Evaluation of vascular anatomy for colon cancer located in the splenic flexure using the preoperative three-dimensional computed tomography angiography with colonography.

PURPOSE: The aim of this study is to reveal the vascular branching variation in SFC (splenic flexure cancer) patients using the preoperative three-dimensional computed tomography angiography with colonography (3D-CTAC). METHODS: We retrospectively analyzed patients with SFC who underwent preoperative 3D-CTAC between January 2014 and December 2019. RESULTS: Among 1256 colorectal cancer (CRC) patients, 96 (7.6%) manifested SFC. The arterial branching from the superior mesenteric artery (SMA) was classified into five patterns, as follows: (type 1A) the left branch of middle colic artery (LMCA) diverged from middle colic artery (MCA) (N = 47, 49.0%); (2A) the LMCA diverged from the MCA and the accessory middle colic artery (AMCA) (N = 26, 27.1%); (3A) the LMCA independently diverged from the SMA (N = 16, 16.7%); (4A) the LMCA independently diverged from the SMA and AMCA (N = 3, 3.1%); (5A) only the AMCA and the LMCA was absent (N = 4, 4.1%). Venous drainage was classified into four patterns, as follows: (type 1V) the SFV flows into the inferior mesenteric vein (IMV) then back to the splenic vein (N = 50, 52.1%); (2V) the SFV flows into the IMV then back to the superior mesenteric vein (SMV) (N = 19, 19.8%); (type 3V) the SFV independently flows into the splenic vein (N = 3, 3.1%); (type 4V) the SFV is absent (N = 24, 25.0%). CONCLUSION: 3D-CTAC could reveal accurate preoperative tumor localization and vascular branching. These classifications should be helpful in performing accurate complete mesocolic excision and central vessel ligation for SFC.

Application and outcomes of a standardized lymphadenectomy in laparoscopic right hemicolectomy requiring ligation of the middle colic artery.

BACKGROUND: Complete mesocolic excision with central vessel ligation may be important for accurate staging and improving the prognosis of right-sided colon cancer. Although the procedure is often performed laparoscopically, approaching the middle colic artery (MCA) is technically demanding, especially when complete ligation of arteries at their roots is desired. We standardized our laparoscopic approach by establishing the dissection boundary along the superior mesenteric artery to achieve D3 lymphadenectomy in the region of the MCA. The aim of the present study was to evaluate, on the basis of perioperative and short-term oncologic outcomes, the feasibility and safety of our technique METHODS: We conducted a retrospective study on consecutive patients with cancer located at the ascending colon and transverse colon who had laparoscopic right hemicolectomy requiring ligation of the MCA. RESULTS: There were 41 patients (22 males, median age 71 years [range 49-86] years). The median operation time was 285 min, and blood loss volume was 40 mL. Conversion to open surgery was required in 1 case. Complications that were Clavien-Dindo grade III or above occurred in 3 patients (7.3%). There was no anastomotic leakage. The median number of lymph nodes harvested was 46. CONCLUSIONS: Our technique was shown to be a safe, feasible, and useful strategy for performance of right hemicolectomy requiring ligation of the MCA in cases of colon cancer. The technique facilitates maximal lymph node dissection. Having obtained favorable outcomes, we look forward to investigation into long-term outcomes.

A New Statistical Model Identified Two-thirds of Clinical T1 Gastric Cancers as Possible Candidates for Endoscopic Treatment.

BACKGROUND: Clinical T1 gastric cancer has low metastatic potential to lymph nodes and is generally curable by local treatment. Endoscopic resection can preserve the whole stomach and does not impair the patient's quality of life; however, its indication is strictly limited to the subset of patients without nodal metastasis. The study was designed to predict reliably the patients without nodal metastasis based only on the clinical information. METHODS: We examined patients with clinical T1 disease who were treated with surgery. The clinically available information was evaluated for its ability to predict nodal metastasis by logistic regression model. Then, the predictive ability of the logistic regression model using the risk factors for nodal metastasis was evaluated by a receiver operating characteristic curve. RESULTS: A total of 511 patients were entered into this study. The clinical depth (cT1a or cT1b), maximal tumor diameter, and pathological type were confirmed to be significantly different between patients with and without nodal metastasis. The cutoff value of the tumor diameter differed depending on the histology and clinical depth: 79 mm for differentiated type and 48 mm for undifferentiated type in cT1a tumors, and 43 mm for differentiated type and 11 mm for undifferentiated type in cT1b tumors. According to these criteria, 348 of the 511 patients (68.1 %) were classified to have predictive N0 status. The negative predictive value was 95.7 % (95 % confidence interval 94.0-97.5 %). CONCLUSIONS: The predictive criteria based on the multivariate logistic model identified that almost two-thirds of the patients with clinical T1 gastric cancer were possible candidates for endoscopic treatment.

