[A Case of Primary Gastrointestinal Stromal Tumor with First Recurrence 13 Years after Surgery and Second Recurrence in the Omentum 6 Years Later].

A 63-year-old man underwent proximal gastrectomy for gastrointestinal stromal tumor(GIST)of the stomach 19 years ago. Local recurrence of GIST of the stomach occurred 13 years later, and the tumor was resected. Since then, he had adjuvant chemotherapy. Six years later, computed tomography revealed a soft-tissue shadow at the left lateral side of the stomach, and positron emission tomography also revealed fluorodeoxyglucose uptake at the same site. The recurrence of GIST was suspected, and therefore laparoscopic resection was performed. The operative time was 70 minutes. Blood loss was 10 g. Immunohistochemical examination showed positivity for c-kit and CD34, leading to a diagnosis of recurrence of GIST. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. At present, the patient is alive without adjuvant chemotherapy 13 months since surgery. GIST may recur 10 years or more after surgery. Therefore, long-term surveillance seems to be mandatory.

The number of metastatic lymph nodes exhibiting poorly differentiated clusters predicts survival in patients with pStage III colorectal cancer.

PURPOSE: Many studies have proposed alternative designations for lymph node (LN) status in colorectal cancer (CRC); however, knowledge of histopathological features in metastatic lymph nodes (MLNs) is limited. This study investigated the clinicopathological significance of poorly differentiated clusters (PDCs) in MLNs. METHODS: Slides from 159 patients with pathological Stage III CRC were reviewed. Those with <12 dissected LNs (DLNs) were ineligible. PDCs composed of ≥5 cancer cells lacking full glandular formation and ≥10 PDCs under ×20 objective lens were defined as positive, and the number of MLNs with positive PDCs (MLNs-PDCs) was counted. Results were correlated with patient survival and comparisons made with other indications of LN status. RESULTS: The mean numbers of MLNs and MLNs-PDCs were 2.8 and 1.0, respectively, and were moderately and positively correlated with each other. Univariate analysis identified cutoffs of ≥5 MLNs (86 vs. 55%, p = 0.024), ≥2 MLNs-PDCs (85 vs. 63%, p = 0.008), and ≥30% LN ratio (85 vs. 44%, p = 0.036) to indicate a positive LN status. However, no cutoff for DLNs was obtained. MLNs-PDCs (≥2) were associated with pT4 tumor (p = 0.0035), open surgery (p = 0.016), greater number of MLNs (p < 0.0001), and positive-PDC primary tumor (p < 0.0001). In multivariate analysis, a prognostic model incorporating ≥2 MLNs-PDCs provided the lowest Akaike information criterion value; consequently, both pT4 tumors (p < 0.001) and ≥2 MLNs-PDCs (p = 0.038) were revealed to be significant prognosticators. CONCLUSION: Results showed that applying the number of MLNs-PDCs could improve stratification in pStage III CRC and may be a valuable candidate for LN status.

A case of long-term survival following hepatectomy for liver metastasis of Merkel cell carcinoma.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare endocrine tumor that presents as a rapidly growing skin nodule of the body, and it is aggressive with regional nodal and distant metastases without clearly defined treatment. There are no reports of long survivors among patients with liver metastasis of MCC. The current case was a patient who underwent surgical resection for liver metastasis of Merkel cell carcinoma. CASE PRESENTATION: This case describes a 73-year-old female with a papule on the dorsal side of the right third finger and liver tumor. The papule of the right third finger was histologically diagnosed as MCC by the skin biopsy. She underwent extensive resection and lymph node dissection of the right third finger and partial resection of the liver. The liver tumor was histologically diagnosed as liver metastasis of MCC. The patient remains well without any evidence of tumor recurrence more than 5 years after surgery. CONCLUSIONS: This is the first report of a long-term survival of more than 5 years following liver metastasis of MCC, which was surgically resected. Patients with small and solitary metastatic liver tumor of MCC may have a chance for a long-term survival following the hepatic resection.

