Extragastrointestinal stromal tumor of the greater omentum: case report and review of the literature.

Primary neoplasms of the greater omentum are rare. We report a case of omental tumors occurring in 58-year-old Japanese man. Ultrasonography showed multiple solid tumors in the abdomen and angiography identified the greater omentum as the precise location. The tumors were completely resected with the major part of the greater omentum and analyzed histologically, immunohistochemically, and genetically. Positive reactivity for CD117 (c-kit, a transmembrane tyrosine kinase receptor) and CD34, and the absence of TLS/FUS-CHOP rearrangement confirmed that the tumors were extragastrointestinal counterparts of a gastrointestinal stromal tumor. Although the higher mitotic activity measured by the Ki-67 labeling ratio suggests the malignant potential of this tumor, there was no recurrence at the 20-month follow-up.

New transhepatic biliary drainage procedures for safe intubation and early extubation.

BACKGROUND/AIMS: The conventional transhepatic biliary drainage method requires a long period of tube placement and a technically difficult intubation. METHODOLOGY: New transhepatic biliary drainage methods were applied in cases undergoing an open choledochotomy. The drainage tube was placed transhepatically using a newly developed, rigid and J-shaped needle (J-Needle) with a vertical, ventral and rotating penetration at the proximal hepatic duct. The tube was then introduced directly to the extraperitoneal space by attaching the parietal peritoneum to the liver surface without tube-fixation (extraperitoneal transhepatic tube method). RESULTS: These procedures were applied in 50 patients. The J-Needle was easily and safely inserted without any complications. In the 39 analyzed cases, the patients were safely extubated on postoperative day 7 and discharged around postoperative day 10. CONCLUSIONS: The combination of the J-Needle and the extraperitoneal transhepatic tube method is useful for safe transhepatic biliary intubation and early extubation, enabling a shorter hospital stay for patients requiring biliary surgery.

Pathologic stage I non-small cell lung cancer with high levels of preoperative serum carcinoembryonic antigen: clinicopathologic characteristics and prognosis.

OBJECTIVE: Surgery alone remains the standard therapy for patients with stage I non-small cell lung cancer. Although the preoperative serum level of carcinoembryonic antigen has been shown to be an independent prognostic factor, it has not yet been included in the staging system and does not alter the treatment strategy, especially in the selection of patients for adjuvant chemotherapy. METHODS: From 1986 to 2003, preoperative and postoperative serum carcinoembryonic antigen levels were measured in 455 patients with completely resected pathologic stage I non-small cell lung cancer. We compared the clinicopathologic characteristics and outcomes among patients who had preoperative serum carcinoembryonic antigen levels within the normal range (N group, n = 323), patients who had high carcinoembryonic antigen levels before surgery but normal levels after surgery (HN group, n = 112), and patients who had high carcinoembryonic antigen levels before and after surgery (HH group, n = 20). RESULTS: The significant characteristics of the HN group included the male sex, greater age, smoking, squamous cell histology, T2 status, lymphatic invasion, vascular invasion, and pleural invasion. Adenocarcinomas in patients of the HN group were more likely to be moderately to poorly differentiated. The 5-year survivals in the HN and HH groups were significantly lower (56.2% and 43.1%, respectively) than those in the N group (85.9%). Multivariate analysis revealed that greater age, non-adenocarcinoma histology, pleural invasion, and the carcinoembryonic antigen in the HN and HH groups were independent prognostic factors. CONCLUSION: Patients with resected pathologic stage I non-small cell lung cancer and high preoperative serum carcinoembryonic antigen levels are a subgroup with a distinctly poor prognosis who display smoking-related clinicopathologic characteristics.

Multidisciplinary treatment for advanced invasive thymoma with cisplatin, doxorubicin, and methylprednisolone.