Diagnostic value of computed tomography for staging of clinical T1 gastric cancer.

BACKGROUND: T1 gastric cancer can be diagnosed only by endoscopy and is almost curable by local treatment. It has been unclear how a multidetector-row computed tomography (CT) evaluation is valuable for clinical T1 patients. METHODS: Patients with clinical T1 disease, as diagnosed by endoscopy and treated with endoscopic submucosal dissection (ESD) or surgery between October 2000 and October 2007, were examined. The efficacy of CT was evaluated by the reversal rate of endoscopic T1 by CT, the incidence of clinical M1 disease, and the accuracy of diagnosing pathological N+ disease in patients who received surgery. To confirm metachronous distant and nodal metastases, the disease-free survival (DFS) also was evaluated. RESULTS: A total of 761 patients, 236 treated by ESD and 525 treated with surgery, were examined. None of the patients had an endoscopic diagnosis of clinical T1 reversed by CT. No clinical M1 disease was found. Among the 525 patients who underwent surgery, 8 showed clinical N+ disease (1.5 %), while 47 demonstrated pathological N+ disease (8.9 %). The accuracy, sensitivity, specificity, positive predictive value, and negative predictive values were 90.3, 4.3, 98.7, 25, and 91.3 %, respectively. The 5-year DFS rate was 93.6 % (95 % confidence interval 91.4-95.8 %). CONCLUSIONS: The present study suggests that diagnostic value of CT is limited for staging of clinical T1 gastric cancer patients, because the reversal rate of endoscopic T1 by CT was very low, clinical M1 disease was rare, the diagnosis of N+ status was unreliable, and metachronous M1 and N+ findings were rare.

[Pulmonary metastasis of metachronous triple cancer occurring in a young patient].

A 24-year-old patient who developed pulmonary metastasis of metachronous triple cancer was presented. She had undergone surgery and combined chemotherapy for osteosarcoma of the right humerus in 1993. Then, she was followed-up without any sign of recurrence. She felt accidentally a lump of the right breast so she had visited a hospital for a work-up in 2004. The detailed examination proved that the right breast mass was primary breast cancer so the right mastectomy was carried out. Moreover, the left mastectomy was also carried out for the primary breast cancer in 2005. Additionally, a solitary nodule shadow was detected by computed tomography in 2007 so she had thoracoscopic partial resection of right middle lobe. Histopathologically, the tumor was diagnosed metastasis from the left breast cancer. It is unlikely that familial cancer disease was the underlying cause because she had no family history of cancer. A more likely explanation is that there is the influence of combined chemotherapy during puberty.

[Surgical treatment for pulmonary aspergillosis with hyper immunoglobulin-E syndrome; report of a case].

A 6-year-old girl who had been diagnosed as hyper immunoglobulin-E syndrome, was admitted to the department of pediatrics of our institute in May 2006, because of pulmonary aspergillosis. The chest X-ray showed bilateral cavities with niveau and fungus ball in the left middle lung field. In spite of medical treatment by antibiotics and antimycotics, the lesions did not improve. Therefore, bilateral lobectomy was done. After surgery, she needed re-operation twice, because of prolonged air leakage. There are few reports of lung surgery for the patient with the hyper immunoglobulin-E syndrome, and we present our case and review previous 2 case reports in the Japanese literature.

Technique and assessment of sentinel lymph node biopsy usefulness in laparoscopy-assisted distal gastrectomy.

BACKGROUND: Recently, some studies have suggested that sentinel node biopsy also can be applied to gastric cancer. The authors apply sentinel lymph node biopsy in laparoscopy assisted distal gastrectomy to perform it as safe limited surgery. Limited surgery is a procedure in which the extent of lesion resection and lymph node dissection is reduced. The authors demonstrate that intraoperative diagnosis of lymph node metastasis is useful in this respect. METHODS: The study was conducted with 38 patients (29 men and 9 women) who had a preoperative diagnosis of T1 tumor invasion. The patients had a mean age of 66.2 years. Patent blue (1%) was injected submucosally into four or five different sites around the primary tumor at 1 ml per site. Blue-stained lymphatics and lymph nodes could be seen by turning over the greater omentum and the lesser omentum extraperitoneally. If blue nodes were found, biopsy was performed. RESULTS: The mean number of blue nodes dissected was 2.5 +/- 1.9. Intraoperative identification and biopsy of blue nodes could be performed for 35 (92.1%) of the 38 patients. Of the 35 patients in whom blue nodes were identified, 4 (9.7%) had metastases in blue nodes confirmed by intraoperative frozen-section diagnosis. Intraoperative frozen-section diagnosis was negative for blue node metastasis in 31 patients. Postoperative permanent section diagnosis also showed no evidence of lymph node metastasis in these 31 patients (100% accuracy, 0% false-negative rates). CONCLUSION: The reported method allows observation of blue-stained lymphatics up to 2 h after patent blue injection. Sentinel node biopsy was performed in laparoscopy assisted distal gastrectomy, making it technically equivalent to open gastrectomy. Sentinel node biopsy can serve as a method to determine the appropriate use of laparoscopy assisted distal gastrectomy for management of T1 gastric cancer.

