human bronchial epithelial cells (HBEC). Mitochondrial morphology was examined by electron microscopy and fluorescence microscopy. Senescence-associated ß-galactosidase staining and p21 Western blotting of primary HBEC were performed to evaluate cellular senescence. Mitochondrial-specific superoxide production was measured by MitoSOX staining. Mitochondrial fragmentation was induced by knockdown of mitochondrial fusion proteins (OPA1 or Mitofusins) by small-interfering RNA transfection. N-acetylcysteine and Mito-TEMPO were used as antioxidants. Mitochondria in bronchial epithelial cells were prone to be more fragmented in COPD lung tissues. CSE induced mitochondrial fragmentation and mitochondrial ROS production, which were responsible for acceleration of cellular senescence in HBEC. Mitochondrial fragmentation induced by knockdown of fusion proteins also increased mitochondrial ROS production and percentages of senescent cells. HBEC senescence and mitochondria fragmentation in response to CSE treatment were inhibited in the presence of antioxidants. CSE-induced mitochondrial fragmentation is involved in cellular senescence through the mechanism of mitochondrial ROS production. Hence, disruption of mitochondrial dynamics may be a part of the pathogenic sequence of COPD development.

Anomalous systemic arterial supply to the Basal segments of the lung: feasible thoracoscopic surgery.

BACKGROUND: Anomalous systemic arterial supply to the basal segments of the lung is a rare anomaly. This study aimed to evaluate the outcomes of thoracoscopic surgery for this anomaly. METHODS: We reviewed patients who underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung between October 2007 and September 2012 at our institution. RESULTS: Four patients (mean age 37.5 years; range, 22 to 54) underwent thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung. The mean diameter of the anomalous arteries was 14 mm (range, 10 to 16 mm). Two patients underwent thoracoscopic segmentectomy, 1 of whom had a complicated anomaly that necessitated conversion to thoracotomy. The other 2 patients underwent thoracoscopic lower lobectomy of the left lung. One of them had an aneurysm in the anomalous artery; therefore, endovascular devices were kept on standby in case massive hemorrhage occurred. The anomalous arteries were divided uneventfully using a vascular stapler in all patients. No patient had severe postoperative complications. CONCLUSIONS: Thoracoscopic surgery for anomalous systemic arterial supply to the basal segments of the lung is feasible, safe, and minimally invasive, with confirmed effectiveness in typical cases.

Oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas.

OBJECTIVES: Thoracoscopic thymectomy has gradually replaced conventional sternotomy for resection of thymoma; however, a thoracoscopic approach for thymoma remains controversial. We evaluated the oncological outcomes of thoracoscopic thymectomy for the treatment of stages I-III thymomas. METHODS: Sixty-two patients who underwent thoracoscopic thymectomy for the treatment of thymoma were retrospectively reviewed between July 2005 and September 2011 at Jikei University Hospital. Surgical outcomes and pathological results between stages I+II and stage III were compared. RESULTS: Twenty-nine patients had Masaoka stage I, 28 had stage II and 5 had stage III. Three stage III patients needed conversions to open surgery. Masaoka stage III comprised pathological type B3 in 3 patients and thymic carcinoma in 2. For all patients, the 5-year overall survival rate was 100%. Three recurrences, diagnosed as thymic carcinoma, were observed in the Masaoka stage II or III patients. The 5-year disease-free survival rate was 94.2% for all patients, 100% for Masaoka stage I, 96.1% for stage II and 37.5% (55 months) for stage III (P=0.002). The 5-year disease-free survival rate was 100% for the World Health Organization classification types A, AB and B1-3 and 0% for thymic carcinoma (P<0.0001). Significant differences were found in the 5-year disease-free survival stratified by the Masaoka stage or WHO classification, but not by surgical procedures. CONCLUSIONS: Thoracoscopic thymectomy for Masaoka stages I and II thymomas presented acceptable oncological outcomes. Further investigation in a large series with longer follow-up is required. Masaoka stage III thymoma requires careful consideration of the approaches, including median sternotomy.

Apoptosis inhibitor of macrophage (AIM) expression in alveolar macrophages in COPD.