Clinical outcomes and quality of life according to types of reconstruction following laparoscopy-assisted distal gastrectomy for gastric cancer.

PURPOSES: Laparoscopy-assisted distal gastrectomy (LADG) has gained wide acceptance and is being more commonly performed at the period of introduction. This study was designed to determine the clinical outcomes and quality of life (QOL) according to types of reconstruction following LADG for gastric cancer. PATIENTS AND METHODS: Between 2007 and 2010, 117 consecutive patients underwent LADG. These patients were classified into 2 groups: Billroth-I group (n=74) and Roux-en-Y group (n=48). RESULTS: Although there were no significant differences in background factors such as sex, body mass index, pN stage, pT stage, or extent of lymphadenectomy between both the groups, patients with Billroth-I reconstruction were found more frequently in the lower portion of gastric cancer (P=0.0173), shorter surgical durations (P<0.0001), and less blood loss (P<0.0001). The overall postoperative complication rates did not significantly differ between both the groups (P=0.0675). However, the incidence of patients with postoperative stasis (P=0.0170) and long hospital stay (P=0.0039) was significantly higher in patients with Roux-en-Y reconstruction. Concerning the evaluation of long-term QOL using the Gastrointestinal Symptom Rating Scale, there were no significant differences in total score between both the groups (P=0.4387). CONCLUSIONS: Billroth-I technique might comparatively be accessible and safe in the reconstruction of LADG. However, the differences of reconstruction do not affect long-term QOL.

Efficacy of perioperative chemotherapy in patients with colorectal cancer undergoing hepatectomy for resectable synchronous liver metastasis.

BACKGROUND/AIMS: Although aggressive resection is recommended for the treatment of resectable liver metastasis of colorectal cancer, recurrences often develop in the remaining liver. In our department, perioperative chemotherapy was introduced for the treatment of colorectal cancer associated with resectable synchronous liver metastasis. The results of this treatment are reported herein. The study population was 20 patients (9 men, 11 women) with colorectal cancer associated with resectable synchronous liver metastasis whose data were collected between April 2009 and September 2012. METHODOLOGY: The patients received chemotherapy (mFOLFOX6 or XELOX + bevacizumab) for 3 months each before and after hepatectomy following resection of the primary lesion. RESULTS: Preoperative chemotherapy yielded a response rate of 66.7%, and no serious postoperative complications were noted. Although recurrence was found in 9 patients after treatment, 4 have so far remained cancer-free after re-resection. Thus, re-resection of the recurrent lesion resulted in patients maintaining cancer-free status for a prolonged period. CONCLUSIONS: The use of perioperative chemotherapy in patients with colorectal cancer associated with resectable synchronous liver metastasis may improve outcomes after hepatectomy.

Invasive mucinous adenocarcinoma associated with adjacent sessile serrated lesion of the appendix vermiform: a case report.

Although the definition of sessile serrated lesion (SSL) of colon is controversial and the risk of progression to malignancy is also under investigation at present, SSL is generally described as a polyp characterized by a serrated architecture. It is estimated to represent a feature of a new cancerization pathway, coined "serrated neoplasia pathway," particularly in right-sided colon adenocarcinomas. On the other hand, in appendix, the role of this pathway remains uncertain, probably because very few cases of appendiceal adenocarcinoma associated with SSL were reported, and furthermore, immunohistochemical examination was rarely carried out. We herein report an interesting case of invasive appendiceal mucinous adenocarcinoma exhibiting SSL, which was pathologically estimated as a potential precursor lesion, and performed representative immunohistochemistry for both the mucinous adenocarcinoma and SSL in the same specimen. To further elucidate the progression of the appendiceal carcinoma from SSL, both an adequate sectioning of the lesion and systematic immunohistochemical examination of a large number of appendiceal carcinoma cases containing adjacent SSL would be required.

[Novel approach to laparoscopy and endoscopy cooperative surgery (LECS) in gastric submucosal tumors near the esophago-gastric junction].

