[Two Cases of Advanced Gastric Cancer Treated with Palliative Radiotherapy].

We report 2 cases of gastric cancer treated with palliative radiotherapy. Case 1: A 74-year-old man presented with gastric cancer. He had severe anemia caused by tumor bleeding and needed frequent blood transfusions. Radiotherapy of 38.25 Gy in 15 fractions was administered to controlbl eeding. We confirmed hemostasis. Case 2: An 81-year-old man presented with peritonealrecurrence 41 months after operation for remnant gastric cancer. Systemic chemotherapy(S-1)was started, but gastrointestinalobstruction worsened. Radiotherapy of 44 Gy in 22 fractions was performed to improve obstruction. Conclusion: Palliative radiotherapy is minimally invasive and is therefore a treatment option for gastric cancer with bleeding and obstruction.

[A Case of Colon Metastasis from Breast Cancer with Resection by Laparoscopic Surgery].

A 50-year-old woman underwent breast-conserving surgery and axillary lymph node dissection for left breast cancer in May 2003. She received chemotherapy and radiation for lymph node, lung, and brain metastases. In October 2015, because of abdominal pain and melena, she underwent colonoscopy for suspected sigmoid colon metastasis from breast cancer. We performed laparoscopic sigmoidectomy and diagnosed sigmoid colon metastasis from breast cancer after histopathological examination. Colon metastasis from breast cancer can occur, although it is very rare.

F-18 fluorodeoxyglucose positron emission tomography for differential diagnosis of pancreatic tumors.

Positron emission tomography with 2-deoxy-2-[(18)F]fluoro-D-glucose (FDG-PET) has been proven useful for differentiating pancreatic ductal cancer from mass-forming chronic pancreatitis. However, there are particular pancreatic tumors having various grades of malignancy such as intraductal papillary mucinous neoplasm (IPMN) or pancreatic neuroendocrine tumor. We examined whether the cut-off value of maximum standardized uptake value (SUVmax) determined by pancreatic ductal cancers is also applicable for other pancreatic tumors. One hundred thirty six patients with pancreatic tumors underwent FDG-PET imaging. We first analyzed the cut-off value to differentiate pancreatic ductal cancers from mass-forming chronic pancreatitis. Secondly, we determined the cut-off value between malignant IPMN and benign IPMN. Thirdly, we computed a cut-off value between malignant pancreatic tumors and benign tumors irrespective of tumor type. The optimal cut-off value to differentiate ductal cancers from mass-forming chronic pancreatitis was 2.5. The optimal cut-off value for differentiating malignant IPMN from benign IPMN was also 2.5, similar to that of reported studies. In all types of pancreatic tumors, the cut-off value was also 2.5. The accuracy for detecting malignancy was 93.4% for all tumors. In the FDG-PET study for pancreatic tumors, an SUVmax of 2.5 would be justified as a cut-off value to differentiate malignant lesions.

A bilateral thoracic approach for esophageal cancer in the prone position.

Esophagectomy in the prone position has recently been introduced as a less-invasive procedure for treating esophageal cancer. We herein present a case of esophageal squamous cell carcinoma (ESCC) treated with a bilateral thoracic approach in the prone position. The patient was a 69-year-old male diagnosed with middle thoracic ESCC. Computed tomography scans and fluorine-18-fluorodeoxyglucose revealed possible metastasis to the lymph nodes on the left dorsal side of the descending thoracic aorta (DTA). After preoperative chemotherapy, we dissected the lymph node metastasis on the left dorsal DTA using the left thoracic approach, following resection of the ESCC by a right thoracic approach in the same prone position. The postoperative course was uneventful, and the patient was discharged 23 days after surgery. A bilateral thoracic approach for esophageal cancer in the prone position may be a new option for surgically treating esophageal cancer.

Comparative outcomes of elderly and non-elderly patients receiving first-line palliative chemotherapy for advanced biliary tract cancer.