BACKGROUND: Marked accumulation of alveolar macrophages (AM) conferred by apoptosis resistance has been implicated in pathogenesis of chronic obstructive pulmonary disease (COPD). Apoptosis inhibitor of macrophage (AIM), has been shown to be produced by mature tissue macrophages and AIM demonstrates anti-apoptotic property against multiple apoptosis-inducing stimuli. Accordingly, we attempt to determine if AIM is expressed in AM and whether AIM is involved in the regulation of apoptosis in the setting of cigarette smoke extract (CSE) exposure. METHODS: Immunohistochemical evaluations of AIM were performed. Immunostaining was assessed by counting total and positively staining AM numbers in each case (n = 5 in control, n = 5 in non-COPD smoker, n = 5 in COPD). AM were isolated from bronchoalveolar lavage fluid (BALF). The changes of AIM expression levels in response to CSE exposure in AM were evaluated. Knock-down of anti-apoptotic Bcl-xL was mediated by siRNA transfection. U937 monocyte-macrophage cell line was used to explore the anti-apoptotic properties of AIM. RESULTS: The numbers of AM and AIM-positive AM were significantly increased in COPD lungs. AIM expression was demonstrated at both mRNA and protein levels in isolated AM, which was enhanced in response to CSE exposure. AIM significantly increased Bcl-xL expression levels in AM and Bcl-xL was involved in a part of anti-apoptotic mechanisms of AIM in U937 cells in the setting of CSE exposure. CONCLUSIONS: These results suggest that AIM expression in association with cigarette smoking may be involved in accumulation of AM in COPD.

Insufficient autophagy in idiopathic pulmonary fibrosis.

Autophagy, a process that helps maintain homeostatic balance between the synthesis, degradation, and recycling of organelles and proteins to meet metabolic demands, plays an important regulatory role in cellular senescence and differentiation. Here we examine the regulatory role of autophagy in idiopathic pulmonary fibrosis (IPF) pathogenesis. We test the hypothesis that epithelial cell senescence and myofibroblast differentiation are consequences of insufficient autophagy. Using biochemical evaluation of in vitro models, we find that autophagy inhibition is sufficient to induce acceleration of epithelial cell senescence and myofibroblast differentiation in lung fibroblasts. Immunohistochemical evaluation of human IPF biospecimens reveals that epithelial cells show increased cellular senescence, and both overlaying epithelial cells and fibroblasts in fibroblastic foci (FF) express both ubiquitinated proteins and p62. These findings suggest that insufficient autophagy is an underlying mechanism of both accelerated cellular senescence and myofibroblast differentiation in a cell-type-specific manner and is a promising clue for understanding the pathogenesis of IPF.

Thoracoscopic surgery for refractory cases of secondary spontaneous pneumothorax.

INTRODUCTION: Secondary spontaneous pneumothorax (SSP) can be life threatening because patients often have severe lung disease with other coexisting diseases such as heart disease. In this study, we evaluate the feasibility of thoracoscopic surgery to treat SSP and discuss thoracoscopic techniques for managing complicated cases. METHODS: We retrospectively evaluated the outcome of thoracoscopic surgeries in 21 SSP patients. RESULTS: Fifteen patients had chronic emphysema, four had interstitial pneumonia, and two had inflammatory lung disease. All patients presented with persistent air leaks, and their median preoperative hospital stay was 11 days. All patients underwent thoracoscopic surgery. In 12 patients, the leaking bullae were excised by endoscopic stapling. Fibrin glue was used in 16 cases and polyglycolic acid sheets in 17. Polyglycolic acid sheets and fibrin glue without bullectomy were used in three cases. Air leaks were treated by simple stapling in four cases and by gelatin-resorcin formaldehyde glue in five. Median postoperative hospital stay was 8 days. No patients required conversion to open surgery. Postoperative complications such as persistent air leaks, pneumonia, and acute respiratory failure were observed in six patients. Four recurrences of pneumothorax were observed during the median postoperative follow-up period of 19.3 months. CONCLUSION: Our results suggest that thoracoscopic surgery is feasible and less invasive than open surgery for high-risk patients, and it improves patient quality of life. Various techniques to stop air leaks enabled us to treat patients with refractory SSP.

Thoracoscopic resection for a pulmonary nodule with the infiltrate of IgG4-positive plasma cells.