[Completion pneumonectomy for pulmonary aspergillosis with hyper immunoglobulin-E syndrome].

A 22-year-old man was admitted to the department of pediatrics of our institute in February 2005, because of pulmonary aspergillosis. He had been diagnosed as hyper immunoglobulin-E syndrome in infancy, and repeated pulmonary infectious desease, such as pulmonary aspergillosis. He received art of right upper lobectomy by pulmonary aspergillosis at the age of 17. In February 2005, he had hemosputum and the chest X-ray showed a giant cavity with niveau in the right lung. In spite of medical treatment by antibiotics and antimycotics, the lesion rapidly increased in size. Therefore, right completion pneumonectomy and omentopexy around the bronchial stump was done. His postoperative course was uneventful.

Postoperative functional evaluation of pylorus-preserving gastrectomy for early gastric cancer compared with conventional distal gastrectomy.

BACKGROUND: Malnutrition, gallbladder dysfunction, dumping syndrome, reflux esophagitis, and gastritis of the remnant stomach are unfavorable sequelae in patients undergoing gastrectomy. Operative procedures should be improved to ensure such patients a satisfactory quality of life. METHODS: After operation, gallbladder function, reflux gastritis, gastric emptying, and caloric intake were evaluated in 20 patients with early gastric cancer undergoing pylorus-preserving gastrectomy (PPG) and 25 patients undergoing conventional distal gastrectomy (CDG). RESULTS: The resting gallbladder area increased significantly after CDG. In contrast, after PPG the gallbladder area showed no significant change and the contraction rate decreased slightly. After CDG, emptying was much more rapid for the first 30 minutes after ingestion of a meal. Although delayed emptying was observed early after PPG, the rate of emptying increased with time. Gastric pH was lower and gastric mucosal injury was milder in patients undergoing PPG. These results are attributed to preserved pyloric function. The caloric intake and changes in body weight after operation were similar in both the CDG and PPG groups. CONCLUSIONS: PPG has advantages over CDG in terms of gallbladder function, the condition of the remnant stomach, and gastric emptying, PPG should be used in carefully selected patients with early gastric cancer to improve their quality of life.

Enhancement of CDDP cytotoxicity by caffeine is characterized by apoptotic cell death.

Through the use of STKM-1 human stomach cancer cells, we investigated the enhancement of the anti-tumor effect and the apoptosis induction of the CDDP and caffeine combination. Even when the concentration of CDDP was low, CDDP significantly decreased the proliferation of STKM-1 human stomach cancer cells, thus confirming the synergistic effect of the CDDP and caffeine group. The apoptotic labeling index of the CDDP plus caffeine combination was significantly higher than that of the CDDP group. In conclusion, caffeine enhanced the effect of CDDP by not only inhibiting DNA repairs but also inducing apoptosis.

Role of nitric oxide in human gastric cancer cells treated with 5-fluorouracil.

We examined whether 5-fluorouracil (5-FU) induces nitric oxide (NO) production and evaluated the role of NO in antitumor activity in human gastric cancer cells. MKN-1 gastric cancer cells were treated with the IC50 of 5-FU in the presence of interferon-gamma (IFN-gamma). In addition, s-methylisothiourea (an antagonist of inducible nitric oxide synthase) or anti-TNF-alpha antibody was added to the culture medium. Production of NO was measured by nitrite assay, TNF-alpha was measured by enzyme-linked immunoabsorbent assay, antitumor activity was evaluated by 3-[4,5-dimethylethiazol-2-yl]-2,5-dipheniltetrasolium bromide (MTT) assay. After 5-FU treatment in the presence of IFN-gamma, NO and TNF-alpha were produced and anti-tumor activity was enhanced. In contrast, s-methylisothiourea abolished the antitumor activity of 5-FU treatment. Anti-TNF-alpha antibody inhibited NO production and decreased the antitumor activity. 5-FU induces NO production by gastric cancer cells, and NO participates in antitumor activity in gastric cancer cells. These effects may be mediated by TNF-alpha production.