BACKGROUND AND PURPOSE: Laparoscopy and endoscopy cooperative surgery (LECS) for gastric submucosal tumors is an excellent surgical procedure that enables prevention of excessive resection and deformity of the stomach. This procedure may be more useful for gastric submucosal tumors near the esophagogastric (EG) junction and the pylorus. We present a novel approach to LECS for gastric submucosal tumors near the EG junction. PATIENTS: From 2010 to 2013, seven consecutive patients underwent LECS for gastric submocosal tumors near the EG junction. Novel approach: Our novel approach to LECS involved (1) minimizing the resection of the stomach wall by using endoscopic mucosal resection for all types of submucosal tumor, (2) selecting the best anastomotic axis in order to avoid deformity of the stomach, (3) using hand sewing if anastomotic complications might occur and (4) sometimes combining anti-reflux surgery with LECS for tumors extremely close to the EG junction. RESULTS: No patient had any anastomotic complications or reflux esophagitis. CONCLUSIONS: LECS is safe and useful for gastric submucosal tumors near the EG junction.

[Usefulness of the retrograde intraduodenal drainage tube for severe duodenum-related complications of gastrectomy for gastric cancer].

No ideal or generally accepted treatment strategy has been established for severe duodenum-related complications of gastrectomy for gastric cancer. Between 1997 and 2012, we successfully treated 5 patients with such complications using the retrograde intraduodenal drainage tube. Of the patients, 3 had anastomotic leakage of the duodenal stump, 1 had an intestinal injury, and 1 had the afferent loop syndrome. None of the patients experienced any further adverse events related to the procedure. This retrograde intraduodenal drainage technique was safe and effective, and may be considered as an optimal treatment strategy for severe duodenum-related complications of gastrectomy for gastric cancer.

Adipose-derived stem cells enhance tissue regeneration of gastrotomy closure.

BACKGROUND: The aim of this study was to examine whether transplantation of adipose-derived stem cells (ADSCs) improves healing of a gastrotomy closure in rats. In digestive surgery, anastomotic leakage is a serious postoperative complication and anastomotic stenosis may reduce quality of life. Recent studies have suggested that ADSCs play material roles in intestinal healing, acceleration of angiogenesis, and reduction of fibrosis, and treatment with ADSCs may improve healing. MATERIALS AND METHODS: ADSCs were isolated from intra-abdominal white adipose tissue of 40 male Wistar rats (weight 300 g) in four groups (n = 10 each). Gastrotomy closures were prepared surgically in all rats. Controls were treated with phosphate-buffered saline injection and sacrificed 7 d (group 1) or 28 d (group 3) after the surgery. Other animals were treated with locally autotransplanted ADSCs (labeled by CM-DiI) and sacrificed 7 d (group 2) or 28 d (group 4) after the surgery. Histopathologic features were evaluated in the four groups. RESULTS: Injection of ADSCs significantly enhanced angiogenesis and collagen deposition after 7 d, indicating improved healing of the gastrotomy closure. In contrast, ADSC transplantation significantly reduced collagen deposition after 28 d. The bursting pressure was higher in the transplant groups after 7 d. CONCLUSIONS: ADSCs enhance tissue regeneration in gastrotomy closures by accelerating angiogenesis and fibrosis in the early healing period. In the late period, ADSCs prevent excessive fibrosis and assist in regeneration of tissues that closely resemble the native structure. These results suggest that therapy with transplanted ADSCs might improve postoperative complications in digestive surgery.

Clinical influence of endoscopic resection on subsequent laparoscopic gastrectomy for gastric cancer.

