Metachronous bilateral pulmonary metastases from cancer of the ampulla duodeni.

We present a 76-year-old man who underwent two lung resections for metastases originating from cancer of the Ampulla duodeni, 9 years-after pancreaticoduodenectomy with lymphadenectomy. Pancreaticoduodenectomy was performed in 2002; histological examination of the original tumor revealed a stage III tubular adenocarcinoma (pT3, N0, M0). Repetitive lung resection was performed in 2007 (left S8) and 2011 (right S1 and extirpation of a pericardial cyst). Although rarely performed, resection of bilateral pulmonary metastases from carcinoma of the papilla of Vater was done to improve the patient's chances for longterm survival.

Expression and role of GLUT-1, MCT-1, and MCT-4 in malignant pleural mesothelioma.

Malignant cells supply their energy needs through increased glucose consumption, producing large quantities of lactic acid via glycolysis. Glucose transporters (GLUTs) and monocarboxylate transporters (MCTs) are therefore commonly up-regulated in human malignancies to mediate glucose influx and lactic acid efflux, respectively. However, their roles in malignant pleural mesothelioma (MPM) have not been fully elucidated. Here, we evaluated GLUT-1, MCT-1, and MCT-4 expression in human MPM and reactive mesothelial hyperplasia (RMH) and elucidated their biological role in vitro. GLUT-1, MCT-1, and MCT-4 expression was determined in human MPM (n = 35) and RMH (n = 20) specimens by immunohistochemistry and in frozen tissue, and MPM cell lines, by real-time reverse transcription-polymerase chain reaction and western blot analysis. GLUT-1, MCT-1, and MCT-4 functions in MPM were evaluated by transfection with small interfering RNA. Immunohistochemical analysis revealed higher levels of GLUT-1, MCT-1, and MCT-4 in MPM than in RMH. Additionally, GLUT-1, MCT-1, and MCT-4 mRNA levels were higher in MPM than in non-neoplastic mesothelial cell lines. The siRNA-mediated knockdown of GLUT-1 or MCT-1 significantly suppressed tumor cell proliferation, and MCT-1 silencing inhibited invasion and induced apoptosis. Taken together, these results indicate that combined application of GLUT-1, MCT-1, and MCT-4 immunohistochemistry might be useful in differentiating MPM from RMH and suggest that MCT-1plays an important biological role.

Pulmonary papillary adenoma.

We present a rare case of solitary pulmonary papillary adenoma. A man consulted our hospital because of abnormal chest radiography finding. Chest computed tomography demonstrated a well-defined, homogeneous nodular shadow 11 mm in size at the left lower lobe. The previous physician had considered it to be an old benign inflammatory granuloma and had kept it under observation. This mass was followed through chest radiographs at annual medical checkups for 4 years. In 2006, enlargement and lobulation were noted. We performed thoracoscopic partial resection of the left lower lobe. On postoperative pathology examination, the nodule was found to be a circumscribed nodule consisting of a papillary growth of cuboidal to low-columnar epithelial cells lining the surface of a fibrovascular stroma. The histological features were consistent with pulmonary papillary adenoma. Only 20 cases of pulmonary papillary adenoma have been reported in the literature.

[Simultaneous surgical case of thymoma combined and non small cell lung cancer; report of a case].

We described a case of simultaneously treated thymoma associated with lung cancer, with reference to previous reports. A male in his forties who was pointed out a mediastinal mass and a nodular shadow in the right lower lung field on chest X-ray was admitted to our hospital. The resection of right lower portion of thymus and right lower lobectomy of the lung were performed. The mediastinal mass appeared to be a thymoma. Although thymomas associated with lung cancer are uncommon, the relationship between thymomas and the incidence of nonthymic malignancy is discussed in several papers. Since lung cancer is increasing in our country, thymoma associated with lung cancer are expected to increase.

Pleural malignant mesothelioma with invasive micropapillary component and its association with pulmonary metastasis.

