Progressive atrophy in a deformed liver as a contributor to sigmoid volvulus.

The effect of a prior defect on secondary liver atrophy is unknown. We describe a case of sigmoid volvulus that was facilitated by progressive atrophy in a deformed liver. A 75-year-old man with abdominal pain and fullness was referred to our hospital. Computed tomography (CT) revealed reduced left hepatic lobe volume and a whirl sign, characteristic of sigmoid volvulus. The sigmoid volvulus was successfully detorted with endoscopy. Retrospective evaluation of liver morphology on CT and magnetic resonance imaging showed that the portal vein at the liver hilum was denuded due to a parenchymal defect of the medial segment, with compression by the crossing artery. As pulse Doppler ultrasonography demonstrated reduced portal blood flow in the region where liver atrophy developed, compression of the denuded portal vein presumably facilitated secondary atrophy and contributed to sigmoid volvulus. The present case shows that a deformed liver itself can be a cause of secondary atrophy. Therefore, continued monitoring of liver morphology and evaluation of portal blood flow to predict liver atrophy may be required, when an individual with a partial liver defect is encountered.

A randomized multicenter Phase II study of perioperative tiotropium intervention in gastric cancer patients with chronic obstructive pulmonary disease.

BACKGROUND: Tiotropium, a long-acting inhaled anticholinergic drug, has been widely used in the treatment of chronic obstructive pulmonary disease (COPD). However, the issue of whether perioperative tiotropium improves postoperative outcomes for gastric cancer patients with COPD remains unclear. Thus, the aim of this study was to determine the efficacy of perioperative tiotropium intervention for gastric cancer patients with COPD. PATIENTS AND METHODS: Eighty-four gastric cancer patients with mild-to-moderate COPD were randomly assigned to receive perioperative pulmonary rehabilitation alone (control group) or pulmonary rehabilitation with 18 µg of tiotropium once daily (tiotropium group). The patients in the tiotropium group received tiotropium for more than 1 week before surgery and for 2 weeks after surgery. Spirometry was performed prior to group assignment and at 2 weeks after surgery. Postoperative complications, forced expiratory volume in 1 second, forced vital capacity, and the ratio of forced expiratory volume in second to forced vital capacity (%) were compared between the two groups. RESULTS: There were no significant differences between the two groups in terms of age, body mass index, smoking, gastrectomy incision, operation time, and bleeding volume (all P>0.05). Postoperative complications and pulmonary functions did not differ significantly between the control and tiotropium groups. A subgroup analysis of gastric cancer patients with moderate COPD showed that perioperative tiotropium intervention significantly decreased the rate of postoperative complications compared with the control group (P=0.046). However, even after gastrectomy, many patients with mild COPD in both the control and tiotropium groups showed improved pulmonary function. CONCLUSION: Although perioperative tiotropium intervention had no significant effects in gastric cancer patients with mild COPD, it may be beneficial in those with moderate COPD. Therefore, the next prospective study should further evaluate perioperative tiotropium intervention for gastric cancer patients with moderate-to-severe COPD.

Life-Threatening Gastrointestinal Mucosal Necrosis during Methotrexate Treatment for Rheumatoid Arthritis.

Methotrexate (MTX), a folic acid antagonist, is widely used in the treatment of neoplasms, psoriasis and rheumatoid arthritis. Despite its efficacy, MTX sometimes finds limited application because of its adverse effects, including renal or liver impairment, bone marrow toxicity and gastrointestinal mucosal injury. Intestinal mucositis, bleeding and peptic ulcers are well-known gastrointestinal adverse effects of MTX, although cases of fatal mucosal necrosis induced by MTX are extremely rare. Here, we report the case of an 82-year-old Japanese woman who developed severe gastrointestinal mucosal necrosis after 8 years of treatment with low-dose MTX (8 mg/week). In the drug lymphocyte stimulation test, MTX showed a strong positive reaction, with a stimulation index of 443% against normal controls. Physicians must be aware of potential drug-induced adverse effects in patients with chronic diseases who are on long-term medication.

Aprepitant plus granisetron and dexamethasone for prevention of chemotherapy-induced nausea and vomiting in patients with gastric cancer treated with S-1 plus cisplatin.