BACKGROUND AND AIM: Few studies have reported the efficacy and safety of palliative chemotherapy in elderly patients with advanced biliary tract cancer. We aimed to investigate the clinical outcomes of palliative chemotherapy for advanced biliary tract cancer in elderly patients. METHODS: We retrospectively evaluated 403 consecutive patients who received palliative chemotherapy between April 2006 and March 2009 for pathologically confirmed unresectable or recurrent biliary tract cancer. Clinical outcomes of the elderly group (≥ 75 years old; n = 94) were compared with those of the non-elderly group (< 75 years old; n = 309). RESULTS: Except for the extent of disease, patient baseline characteristics were well balanced between both groups. The median overall survival was 10.4 months in the elderly group and 11.5 months in the non-elderly group (hazard ratio, 1.14; 95% confidence interval, 0.89-1.45; P = 0.31). Although the frequency of adverse events between both groups was similar, interstitial pneumonitis was significantly more frequent in the elderly group than in the non-elderly group (4.3% vs 0%, P < 0.01). CONCLUSIONS: In advanced biliary tract cancer, overall survival of elderly patients receiving palliative chemotherapy is comparable with that of non-elderly patients. To our knowledge, this is one of the largest studies that have reported the clinical outcomes of elderly patients following palliative chemotherapy.

Patients with recurrent biliary tract cancer have a better prognosis than those with unresectable disease: retrospective analysis of a multi-institutional experience with patients of advanced biliary tract cancer who received palliative chemotherapy.

BACKGROUND: Prognostic factors for patients with advanced biliary tract cancer (BTC) who received palliative chemotherapy have not been fully established. Especially, the status of unresectable/recurrent disease has not been well studied because of a small number of patients with recurrent BTC in previous studies. METHODS: This multicenter retrospective study was conducted in 18 institutions in Japan. We retrospectively reviewed data regarding 403 patients with pathologically proven BTC who received palliative chemotherapy between April 2006 and March 2009. One hundred and ninety-two patients with recurrent BTC were included. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: The median overall survival was significantly longer in the recurrent BTC patients than in the unresectable BTC patients (398 days vs. 323 days, P = 0.004). After adjustment using multivariate analysis, the status of recurrent/unresectable disease remained an independent prognostic factor (hazard ratio 1.33, 95% confidence interval 1.04-1.70, P = 0.022) in addition to performance status, extent of disease, carbohydrate antigen 19-9 levels, and carcinoembryonic antigen levels. CONCLUSIONS: The status of unresectable/recurrent disease was shown as an independent prognostic factor in the BTC patients. This result may help to predict life expectancy of BTC patients and design future clinical trials evaluating palliative chemotherapy in BTC.

Barium-induced appendicitis mimicking accidental ingestion of a dental metal crown in radiological findings.

Barium appendicitis is a rare complication that has only been reported in a small number of case reports in the medical literature. A 57-year-old male presented to the emergency room with a sudden onset of sharp right lower quadrant abdominal pain. He had undergone contrast barium examination of his stomach 2 months previously as part of a periodic examination for gastric cancer. The radiological findings showed that the shape and radiopaque levels were similar to those of a dental metal crown silhouette. The patient was strongly suspected to have a localized intra-abdominal abscess due to ileocaecal perforation with a foreign body such as a dental metal crown. Emergency surgery revealed acute phlegmonous appendicitis. The resected specimen demonstrated a phlegmonous appendix which contained solid coproma. Pathological diagnosis and composition analysis confirmed the onset of appendicitis to be a result of the patient's ingestion of barium sulfate.

Transfection of naked nuclear factor-κB decoy oligodeoxynucleotides into liver by rapid portal vein infusion in rats: its effect on ischemia-reperfusion injury of liver.

This study was aimed at examining whether rapid portal vein infusion (RPVI) of a small volume of naked oligodeoxynucleotides (ODNs) could be used to transfect sufficient amounts of nuclear factor-κB (NF-κB) decoy ODN into the liver to suppress NF-κB activation during liver ischemia-reperfusion (I/R) injury, in which NF-κB plays a central role in regulating the production of inflammatory cytokines. One milliliter of naked NF-κB decoy ODN solution was administered into the portal vein for a few seconds. Transfection efficacy was examined by labeling the ODN with a fluorescent tag. Activation of NF-κB was investigated by electrophoretic mobility shift assay. Levels of serum liver enzymes and cytokines were measured during liver I/R injury. NF-κB decoy ODN was preferentially incorporated into Kupffer cells and sinusoidal endothelial cells, but not hepatocytes, in the rat liver. Transfected NF-κB decoy ODN suppressed the function of NF-κB in both Kupffer cells and sinusoidal endothelial cells during liver I/R injury, causing significant decreases in serum tumor necrosis factor-α and interleukin-6 levels 3 hr after reperfusion. Although the decrease in serum liver enzymes was not significant, naked NF-κB decoy ODN was successfully incorporated into Kupffer cells and sinusoidal endothelial cells by rapid portal vein infusion, inhibited NF-κB activation in both cells, and suppressed the production of inflammatory cytokines during the early phase of liver I/R injury.