The micropapillary pattern (characterized by papillary structure with tufts lacking a central fibrovascular core) is a predictor of aggressive carcinoma. The purpose of the present study was to review 34 pleural malignant mesotheliomas (21 epithelioid, five sarcomatoid, seven biphasic and one lymphohistiocytoid), with special reference to the presence of invasive micropapillary component. Two invasive micropapillary pattern-positive tumors were identified. The invasive micropapillary pattern was seen to have a focal distribution in 15-20% of the tumor tissues. The majority of the invasive micropapillary clusters expressed MUC1 along the outer cell surface. Analysis of pleural malignant mesotheliomas with epithelioid features and with or without invasive micropapillary pattern (21 epithelioid and seven biphasic subtypes) indicated pulmonary micrometastases in only the invasive micropapillary-positive tumors (P < 0.015), and the spread was probably via the lymphatics. Lymphatic involvement (confirmed on immunohistochemistry with D2-40 antibody) and lymph node metastasis were found in both of the invasive micropapillary-positive tumor patients, whereas they were noted in only one of 10 (10%, P < 0.046) and three of nine (30%) invasive micropapillary-negative patients. To the authors' knowledge this is the first study to indicate the presence of invasive micropapillary component in pleural malignant mesothelioma. This component can predict more aggressive lymphatic spread, similar to that of carcinomas in other organs with micropapillary pattern.

Neonatal gastrointestinal perforation.

Infants, especially extremely low birth weight infants (ELBWIs, birth weight <1,000 g) continue to have a high mortality after gastrointestinal (GI) perforation. In Japan, the overall mortality rate for neonates under 30 days having GI perforation was 31.6% in 2003. From 1974 to 2003, 34 cases of GI perforation in neonates were treated surgically in Fukuoka University Hospital. The overall mortality rate was 50% (17 of 34). Etiologies included necrotizing enterocolitis (NEC) (35.3%), meconium peritonitis (25%), idiopathic (25%), and gastric perforation (11.8%). The present series was divided into four groups: survival and non-survival neonates of the early (1974 to 1997) and recent (1998 to 2004) periods. Several prognostic factors of neonatal GI perforation were compared between several groups. The gestational week (GW) at birth, birth weight (BW) and weight at operation were significantly lower for non-surviving neonates in the recent period compared with the other three groups. Although a real improvement in surgical outcome was noted with improved neonatal intensive care management, the mortality rate was still high, especially in extremely premature cases under both 1,000 g and 29 GWs. The vast majority of these extremely premature babies thus comprised the NEC patients. It is therefore necessary to substantially improve the medical treatment level for such premature babies.

PPARalpha ligand WY14643 reduced acute rejection after rat lung transplantation with the upregulation of IL-4, IL-10 and TGFbeta mRNA expression.

BACKGROUND: The peroxisome proliferators-activated receptor-alpha (PPARalpha) is important in lipid metabolism and regulation of inflammation. Recent studies have demonstrated the immunoregulatory effects of PPARalpha. This investigated the immunosuppressive effects of PPARalpha using its ligand, WY14643, on acute lung allograft rejection in a rat model and its mechanism of action. METHOD: The left lungs were transplanted orthotopically from Brown-Norway donors to F344 recipients. The recipients were then divided into control and WY14643 treatment groups. The allograft rejection was evaluated by daily chest X-ray imaging and was evaluated histologically on Day 7 after transplantation. The cytokine messenger RNA (mRNA) expression at Days 3 and 5 were also evaluated in allografts and recipient spleens. RESULTS: The radiologic and histologic findings indicated that treatment with the WY14643 reduced acute allograft rejection. WY14643 also significantly extended the allograft survival time. This amelioration of acute rejection by WY14643 was also associated with up-regulated interleukin (IL)-4, IL-10, and transforming growth factor-beta (TGFbeta) mRNA expression in the lung allografts and spleens. CONCLUSION: This study demonstrated that the administration of the PPARa ligand, WY14643, ameliorates acute lung allograft rejection in rats. Treatment with WY14643 reduced histopathologic scores, prolonged graft survival, and up-regulated the expression of anti-inflammatory cytokine IL-4, IL-10, and TGFbeta mRNA compared with the control.

Thoracoscopic surgery in children in the Kyushu area of Japan.