BACKGROUND: We aimed to evaluate the efficacy of a new combination antiemetic therapy comprising aprepitant, granisetron, and dexamethasone in gastric cancer patients undergoing chemotherapy with cisplatin and S-1. METHODS: Gastric cancer patients scheduled to receive their first course of chemotherapy with cisplatin (60 mg/m(2)) and S-1 (80 mg/m(2)) were treated with a new combination antiemetic therapy aprepitant, granisetron, and dexamethasone on day 1; aprepitant and dexamethasone on days 2 and 3; and dexamethasone on day 4. The patients reported vomiting, nausea, use of rescue therapy, and change in the amount of diet intake, and completed the Functional Living Index-Emesis (FLIE) questionnaire. The primary endpoint was complete response (CR; no emesis and use of no rescue antiemetics) during the overall study phase (0-120 h after cisplatin administration). The secondary endpoints included complete protection (CP; CR plus no significant nausea); change in the amount of diet intake; and the impact of chemotherapy-induced nausea and vomiting (CINV) on daily life during the overall, acute (0-24 h), and delayed (24-120 h) phases. RESULTS: Fifty-three patients were included. CR was achieved in 88.7, 98.1, and 88.7% of patients in the overall, acute, and delayed phases, respectively. The corresponding rates of CP were 67.9, 96.2, and 67.9%. Approximately half of the patients had some degree of anorexia. FLIE results indicated that 79.5% of patients reported "minimal or no impact of CINV on daily life". CONCLUSIONS: Addition of aprepitant to standard antiemetic therapy was effective in gastric cancer patients undergoing treatment with cisplatin and S-1.

[A case of advanced colon cancer successfully treated with combination therapy of cetuximab and oxaliplatin, leucovorin, and 5-fluorouracil].

A 65-year-old woman was referred to our hospital for examination of anemia. Colonoscopy showed a type 1 tumor in the ascending colon with nearly complete stenosis that was diagnosed as a tubular adenocarcinoma. Computed tomography (CT) revealed swelling of the regional, periaortic, and celiac lymph nodes and lymphangitis carcinomatosa. The patient was diagnosed as having Stage IV ascending colon cancer, and neoadjuvant chemotherapy was administered to avoid non-curative resection. The patient was treated with cetuximab and oxaliplatin, Leucovorin, and 5-fluorouracil( mFOLFOX6) combination chemotherapy. After 6 courses of chemotherapy, the primary lesion and multiple lymph node swellings greatly reduced in size and lymphangitis carcinomatosa improved. Accordingly, right colectomy with D3 nodal dissection was performed. The patient was recurrence free at her 8-month follow-up examination. Neoadjuvant chemotherapy with molecular targeted drugs is useful in the treatment of patients with unresectable primary cancer.

[A case of locally advanced rectal cancer successfully treated by laparoscopic intersphincteric resection and effective neoadjuvant chemoradiation therapy].

A 74-year-old woman was diagnosed as having lower rectal cancer. Colonoscopy revealed a type 2 circular tumor over 15 cm from the port side close to the dentate line. The patient was diagnosed as having a moderately differentiated adenocarcinoma by biopsy. Computed tomography (CT) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) revealed thickening of the wall from near the anus to the rectosigmoid junction and an increase in the concentration of the surrounding adipose tissue as well as swelling of the left internal iliac lymph nodes with FDG accumulation. The patient was diagnosed as having cSE, cN3, cM0, cStage IIIb rectal cancer. Because the tumor was very close to the anus with advanced extramural invasion and because the patient desired anal sphincter preservation, we performed preoperative chemoradiation therapy( CRT) combined with capecitabine plus oxaliplatin( XELOX) and bevacizumab( BV). Radiation therapy was performed with a linear accelerator( LINAC) for stereotactic radiation therapy( Novalis®). Partial response (PR) was achieved by this therapy. Five weeks after CRT, the patient underwent laparoscopic-assisted intersphincteric resection( total ISR). Pathological examination revealed minimal residual cancer cells( Grade 2, pPR, pA, N0, M0, pPM0, pDM0, pRM0, pStage II). Increased implementation of anus-preserving surgery can be expected owing to the successful control of regional and distant metastases by neoadjuvant CRT. Based on these encouraging findings, we should consider the challenges posed by neoadjuvant CRT for the treatment of lower rectal cancer.