Pigmentary complication of the peristomal skin in colorectal cancer patients under systemic chemotherapy using S-1: report of cases.

PURPOSE: This study describes hyperpigmentation at the epidermis around a colostomy during and after systemic chemotherapy with S-1 (a compound of tegaful, gimestat, and potassium oxonate). SUBJECTS AND SETTING: Thirty-one colorectal cancer patients (male 17, female 14) visited the stoma-care clinic, akita university hospital between april 2003 and march 2006. fourteen patients (male 8, female 6) had been observed continuously for more than 3 months. METHODS: Results of 5 male patients who received systemic chemotherapy using S-1 were compared to those of 9 male and female patients who did not receive S-1. the shades of epidermal pigmentation at the peristomal area were graded on a 3-point likert scale, where grade 2 indicated very dark pigmentation, grade 1 indicated moderately dark pigmentation, and grade 0 indicated no pigmentation of the peristomal skin. RESULTS: Pigmentation scores in patients receiving S-1 were significantly higher than scores in patients who did not receive S-1 systemic chemotherapy. CONCLUSIONS: Rapid and excessive pigmentation of the peristomal skin may occur in patients receiving S-1 systemic chemotherapy because it indicates an adverse event related with systemic chemotherapy and leads to peristomal skin problems.

Changes in the fatty acid composition of the liver with the administration of N-3 polyunsaturated fatty acids and the effects on warm ischemia/reperfusion injury in the rat liver.

Prostanoids play a pivotal role among the inflammatory mediators associated with I/R injury. The aim of this study was to determine the effects of oral supplementation of n-3 polyunsaturated fatty acids (PUFA)-rich oil on inflammatory reactions and microcirculatory disorders caused by a hepatic warm I/R in rats. The rats were orally supplemented with n-3 PUFA-rich oil, n-6 PUFA-rich oil, or the same volume of water for 7 days. The PUFA concentration in the blood and liver tissues were evaluated, and the effects on I/R injury of the liver were assessed. The n-3 PUFA supplementation elevated the n-3/n-6 ratio in the blood and liver tissues. After reperfusion, thromboxane B(2) in the blood and prostaglandin E(2) in the liver were significantly suppressed in the n-3 PUFA-treated rats. Hepatic microcirculation was well maintained from the early phase (30 min) of reperfusion, and the serum concentrations of TNF-alpha and IL-6 were significantly lower in this group. The transaminase blood levels were also suppressed in the n-3 PUFA-treated rats. Expression of COX-2 mRNA was increased in all groups at 2 h after reperfusion but there were no differences among three groups. In conclusion, preoperative n-3/n-6 ratio augmentation in the blood and in the liver can result in a successful alleviation of hepatic I/R injury.

Clinical and prognostic significance of urinary trypsin inhibitor in patients with hepatocellular carcinoma after hepatectomy.

BACKGROUND: Urinary trypsin inhibitor (UTI), produced in the liver, has been considered to suppress inflammation. The production of UTI may decrease after a hepatectomy and thereby increase the incidence of postoperative inflammation. This study investigated whether the changes in the UTI level affected the postoperative course in patients undergoing a hepatectomy for hepatocellular carcinoma (HCC). The prognostic significance of UTI was also analyzed. METHODS: The perioperative plasma UTI was measured in 25 HCC patients who underwent hepatic resection, and the correlation between the kinetics of UTI and clinicopathological factors was investigated. The expression of UTI in the resected specimens was examined by immunohistochemistry in 65 patients. Expression of UTI in the cancer cells were then correlated to both the liver pathology and the clinical outcomes in the corresponding patients. RESULTS: The plasma UTI level greatly decreased on the first postoperative day. This decrease significantly correlated with the resected tumor volume (r (s) = -.530, P = .006), but it had no influence on inflammatory complications. Immunohistochemistry revealed UTI expression in both noncancerous and cancerous lesions. An overexpression of UTI in HCC tissue was found to be an independent prognostic factor for early recurrence (P = .006). CONCLUSIONS: Although UTI plasma levels were noted to decrease after the removal of an HCC tumor, this decrease did not lead to an increase in inflammatory complications. However, overexpression of UTI in cancer was found to be a risk factor for tumor recurrence after resection, suggesting that UTI expression may be a useful prognostic marker.