BACKGROUND: Endoscopic resection (ER) causes inflammation, edema, fibrosis of the stomach, and severe adhesions around the surrounding tissue. However, little is known about the clinical influence of ER on subsequent laparoscopic gastrectomy (LG) for gastric cancer. PATIENTS AND METHODS: Between October 2007 and April 2011, 202 consecutive patients underwent curative LG for gastric cancer. Out of these, 30 (15%) LG cases had previously undergone ER and further LG to achieve a cure. The remaining 172 patients (85%) had no history of ER. We reviewed their hospital records retrospectively. RESULTS: Intraperitoneal adhesions were detected in all patients after ER. However, there were no significant differences in clinical outcome, such as surgical duration, blood loss, number of dissected lymph nodes, complications, or hospital stay, between LG cases with and those without previous ER. Of the 30 cases of LG with previous ER, 15 treated within two months after ER had greater blood loss (p<0.005) and a longer surgical duration (p=0.06). LG cases with major or minor perforation during ER also had slightly greater blood loss (p=0.07) than those without. However, the number of dissected lymph nodes associated with surgical curability and postoperative complications were not significantly different in patients with and those without these clinical factors. CONCLUSION: LG can be performed curatively and safely even after ER. Perforation during ER and shorter time to LG after ER may be potential risks of surgical difficulty in subsequent LG.

Comparison of prognostic compatibility between seventh AJCC/TNM of the esophagus and 14th JCGC staging systems in Siewert type II adenocarcinoma.

BACKGROUND AND AIM: The Seventh American Joint Committee on Cancer (AJCC)/TNM classification defined that the classification for adenocarcinoma of the esophagogastric junction (AEG) was included in the esophageal category. However, there still remain various classifications in AEG such as the Seventh AJCC/TNM of the esophagus and the 14th Japanese Classification of Gastric Cancer staging system (JCGC) in Japan. This study was designed to evaluate the compatibility of both the Seventh AJCC/TNM of the esophagus and the 14th JCGC staging systems in Siewert type II adenocarcinoma. PATIENTS AND METHODS: Between 1999 and 2011, 47 consecutive patients with Siewert type II adenocarcinoma underwent curative surgery at our Institution. We reviewed their hospital records retrospectively. RESULTS: Overall survival rates at 3 and 5 years were 44.3% and 33.4%, respectively. Multivariate analyses revealed that the extent of lymph node metastasis was the only independent prognostic factor (p=0.0194, HR=12.927). In the ≤pN2 group by 14th JCGC, deeper tumor depth was significantly correlated with poor prognosis, whereas in the ≥pN3 group, deeper tumor depth did not affect prognosis, suggesting a strong effect of nodal factor on prognosis and more similar prognostic stratification to the Seventh edition of the AJCC/TNM classification of the esophagus. CONCLUSION: Nodal involvement status might be a more important prognostic factor than tumor depth in patients with Siewert type II adenocaricinoma. The Seventh classification of AJCC/TNM of the esophagus might be more compatible with Siewert type II adenocarcinoma.

Total pancreatectomy for pancreatic carcinoma: evaluation of safety and efficacy.

BACKGROUND/AIMS: To determine the safety and the efficacy of total pancreatectomy for the curative treatment of pancreatic carcinoma. METHODOLOGY: Retrospective analysis was performed using 10 patients receiving total pancreatectomy. RESULTS: The median duration of the operative procedure was 8.7 hours and the median estimated blood loss was 2,700mL. Seven patients developed postoperative complications, including infections in 5 cases. There was no death associated with the operative procedure itself. Median period of postoperative hospital stay was 55 days. Anastomotic ulcer was prevented by administration of proton- pump inhibitors. Blood glucose level was well controlled by subcutaneous injection of sliding scale insulin during the postoperative period and the dosage of insulin required was 0.45±0.13units/kg body weight/ day at the time of discharge. The mean HbA1c level at 3 months after the operation was 6.1%. Four patients needed medication with anti-diarrheal drugs. CONCLUSIONS: Total pancreatectomy could be performed safely and postoperative daily performance was reasonable with effective medication. We suggest that total pancreatectomy should be considered for the treatment of pancreatic carcinoma when the patient status is appropriate for this procedure.

[A case of breast cancer with large cancer ulcer and multiple bone and liver metastasis responding to combination therapy of radiation and chemotherapy].