Locally advanced breast cancer made amenable to radical surgery after a combination of systemic therapy and Mohs paste: two case reports.

INTRODUCTION: Chemotherapy and other systemic therapies are the primary treatments for patients with unresectable, locally advanced breast cancer. The clinical application of supportive care using Mohs paste has become widespread for the purpose of improving patients' quality of life. Here, we report two cases of locally advanced breast cancer, for which the patients underwent radical surgery after a combination of systemic therapy and Mohs chemosurgery. CASE PRESENTATIONS: Patient 1 was a 90-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4bN1M0). The treatment included Mohs paste application and hormonal therapies. Patient 2 was a 60-year-old Japanese woman with right breast cancer diagnosed as stage IIIB (T4cN2aM0). Her treatment included Mohs paste application, together with chemotherapy (four cycles of 5-fluorouracil, epirubicin, and cyclophosphamide, and four cycles of docetaxel). In both cases, a reduction in the primary tumor volume was observed, and radical mastectomy and axillary lymph node dissection were possible without relaxation incision or skin flap. CONCLUSION: We report patients with no distant metastases who were able to undergo radical resection after a combination of systemic therapy and Mohs chemosurgery. For locally advanced breast cancer, Mohs chemosurgery, in addition to multidisciplinary treatment, is useful.

Cholecystomucoclasis: revaluation of safety and validity in aged populations.

BACKGROUND: We evaluated the safety and validity of cholecystomucoclasis (CM) and compared its intraoperative characteristics with those of standard cholecystectomy (SC). METHODS: We enrolled 174 patients who underwent cholecystectomy and retrospectively evaluated the outcomes of patients in the SC and CM groups. RESULTS: Significant differences in age (71.1 vs. 61.9 years), American Society of Anesthesiologists physical status (ASA-PS), and serum C-reactive protein levels (CRP) (18.1 vs. 4.7 mg/dL) were observed between the CM and SC groups. Conversely, no significant differences were observed in the operation time (129 vs. 108 min), amount of blood loss (147 vs. 80 mL), intraoperative complications (0% vs. 5.7%), or duration of hospital stay (13.2 vs. 8.9 days) between the 2 groups. A high conversion rate (35.3%), postoperative complications (33%), and frequent drain insertions (94%) were observed in the CM group. CONCLUSIONS: CM is a safe and valid surgical procedure and surgeons should not hesitate to transition to CM for patients who are of advanced age, in poor general condition (high ASA classification), or have high levels of serum CRP.

Xanthogranulomatous gastritis mimicking malignant GIST on F-18 FDG PET.

Xanthogranulomatous gastritis (XGG) is a rare inflammatory lesion of the stomach, with only 11 reported cases worldwide. Furthermore, reports on the use of detailed diagnostic imaging in XGG are not available. Herein, we describe a case of XGG with detailed diagnostic imaging mimicking malignant gastrointestinal stromal tumor (GIST) in light of the current literature. A 79-year-old woman who presented with epigastric pain was referred to our hospital. Upper gastrointestinal endoscopy revealed an elevated lesion similar to a submucosal tumor (SMT). F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) showed intense FDG uptake in the mass. Additional imaging studies revealed a malignant GIST, which was suspected of having infiltrated the left lobe of the liver. Open surgery was carried out, but tumorous lesions were not found. For exact histopathological diagnosis, partial resection of the thickening gastric wall was performed, and XGG was diagnosed. We conclude that benign conditions, including XGG, should be considered when intense FDG uptake in SMT is found.

Stenotic ischemic colitis treated with laparoscopy-assisted surgery.

Ischemic colitis is the most common type of intestinal ischemia. The etiology of this condition is multifactorial, and the diagnosis is based on a combination of clinical symptoms, as well as endoscopic and histological findings. Although conservative therapy is effective in most cases, surgery still plays a key role in the treatment of ischemic colitis. Here, we describe a case of a 73-year-old man in whom laparoscopy-assisted left colectomy was performed 80 d after the onset of ischemic colitis. He recovered completely after surgery, and the pathological findings were consistent with ischemic colitis. To the best of our knowledge, there are no detailed reports of laparoscopic surgery for chronic segmental stenotic ischemic colitis. We discussed the usefulness of laparoscopic surgery, comparing it with endoscopic treatment, and we propose an optimal treatment strategy from a viewpoint of stenosis length and duration of disease.