[A case of surgical treatment for solitary lymph node recurrence of hepatocellular carcinoma simultaneously developed in the mediastinum and abdominal cavity].

We report a surgically treated case of lymph node recurrence from hepatocellular carcinoma (HCC) that occurred simultaneously but individually in the mediastinum and abdominal cavity with no metastasis. A 52-year-old man had undergone left lateral segmentectomy for poorly differentiated HCC. Three months after surgery, abdominal computed tomography revealed an enlarged solitary lymph node along the common hepatic artery. Another isolated mediastinal lymph node was also positive on whole body 18F-fluorodeoxyglucose positron emission tomography. Because no other metastatic lesions were identified, we resected these two lymph nodes under a diagnosis of lymph node metastases from HCC. Histopathologically, both of them were classified as poorly differentiated HCC with solid growth. No further recurrence has been found during 20-month follow-up period. Our experience suggested that even though metastatic lymph nodes of HCC were present in the mediastinum and abdominal cavity, resection may provide survival benefit if each metastasis is individually solitary.

Implication of protein kinase A for a hepato-protective mechanism of milrinone pretreatment.

BACKGROUND: We have previously reported that an increase of adenosine 3',5'-cyclic monophosphate (cAMP) in liver tissue after an administration of milrinone, a phosphodiesterase-3 inhibitor attenuates hepatic warm ischemia-reperfusion injury. The aim of this study was to determine whether cAMP-dependent protein kinase (protein kinase A) activation was involved in the milrinone-induced hepatoprotective effect on an ischemia-reperfusion injury in an in vivo model. MATERIALS AND METHODS: Male Lewis rats were allocated into 3 groups. In Group M, milrinone was administrated before ischemia; in Group I, a protein kinase A inhibitor, adenosine 3',5'-cyclic monophosphorothioate, 8-bromo-, Rp-isomer, sodium salt (Rp-8-Br-cAMPS), was injected prior to the administration of milrinone; and in Group C, the control group, there was no pretreatment. After pretreatment, all rats were exposed to a 45-min total hepatic inflow occlusion. RESULTS: After milrinone administration, liver cAMP concentrations and protein kinase A activity ratios were elevated. They protected the liver from ischemia-reperfusion injury. Rp-8-Br-cAMPS suppressed protein kinase A activation without affecting cAMP elevating responses to milrinone. Compared with Group C, hepatocellular necrosis, neutrophil infiltration, and congestion were ameliorated, and serum tumor necrosis factor-alpha, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase levels were significantly suppressed in Group M. Rp-8-Br-cAMPS canceled this effect, showing histological damages in Group I as severe as in Group C. The levels of tumor necrosis factor-alpha, aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase were the same in Groups C and I. CONCLUSIONS: Activation of protein kinase A might play an important role in the mechanism of milrinone-induced ischemic tolerance in the liver.

Analysis of gene and protein expression of cytochrome P450 and stress-associated molecules in rat liver after spaceflight.

As the incidence and length of spaceflight increases, the need to administer pharmacological agents to crew members may become greater. The final goal is to predict the therapeutic or toxic effects of drugs, especially those with a low therapeutic index, during spaceflight. The liver is central to systemic metabolism, therefore, various drugs rely on hepatic metabolism by cytochrome P450 (CYP). The function of individual CYP enzymes is diverse because they are subject to different regulatory mechanisms and substrate specificity. Because spaceflight may be a stressor and influence each CYP expression individually, the purpose of the present study was to measure the expression of 11 CYP genes and protein distribution in the liver of rats after spaceflight, using real-time polymerase chain reaction and immunohistochemistry, respectively. The gene and protein expression of stress-related proteins such as cold-inducible RNA binding protein (Cirp), heat shock protein 70 (HSP70), HSP90 and the p53 tumor suppressor gene, were also determined. CYP4A1and Cirp gene expression was significantly increased whereas HSP90 and p53 gene expression was significantly decreased in the flight group than in the ground control. Combined with histology, it is concluded that the effects of spaceflight on the liver may be similar to mild cold stress or fasting.