We report a case of breast cancer in a 58-year-old female patient. In 2005, she was hospitalized for therapy of left breast cancer. The tumor observed was accompanied by invasion of the skin and ribs. At the same time, multiple liver and bone metastases were also observed(solid tubular adenocarcinoma, ER(+), PgR(±), HER2(3+), T4NxM1, stage IV). She was started on radiation therapy and chemotherapy(paclitaxel+trastuzumab). While the liver and bone metastases remained unchanged, the primary focus became noticeably smaller. In the course of follow-up visits, we began to administer her paclitaxel biweekly. This treatment, however, worsened her liver metastases and led us to switch to combination chemotherapy with vinorelbine and capecitabine. After 6 courses of the therapy, her liver metastases disappeared and her tumor marker levels became normal. The combination chemotherapy was continued for 1 year and then followed by 18 months of chemotherapy with capecitabine alone until recurrence of liver metastases was observed. Capecitabine along with cyclophosphamide was orally administered, bringing her tumor marker levels down to the normal range again. After approximately 6 years from the start of treatment, the patient is still alive.

REGIV as a potential biomarker for peritoneal dissemination in gastric adenocarcinoma.

BACKGROUND: This study examined the clinical significance of regenerating islet-derived family member 4 (REGIV) in surgically resected gastric tumors. The potential of REGIV as a biomarker in gastric cancer was also assessed including its predictive value for prognosis and recurrence after surgery. METHODS: Immunohistochemistry was performed to assess the clinical significance of REGIV expression status in surgically resected specimens. The quantitative genetic diagnostic method, transcription-reverse transcription concerted reaction (TRC) that targeted REGIV mRNA was applied for prediction of peritoneal recurrence in gastric cancer. RESULTS: Positive immunostaining for REGIV was observed in 85 cases (52.5%), and correlated significantly with diffuse type histopathology (P = 0.001), advanced T stage (P = 0.022), and frequent peritoneal recurrence (P = 0.009). Multivariate analysis identified advanced T stage (P < 0.001) and REGIV expression (P = 0.034) as independent prognostic factors for peritoneal recurrence-free survival. Overexpression of REGIV protein was evident in the majority of peritoneal tumors (93.8%). REGIV mRNA assessed by TRC could be a predictive marker for peritoneal recurrence after curative operation. CONCLUSIONS: REGIV overexpression is common in primary gastric tumors and a potentially suitable marker of diffuse type histopathology and peritoneal dissemination. Overexpression of REGIV mRNA, assessed by the TRC method, is a potentially suitable marker of peritoneal recurrence after curative resection.

Use of multidetector-row computed tomography to evaluate branch duct type intraductal papillary mucinous neoplasms of the pancreas: influence on surgical decision-making.

BACKGROUND/AIMS: The purpose of this study was to evaluate factors predictive of the malignant grade associated with branch duct type intraductal papillary mucinous neoplasm (BD-IPMN) using multidetectorrow computed tomography (MDCT). METHODOLOGY: We reviewed the morphological features of 26 BDIPMNs using MDCT. Tumor size, caliber of the main pancreatic duct, number of mural nodules, diameter of the largest mural nodule and volume of the largest mural nodule were assessed and correlated with the pathological findings. RESULTS: By multiple- and single-regression analyses and Mann-Whitney U test, significant differences in the caliber of the main pancreatic duct and number of mural nodules were observed between adenoma and non-invasive carcinoma and in the number of mural nodules between adenoma and invasive carcinoma. No significant differences were observed between non-invasive carcinoma and invasive carcinoma. Based on the differential diagnostic criterion of 1 or more mural nodules for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma, the sensitivities were 60% and 100%, respectively, and the specificity was 93% for both. CONCLUSIONS: Although it was impossible to distinguish non-invasive carcinoma from invasive carcinoma, MDCT was reliable for distinguishing adenoma from non-invasive carcinoma and invasive carcinoma.

Prognostic impact of microscopic positive margin in gastric cancer patients.