Portal and superior mesenteric venous thrombosis treated with thrombolytic therapy via the superior mesenteric artery and vein.

A 61-year-old man was hospitalized for treatment of portal and superior mesenteric venous thrombosis (PSMVT). We selected interventional radiology (IVR) because there were no signs of intestinal necrosis. The thrombosis was significantly reduced and the patient made progress after we performed thrombectomy via catheter aspiration, and thrombolytic therapy via both the superior mesenteric artery and vein. Even if there are no signs of intestinal necrosis, treatment which prevents intestinal necrosis is vital. In the present case, single-stage IVR therapy via both the superior mesenteric artery and vein improved the therapeutic outcome of PSMVT.

False-Positive Mediastinal Lymphadenopathy on 18F-Fluorodeoxyglucose Positron Emission Tomography and Computed Tomography after Rectal Cancer Resection: A Case Report of Thoracoscopic Surgery in the Prone Position.

(18)F-fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (integrated FDG PET/CT) has been used to diagnose recurrence and differentiate postoperative changes from lymph node metastasis in colorectal cancer, although its accuracy is questionable. We report a prone thoracoscopic surgery for a rectal cancer patient in which false-positive mediastinal lymph nodes were found on FDG-PET/CT. A 60-year-old man underwent a laparoscopic high anterior resection and D3 lymph node dissection for rectal cancer. The histopathological diagnosis was moderately differentiated adenocarcinoma of the rectum, stage IIIB (pT3N1M0), necessitating oral fluoropyrimidine agent S-1. After the primary surgery, a solitary mediastinal lymph node measuring 30 mm in diameter was detected, and abnormal accumulation was confirmed by FDG-PET/CT (SUV(max), 11.7). Thoracoscopic resection was performed in the prone position, but histopathological results showed no metastasis. He was subsequently diagnosed with reactive lymphadenitis. The patient was discharged on postoperative day 4 in good condition and is alive without recurrence 12 months after surgery. PET/CT is useful for the detection of colorectal cancer recurrence; however, it does have a high false-positive rate for mediastinal lymph nodes. There is a limit to its diagnostic accuracy, and one must determine the indication for surgical treatment carefully. Surgery in the prone position is a useful and minimally invasive approach to the mediastinum and allows aggressive resection to be performed.

Arabidopsis mutants by activation tagging in which photosynthesis genes are expressed in dedifferentiated calli.

In an effort to delineate the precise mechanisms underlying the organ-specific expression of photosynthesis genes, Arabidopsis lines homozygous for each transgene construct made with the gene for hygromycin B phosphotransferase or beta-glucuronidase (GUS) placed under control of the promoter of the nuclear gene for the small subunit of ribulose-1,5-bisphosphate carboxylase/oxygenase (RBCS-3B) were constructed. Furthermore, activation tagging with T-DNA possessing quadruply repeated enhancers derived from the cauliflower mosaic virus 35S promoter was applied to a transgenic line of Arabidopsis. Mutants resistant to hygromycin B during the growth of calli generated from non-green roots on callus-inducing medium resulted from the expression of hygromycin B phosphotransferase driven by the RBCS-3B promoter. Three mutant lines, ces101 to ces103 (callus expression of RBCS), were obtained from approximately 4,000 calli resistant to a selectable marker for transformation. The active transcription driven by the RBCS-3B promoter in all the calli of ces mutants was confirmed by expression of both the GUS reporter gene and endogenous RBCS-3B. Chlorophyll and carotenoids, as well as light-dependent O(2) evolution, have been detected in the calli of all ces mutants. The loci where T-DNA was integrated in the ces101 line were determined by thermal asymmetric interlaced (TAIL)-PCR. The introduction of a DNA fragment harboring the gene for receptor-like kinase placed under the influence of enhancers into the parental line reproduced the phenotype of ces mutants. We have thus concluded that CES101 is a receptor-like kinase. The strategy presented in this investigation may promise to select a greater number of ces mutants.