This report describes a rare case of IgG4-related lung disease that was difficult to distinguish from lung cancer. CT revealed a well-demarcated round tumor in S10 of the right lung of a 56-year-old man suspected of having lung cancer. PET revealed high fluorodeoxyglucose uptake with a maximum standardized uptake value of 14.0. Because primary lung cancer was strongly suspected, lower lobectomy was performed via the thoracoscopic approach without mini-thoracotomy. Histopathology showed lymphoplasmacytic infiltration. Immunostaining revealed numerous IgG4-positive plasma cells diffusely infiltrating the tumor. Serum IgG4 levels increased, thereby confirming the diagnosis of IgG4-related lung disease.

Chest wall reconstruction using Gore-Tex® dual mesh.

PURPOSE: This study aimed to evaluate the clinical outcomes of chest wall reconstruction using a relatively new expanded polytetrafluoroethylene prosthesis Gore-Tex(®) dual mesh. METHODS: We reviewed charts of 11 patients who underwent bony chest wall resection from April 2006 to January 2011. RESULTS: Six patients underwent three ribs resection, three patients underwent two ribs resection, and the other two patients underwent sternal resection. Of six patients after three ribs resection, three underwent reconstruction using 2 mm Gore-Tex(®) dual mesh, one using Gore-Tex(®), one using Bard composite E/X, and the remaining one used no prosthesis. Three patients who underwent two ribs resection underwent no chest wall reconstruction using prosthesis. Two patients who underwent sternal resection underwent chest wall reconstruction using dual mesh with or without a vascularized musculocutaneous pedicle flap. Immediate postoperative extubation was performed in all patients, except one who was extubated the following day. No postoperative deaths or cases with paradoxical respiration occurred. CONCLUSION: Chest wall reconstruction using Gore-Tex(®) dual mesh demonstrated acceptable durability.

Thoracoscopic resection of a mediastinal venous hemangioma: Report of a case.

Mediastinal hemangioma is a rare tumor, accounting for 0.5% or fewer of all mediastinal tumors in most reports. We herein report a case of thoracoscopic resection of venous hemangioma in the middle mediastinum. A 48-year-old man was referred to our hospital for dysphagia. A chest computed tomography scan showed the mass to have a smooth surface and heterogeneous contents. Magnetic resonance imaging demonstrated the morphology of the vascular tumor to be a hyperintense mass on a T2-weighted image. Using thoracoscopic surgery, the tumor was completely extirpated and confirmed histologically to be a venous hemangioma. In this case, thoracoscopic surgery provided a satisfactory view and facilitated correct handling for the mediastinal venous hemangioma.

[A case of advanced gastric cancer with long-term survival treated by S-1/paclitaxel as neo-adjuvant chemotherapy].

A 61-year-old male presented with advanced gastric cancer with lymph node swelling around the root of superior mesenteric artery lymph nodes and invasion of pancreas. We thought a complete resection would be difficult, so he was given neo-adjuvant chemotherapy in combination with S-11 20 mg/body/day (3 weeks administration and 1 week rest) and paclitaxel (PTX) 80 mg/m(2) (day 1, 8, 15). After 2 courses of this neo-adjuvant chemotherapy, the tumor and lymph node swelling decreased in size. Total gastrectomy, Roux-en Y and D1+beta type nodal dissection were performed. Intraoperative findings included tumor exposure on the serous membrane and enlarged lymph nodes on the lesser curvature; however, no marked pancreatic invasion was observed and the lymph nodes had become scarred. The changes with neo-adjuvant chemotherapy were judged to be grade 2. After the operation, there was no side effect, though he received the same chemotherapy as an outpatient in three courses. Five years passed from the first medical examination. The patient remains alive, and the neo-adjuvant chemotherapy proved effective.

[A case of long-term, high-dose transdermal fentanyl application for lung cancer pain].

Transdermal fentanyl patch represents a new administration route for cancer pain relief. We reported here a successful experience with a high-dose of transdermal fentanyl for cancer pain therapy. A 71-year-old woman suffering from metastatic lung cancer to bone had already been treated with radiation at a different hospital. She suffered from severe lumbar pain upon admission to our hospital. During the past 15 months, she has been treated with 30 mg or more of transdermal fentanyl for cancer pain relief. No severe side effects were observed, and she experienced a better quality of life at home using this patch long-term.