BACKGROUND: Recently, minimally invasive thoracoscopic surgery has offered several options for both the diagnosis and surgical treatment in the field of pediatric surgery. This report reviews the surgical experience in order to assess the problems including the complications, encountered during thoracoscopic surgery in children under 15 years of age in the Kyushu area, Japan. METHODS: From 1993 to 2005, 153 boys and 103 girls underwent thoracoscopic surgery for chest disease. Pertinent information included number of operations for each year, sex, age, indication, treatment procedure, follow-up duration, cause of conversion to thoracotomy, method of treatment, and complication. RESULTS: There has gradually been an increase in the number of operations every year. These included procedures for funnel chest, n= 121; pneumothorax, n= 25; mediastinal tumor, n= 25; palmar hyperhydrosis, n= 23; neuroblastoma, n= 11; and cystic lung disease, n= 10. A large portion of the surgery was for patients under 1 year of age excluding neonates. Approximately half of the procedures were for the excision of a neuroblastoma. Approximately half of the patients older than 5 years of age underwent Nuss procedure for funnel chest. Almost all of the pneumothorax and palmar hyperhydrosis surgery was for patients 14 or 15 years old. Three patients required a conversion to a standard thoracotomy. Six complications occurred. There was no mortality associated with the thoracoscopic surgical procedures. CONCLUSIONS: Thoracoscopy is a useful diagnostic and therapeutic tool for both infants and children. Various thoracoscopic complex procedures have been performed both safely and effectively.

Presence of microsatellite lesions with colorectal liver metastases correlate with intrahepatic recurrence after surgical resection.

Hepatectomy is the treatment of choice for patients with resectable colorectal carcinoma metastases. However, recurrences occur in about half to two-thirds of the patients after surgery. To reduce the recurrence rate, it is important to isolate those factors that influence intrahepatic recurrence. In this study, we assessed histopathological factors associated with intrahepatic recurrences in 53 cases of liver metastases with special reference to microsatellite metastases. In 18 of the 53 cases, the entire resected liver tissue block was sectioned, processed into H&E slides, and examined microscopically. For the 53 cases, 1-, 3-, and 5-year survival rates were 87.9, 65.7 and 46.1%, respectively, with a median survival of 74 months. Univariate analysis showed a significant association of intrahepatic recurrence (p=0.039), intra- or extrahepatic recurrence (p=0.003), and surgical margin status of <1 mm (p=0.013) with poor overall survival. Multivariate analysis showed that intra- or extrahepatic recurrence was an independent indicator of poor overall survival (p=0.034). In the fully examined 18 cases, intrahepatic recurrences were significantly associated with microsatellite metastases around the main metastatic tumors. Microsatellite metastases were detected in 10 cases (55.5%) and showed a trend toward a worse overall survival. Moreover, all microsatellite lesions were found within 4 mm from the advancing margin of the main metastases, and most of them (7/10) were located within 2 mm of the tumor border. Collectively, a surgical margin of 1 mm at least is needed, however, a minimum surgical margin of 2 mm seems preferable based on the distribution of intrahepatic recurrence-associated microsatellite lesions.

Small cluster invasion: a possible link between micropapillary pattern and lymph node metastasis in pT1 lung adenocarcinomas.

Lung adenocarcinomas with micropapillary pattern (MPP) are associated with frequent nodal metastasis. However, little is known about the mechanisms that underlie MPP-associated nodal metastasis. In this study, we investigated how small micropapillary clusters of carcinoma cells present in tumoral alveolar spaces lead to increased lymph node metastasis. We analyzed 146 cases of pT1 lung adenocarcinomas with reference to the presence of MPP, small cluster invasion (SCI), and lymphatic involvement. SCI was defined as markedly resolved acinar-papillary tumor structures with single or small clusters of carcinoma cells invading stroma within fibrotic foci. The MPP-positive group (88/146 cases) was associated with significantly more frequent nodal metastasis and significantly worse survival. Moreover, SCI was significantly more frequent in the MPP-positive group (71/88 cases) than MPP-negative group (10/58 cases) and was significantly associated with lymphatic involvement (p < 0.0001) and nodal metastasis (p = 0.0073). The SCI-positive group showed significantly worse survival (5-year survival, 70%) than the SCI-negative group (91%, p = 0.0017). Carcinoma cells undergoing SCI demonstrated the same characteristic MUC-1 expression on the outer surface of cell clusters as those undergoing MPP. Thus, SCI could link MPP to nodal metastasis; carcinoma cells with MPP tend to undergo SCI in scars and invade lymphatics in pT1 lung adenocarcinomas.