BACKGROUND AND OBJECTIVES: Advanced invasive thymomas are not usually manageable by surgical resection and radiotherapy. We reviewed our experience with a multidisciplinary approach and evaluated chemotherapy in the treatment of invasive thymoma. PATIENTS AND METHODS: Seventeen consecutive patients with invasive thymoma were treated with multimodality therapy consisting of chemotherapy, surgery, and/or radiotherapy. Four patients had stage III disease with superior vena cava invasion, nine had stage IVa disease, and four had stage IVb disease. The chemotherapy regimen consisted of cisplatin, doxorubicin, and methylprednisolone (CAMP). Chemotherapy was administered in a neoadjuvant setting to the 14 patients and in an adjuvant setting to the remaining three patients. Surgical resection was intended in all patients. After those treatments, chemotherapy and/or radiation therapy were performed. RESULTS: All but one of the 14 patients with induction chemotherapy responded to the CAMP therapy, and the response rate was 92.9%. Seven of these patients underwent complete remission after surgical resection and chemoradiotherapy, and the others underwent partial remission. All three patients treated with surgical resection and then chemotherapy with or without radiotherapy also achieved complete remission. Tumor progression after multimodality therapy occurred in 10 patients. After retreatment, eight of these patients were alive at the time of analysis, with a median survival time after recurrence of 30 months. The 5- and 10-year overall survival rates for all patients were both 80.7%. The major side effect of CAMP therapy was acceptable neutropenia. CONCLUSIONS: CAMP therapy was highly effective for invasive thymomas, and the multimodality therapy containing this chemotherapy brought about good disease control in the majority of patients. We believe that this multidisciplinary treatment with CAMP therapy, surgery, and radiotherapy is a justifiable initial treatment for patients with advanced invasive thymoma. Furthermore, appropriate treatments are essential for the long-term survival of patients with recurrences after multimodality therapy.

Clinicopathological and immunohistochemical features of extragastrointestinal stromal tumors: report of two cases.

CD117 (c-kit proto-oncogene protein product) is expressed in most gastrointestinal stromal tumors (GISTs) and plays a crucial role in the pathogenesis and treatment of this disease. However, the clinicopathological and immunohistochemical features of CD117-positive mesenchymal tumors without connection to the gastrointestinal tract, known as extragastrointestinal stromal tumors (EGISTs), are not well documented because these tumors are rare. We describe the clinicopathological and immunohistochemical features of two cases of EGIST and compare them with those of GIST. Of the 1855 abdominal or esophageal tumors resected during the past 10 years at our hospital, 23 were GISTs and 2 were EGISTs. The clinicopathological or immunohistochemical characteristics do not seem to differ remarkably between EGISTs and GISTs. Although rare, CD117 positivity should be tested in abdominal mesenchymal tumors that have no connection to the gastrointestinal tract. The clinicopathological features of CD117-positive abdominal mesenchymal tumors may not depend on whether the tumor is connected to the gastrointestinal tract.

A case of postoperative recurrence of fibrolamellar hepatocellular carcinoma with increased vitamin B12 binding capacity in a young Japanese female.

A 17-year-old Japanese female underwent major hepatic resection for a huge fibrolamellar hepatocellular carcinoma that was compressing the inferior vena cava. The tumor was not exposed at the surgical margin but was very close to it. A recurrent lesion at the surgical margin of the liver and a lymph node metastasis were discovered 9 months postoperatively together with a marked elevation of vitamin B12 binding capacity. These lesions were resected, and vitamin B12 binding capacity decreased thereafter. Peritoneal dissemination was detected by CT 16 months postoperatively, together with recurrent elevation of vitamin B12 binding capacity. Several types of chemotherapy, including intraperitoneal injection of epirubicin, were applied and improved the patient's quality of life somewhat, but the patient died of recurrent disease 34 months after the initial hepatic resection. This is the first report in Japan of fibrolamellar hepatocellular carcinoma with increased vitamin B12 binding capacity as a useful marker. Fibrolamellar hepatocellular carcinomas, if resected, have a better prognosis than ordinary hepatocellular carcinoma in Japan, as well as in Western countries. An aggressive strategy should be chosen, which consists mainly of precise surgical resection and postoperative multimodality therapy, including chemotherapy.

A novel approach to the prevention of postoperative delirium in the elderly after gastrointestinal surgery.

PURPOSE: Postoperative delirium (POD) is known to be one of the most critical complications of major operative procedures in elderly patients. Since disorders of the sleep-wake cycle have been reported to be one of the key factors in POD, we attempted to clarify the effectiveness of improving sleep-wake cycle disorders with medication after surgery to prevent POD, by conducting a prospective randomized study of 42 elderly patients who underwent resection of either gastric or colon cancer through an open laparotomy. METHODS: The delirium-free protocol (DFP) group was given an intramuscular injection of diazepam at 20:00 h each night, as well as a continuous intravenous infusion of flunitrazepam and pethidine administered over 8 h, for the first three nights postoperatively. Two patients were excluded because of failure to complete the DFP. RESULTS: The incidence of POD was 7/20 (35.0%) in the non-DFP group and 1/20 (5.0%) in the DFP group, this difference being significant (P = 0.023). Morning lethargy produced by the DFP was observed in 40% of the DFP group; however, no other side effects were seen. CONCLUSIONS: These findings indicate that DFP treatment is effective for controlling POD in elderly patients after general surgery and does not appear to be associated with severe complications or side effects. To our knowledge, this is the first report proposing artificial control of the sleep-awake rhythm by medication as a means of preventing POD in elderly patients.