The use of magnetic anchors in the bowel lumen for laparoscopic anterior resection of rectosigmoid colon in pigs: with video.

BACKGROUND: This article describes a new technique for retracting the rectum upward during laparoscopic surgery using the pulling force created between two magnets. METHODS: A magnet and a colonoscope were inserted into the rectal cavity of a swine model, and a second magnet was placed on the abdominal wall creating a magnetic anchor or retraction that pulled the rectum upward. Subsequently, a laparoscopic anterior resection of the rectosigmoid colon was performed. The magnetic anchor transferred an electromagnetic force through the abdominal wall, creating effective organ retraction without the need of a trocar. RESULTS: Surgery without the use of trocars allows for increased flexibility in the angle, distance, and location of the retraction. Since retraction was achieved without a shaft device that can impede visibility within the abdominal cavity, the surgeons achieved excellent endoscopic views. Because the intraluminal magnetic anchor was placed directly on the inside wall of the target organ, tracking target organ movement closely with the movement of the extracorporeal control magnet was possible and synchronizing their movements was not difficult. CONCLUSION: The technique presented in this article might be less invasive and could provide more effective manageability for laparoscopic surgery.

A newly designed magnet-retracting forceps for laparoscopic cholecystectomy in a swine model.

We designed a method for remote-controlled endoscopic surgery using magnet-retracting forceps. To evaluate the feasibility of this technique, laparoscopic cholecystectomy was attempted in a swine model. This method takes advantage of the attractive force between two magnets, one inserted into the peritoneal cavity and the other located outside the abdominal wall. An intra-peritoneal magnet was fixed to the fundus of the gallbladder using an endovascular clip. Laparoscopic cholecystectomy was accomplished by magnetic retraction of the gallbladder. This magnet-retracting forceps provided port-less access to the abdominal cavity. Since the direction and range of retraction were unrestricted by the location of access-ports fixed on the abdominal wall, surgery could be less invasive. In addition, this procedure provided surgeons with excellent endoscopic views, as retraction force was supplied without any shaft device in the abdomen. This operation system using magnetic retraction appears promising.

Epstein-Barr virus-positive inflammatory pseudotumor of the spleen managed with laparoscopic splenectomy.

We report a case of Epstein-Barr virus (EBV)-positive splenic inflammatory pseudotumor treated by laparoscopic splenectomy. A 66-year-old female without symptoms was found to have a solitary, avascular, solid tumor of the spleen by contrast-enhanced computed tomography. The tumor was compatible with a primary tumor of the spleen. A benign splenic tumor was the most likely diagnosis, but malignant lymphoma could not be ruled out because the serum-soluble interleukin-2 receptor (sIL-2R) level was elevated. Laparoscopic splenectomy was performed to enable a definite diagnosis. Removal of the whole spleen without injury was possible. Possible contamination of the extirpation orifice by cancer cells was carefully prevented by enclosing the spleen in a plastic bag. Histopathological examination showed the tumor to be an EBV-positive inflammatory pseudotumor. To the best of our knowledge, this is only the second report of an EBV-positive splenic inflammatory pseudotumor with an increased serum sIL-2R level. Although EBV-positive inflammatory pseudotumors have been reported to recur, no sign of recurrence has been detected in the present case in the 17 months following splenectomy.

A case report of hepatorenal syndrome treated with plasma diafiltration (selective plasma filtration with dialysis).

Plasma diafiltration (PDF) (selective plasma filtration with dialysis) is blood purification therapy in which simple plasma exchange is performed using a membrane plasma separator (Evacure EC-2A) while dialysate flows outside of the hollow-fibers. A 74-year old man with hepatorenal syndrome underwent four sessions of PDF and three sessions of HDF. Finally he recovered from hepatorenal syndrome. In this therapy, the levels of total bilirubin, interleukin-18, creatinine, and cystatin C were significantly reduced. On the other hand, there were no significant differences in the total protein and albumin levels before and after PDF. PDF may be one of the most useful blood purification therapies for hepatorenal syndrome in terms of medical economics.