The port site recurrence after a thoracoscopic and video-assisted esophagectomy for advanced esophageal cancer.

INTRODUCTION: Thoracoscopic or video-assisted thoracic esophagectomies have been performed for the last 10 years. Nevertheless, some reports have showed a risk of dissemination with endoscopic or video-assisted surgery for malignant disease. This institute experienced three cases of port site recurrence after a thoracoscopic esophagectomy for advanced esophageal cancer. Following those cases, induction chemo-radiation therapy was performed for patient with advanced esophageal cancer before thoracoscopic or video-assisted esophagectomy. Since introducing induction chemo-radiation therapy, no patients have experienced port site recurrence after a thoracoscopic or video-assisted esophagectomy for advanced esophageal cancer. In this study, the two patients groups are compared before and after the introduction of induction chemo-radiation therapy. PATIENTS AND METHODS: Between November 1995 and December 2005, thoracoscopic and video-assisted esophagectomies were performed on 112 (72.7%) patients out of 154 who underwent a surgical resection for thoracic and abdominal esophageal cancer. The histologic type of cancer was squamous cell carcinoma in 109 (97.4%) patients and adenocarcinoma in 3 (2.6%). Ninety-one patients were men and 21 were women. The tumor was located in the upper thoracic esophagus in 22 (19.6%) patients, the middle thoracic esophagus in 49 (43.8%), the lower thoracic esophagus in 34 (30.4%), and the abdominal esophagus in 7 (6.2%). RESULTS: Before December 1999, port site recurrence occurred in three cases of those of 29 patients with clinical T2-T4 esophageal cancer from 3 to 6 months after surgery, and pleural dissemination was observed in two of those patients. Since January 2000, induction chemo-radiation therapy (low-dose fluorouracil and platinum + 40 Gy radiation) has been performed to 31 patients with clinical T2-T4 disease, and port site recurrence has not occurred in any patients who received trimodality therapy. CONCLUSIONS: We think that the trend toward less port site recurrences with induction therapy should be examined in future studies of video-assisted thoracic surgery esophagectomy to confirm our findings.

Iatrogenic ileal perforation: an accidental clamping of a hernia into the umbilical cord and a review of the published work.

This report describes the case of an ileal perforation secondary to clamping of the exomphalos minor in 3-day-old girl. Eighteen accidental clamping or cutting cases were found in the published work. It is thought that this defect resulted from either the clamping, ligation or cutting of the bowel in a small unrecognized omphalocele. These complications are extremely rare, but should be held in mind when performing an umbilical ligation.

How much skill should we need for a VATS lobectomy in stage I lung cancer? An evaluation of surgeon groups.

Although there has been progress in video-assisted thoracic surgery (VATS), there have been no reports about the skill needed to perform this surgery for patients with stage I lung cancer. We reviewed a randomized series of surgeons in a single institution and attempted to identify the quality of skill needed in this surgery. Cases of surgery on clinical stage I non-small cell lung cancer (NSCLC) involving 103 patients (56 VATS and 47 conventional approach) from January 2000 to April 2006 were assessed for eligibility. We reviewed these patients and placed them in random order into three surgeon groups (groups A, B, and C) that were based on surgeons who had performed 50 lobectomies through thoracotomy. Three patients were converted to a thoracotomy. Of the remaining 53 patients, 17 were in group A, 15 were in group B, and 21 were in group C. There were no significant differences between the three surgeon groups regarding technical factors such as blood loss and operation time. After a short initial learning period, two of the three surgeon groups significantly decreased total blood loss. Morbidity and recurrence did not differ between the groups, and there was no mortality in our sample. The volume of VATS operations performed by individual surgeons who have had good training in open lobectomy may not make for a positive impact on clinical outcomes. The decision for a VATS lobectomy in cases of stage I NSCLC should not be limited only by a surgeon's thoracoscopic experience.

Immunochemotherapy with PSK and fluoropyrimidines improves long-term prognosis for curatively resected colorectal cancer.