BACKGROUND: Complete resection with negative surgical margins has been a long-held surgical philosophy based on the concept that even minimal remaining cancer cells will develop recurrences. OBJECTIVES: This study investigated the clinical significance of microscopic positive margin on the outcome of patients with gastric cancers. METHODS: The relationships between the margin status and other clinicopathologic factors were examined in gastric cancer patients undergoing gastrectomy, and then the prognostic impact of the margin status was evaluated by univariate and multivariate analysis. RESULTS: The microscopic positive margin was identified in 23 patients (2.8%) by standard H&E staining. The positive margin showed a strong correlation significantly with tumor size (P < 0.05). Microscopic positive margin was found to be a significant prognostic factor on univariate analysis (5-year survival rate 51.9% vs. 82.2%, P < 0.0001), as well as multivariate analysis (risk ratio 3.24, 95% CI: 1.24-6.50, P < 0.01). Detailed analysis of margin status demonstrated that patients with positive margin in a deep site and/or in multiple layers showed poor survival. CONCLUSIONS: Microscopic positive margin was found to be an independent prognostic factor in gastric cancer patients. The status of the surgical margin might provide useful information for selecting additional treatments and performing intensive follow-up.

Salvage surgery for uncontrollable hepatocellular carcinoma treated with repeated non-surgical therapies.

BACKGROUND/AIMS: Some hepatocellular carcinoma (HCC) cases undergo surgery because tumor progression cannot be controlled by various non-surgical therapies. This retrospective study sought to clarify the clinicopathologic features of such HCC cases. METHODOLOGY: Among cases with solitary small HCCs (< or = 3.0cm at the time of detection), the clinicopathologic features of 7 patients who had undergone hepatectomy after various non-surgical therapies (Salvage (S) group) were analyzed and compared with those of 30 patients who received hepatectomy as the initial treatment (Control (C) group). RESULTS: In S group, the serum alpha-fetoprotein level was higher (p = 0.045) and macroscopic ductal invasion was more common (p = 0.028) at the time of the operation. Lobectomy was more commonly performed (p = 0.034) and curability B (No residual cancer, but Stage III or IV) was more frequent (p = 0.011). Other organ recurrence was more common (p = 0.0044). The survival time after the initial treatment (post-initial treatment survival) was worse (p = 0.028). Univariate analyses revealed that those with maximum tumor sizes of > 3.0 cm at the time of the operation were significantly worse compared with the other patients (p = 0.012). CONCLUSIONS: The timing for changing from a non-surgical treatment to a surgical treatment is important.

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

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

[The role of adjuvant chemotherapy with S-1 for gastric cancer patients].

A randomized controlled trial of adjuvant chemotherapy with S-1 for gastric cancer (ACTS-GC) demonstrated that the chemotherapy with S-1 improved the relapse-free survival and overall survival rates of patients with locally advanced gastric cancer. We examined retrospectively 47 patients with locally advanced gastric cancer, who received adjuvant chemotherapy with S-1 after curative gastrectomy. Patients who received more than 50% of the total scheduled dose of S-1 during the first 1 year after starting the chemotherapy showed a tendency to favorable outcome in terms of relapse-free survival compared with patients who received less than 50% of the dose, although no statistical significance was detected. Age did not show a significant correlation with tolerability. The number of elderly people with gastric cancer will increase in the next decade. They should be candidates for adjuvant chemotherapy on the basis of a geriatric assessment.

Surgical treatment of hepatocellular carcinoma with severe intratumoral arterioportal shunt.

We report a case of hepatocellular carcinoma (HCC) that caused a severe arterioportal shunt (APS). A 49-year-old man was admitted to hospital due to esophagogastric variceal hemorrhage and HCC, and underwent endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS). He was then referred to our hospital. Abdominal computed tomography revealed a low-density lesion in the posterior segment of the liver and an intratumoral APS, which caused portal hypertension. Although the patient underwent EVL, EIS, Hassab's operation, and transcatheter arterial embolization for APS, he vomited blood due to rupture of esophagogastric varices. Right hepatectomy was performed for the treatment of HCC and APS, although the indocyanine green retention value at 15 min after intravenous injection was poor (30%). The patient's postoperative course was uneventful. Eventually, APS disappeared and the esophagogastric varices improved.