Long-term survival, which extends beyond 5 years, is a desired outcome for colorectal cancer patients. In the present study, we retrospectively compared the 10-year overall survival between the control group and the polysaccharide kureha (PSK) group and analyzed the factors influencing the prognosis. The control group was treated exclusively with oral fluoropyrimidines, whereas the PSK group was treated with fluoropyrimidines, given in conjunction with PSK for 24 months. The 10-year survival rates for the PSK group (81.9%) were significantly superior to those of the control group (50.6%). In Dukes' C cases, the 10-year overall survival rates for the PSK group were also significantly higher than those of the control group. In cases with lymphatic invasion graded ly2-ly3 or venous invasion graded v2-v3, the 10-year overall survival rates were 80.6% in the PSK group, which were significantly superior, compared to 25.9% in the control group. Analysis by Cox's proportional hazard model showed a significant difference between the control and PSK groups. These results indicate that postoperative adjuvant immunochemotherapy with PSK greatly improves prognosis at 10 years. On the basis of these results, we recommend postoperative adjuvant immunochemotherapy combined with PSK for patients with Dukes' C and in cases with ly2-ly3 or v2-v3 invasion.

An antenatal appearance of megacystis-microcolon-intestinal hypoperistalsis syndrome.

We herein present a megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) case followed by ultrasound (US) examinations before birth. During the prenatal US examination of a 34-year-old woman, an enlarged bladder with bilateral hydronephrosis and hydroureter of the fetus were detected. The amniotic fluid was normal in the second trimester but polyhydramnios was observed in the third trimester. A female baby was born by cesarian section weighing 2632 g. Imaging studies detected an enlarged bladder with bilateral hydronephrosis, hydroureter and microcolon. Laparotomy on the 9th day confirmed a short small bowel with caliber change and the existence of ganglion cells and plexus of the nerve in the intestine. These findings correlated with the previously reported characteristics of MMIHS. An enlarged bladder in the second trimester and polyhydramnios in the third trimester have been reported in many cases of MMIHS. These findings may thus help to accurately diagnose MMIHS before birth.

Modification of the endoscopic management of congenital duodenal stenosis.

This report documents a new endoscopic management modality for congenital membranous stenosis in the third portion of the duodenum. Standard approaches to duodenal stenosis in newborns include a laparotomy with an enteroenterostomy, bypassing the obstruction, or a duodenoduodenostomy with excision. We successfully developed a modification of the endoscopic treatment modality for congenital duodenal diaphragm.

Association between the expression of chemokine receptors CCR7 and CXCR3, and lymph node metastatic potential in lung adenocarcinoma.

Chemokines and their receptors are essential for leukocyte trafficking, and are also involved in cancer metastasis to specific organs. Although the migration of tumor cells into the lymph nodes is an important aspect of cancer, the processes involved are poorly understood. Chemokine receptors CCR7 and CXCR3 have been shown to play an important role in tumor cell migration and lymph node metastasis. Therefore, the assessment of chemokine receptor expression on lung adenocarcinomas may improve the prediction of the spread of this carcinoma to the lymph nodes. In this study, we examined the expression and function of these two chemokine receptors (CCR7 and CXCR3) in lung adenocarcinoma. By using flow cytometry, they were detected in all of the lung adenocarcinoma cell lines examined. In the chemotaxis assays, A549 cells exhibited CCL21-induced migration, which was significantly suppressed by neutralizing anti-CCR7 antibody. The CXCL10-induced migration of A549 cells was also significantly suppressed by neutralizing anti-CXCR3 antibody. In clinical lung adenocarcinoma samples, we found the expression of CCR7 and CXCR3 in 65 and 90% cases, respectively, most of which had lymph node metastasis. Importantly, the expression of CCR7 was significantly associated with lymph node metastasis, although the expression of CXCR3 was not. These results suggest that the activation of CCR7 and CXCR3 with their ligands preferentially stimulates lung adenocarcinoma metastasis to the draining lymph nodes.

Alpha-fetoprotein (AFP)-producing adrenocortical carcinoma--long survival with various therapeutic strategies including a lung resection: report of a case.

We experienced a very rare case of late pulmonary metastasis from ACC. The patient was a 40-year-old woman who had undergone a left adrenectomy 12 years earlier. Instead of a large metastatic lung tumor with hemothorax and the existence of metastases in other organs, combined therapy of repeated resections for metastases and adjuvant therapy allowed for almost a 36-month survival following the first recurrence and a good quality of life. In addition, a blood and pathological study revealed that the tumor in this case was an alpha-fetoprotein-producing ACC, which is, as far as we could ascertain, the first case of its kind.