Expression of CA19-9, SLX, STN and CEA in relatively early gastric carcinoma.

Expression and presence of the carbohydrate antigens CA19-9, SLX and STN, and CEA in tissues and serum were examined in 132 patients with early or propria muscle invaded gastric cancer. The seropositive rate was not different in patients with cancer or gastritis. In tumor tissue, the positive rate for these antigens was 28.8% in CA19-9, 9.1% in SLX, 47.0% in STN and 72.9% in CEA. Results showed that gastric cancers, even at an early stage, produce abnormal carbohydrate antigens not detected in normal tissues. However, transfer of antigens into the circulation was not observed in patients with early gastric cancer, suggesting the possibility that number of carcinoma cells may be involved in the transfer of antigens into blood.

Combined effect of CDDP and caffeine against human gastric cell line in vivo.

This study was conducted to clarify the enhancement of the anti-tumor effect of CDDP by caffeine using a tumor-bearing peritoneal disseminated metastasis model in vivo. To evaluate the combined effect of CDDP and caffeine on the survival in vivo, nude mice bearing STKM-1 gastric cancer cells were administered CDDP alone, caffeine alone, or in both combination intraperitoneally. Treatment was started from 8 days after tumor inoculation. The combination of CDDP and caffeine more markedly prolonged the survival time than CDDP alone or caffeine alone. In conclusion, the results of the present in vivo study suggest that clinical application of caffeine in combination with CDDP might be effective against peritoneal disseminated metastasis in gastric cancer patients.

Clinicopathologic differences between gastric remnant cancer and primary cancer in the upper third of the stomach.

BACKGROUND: The prognosis of gastric remnant cancer is considered to be poor compared with that of primary cancer. MATERIALS AND METHODS: This study was conducted to elucidate the differences of clinicopathologic findings and treatment results between 59 patients with gastric remnant cancer (GRC) and 579 patients with primary proximal gastric cancer (PGC). RESULTS: There was no significant difference in the incidence of lymph node metastasis between GRC and PGC. However, changes in the metastatic pattern to lymph nodes were observed in GRC. In GRC, the tumor easily invaded the neighboring organs due to the adhesions around the remnant stomach, resulting in a low resectability with curative intent. The 5-year survival rate after curative resection for advanced GRC was 50.9%. GRC patients without serosal invasion had a good prognosis. CONCLUSION: Although the survival rate after curative resection for GRC patients was similar to that of PGC, GRC patients without serosal invasion had a better prognosis. Therefore, early detection is an important way to improve overall survival in GRC.

The detection of microscopically disseminated cancer cells in the abdominal cavity by intraoperative lavage cytology combined with an immunocytochemical method in gastric cancer.

This study was conducted to clarify the possible role of the immunocytochemical examination of intraoperative lavage cytology in gastric cancer. The expression of CA19-9, STN, SLX and CEA in tissues were examined in 70 patients with advanced gastric cancer who underwent gastric resection. The tissue sections were processed with the hematoxylin and eosin staining and immunostaining using the avidin-biotin-peroxidase complex (ABC) method. Fifty one patients underwent the lavage cytology. The cytologic samples were stained by the conventional Papanicolau method and ABC immunocytochemical method. Expression of CEA was detected at obviously higher frequency than those of the 3 carbohydrate antigens. The method combined with 4 antibodies increased the detection rate to 97.2%. Conventional lavage cytology was positive in 16 out of 51 patients. The diagnosis of class III in four patients was changed to class V through the immunocytochemical examination. The immunocytochemical examination of lavage cytology is very useful to verify the microscopically disseminated cancer cells in gastric cancer.

A case of segmental primary sclerosing cholangitis.

A 74-year-old man was admitted to the Yokohama City University School of Medicine for investigation of high values of ALP and Y-GTP. Radiographic examinations, including abdominal computed tomography and percutaneous transhepatic cholangiography, strongly suggested bile duct cancer in the hepatic hilus. After left lobectomy, pathological examination disclosed segmental primary sclerosing cholangitis. Clinical examination cannot always distinguish primary sclerosing cholangitis from cancer. We report a case of segmental primary sclerosing cholangitis and discuss the diagnosis and the treatment of this disease.

The efficacy of 1 alpha hydroxy vitamin D3 treatment of the metabolic bone disorder in patients who underwent gastrectomy for gastric cancer.

BACKGROUND/AIMS: The aim of this study was to elucidate the efficacy of 1 alpha hydroxy vitamin D3 for treatment of metabolic bone disorder after gastrectomy. METHODOLOGY: MD-MS method was performed in 16 patients who underwent gastrectomy to evaluate the metabolic bone disorder and compared before and after 1 alpha hydroxy vitamin D3 treatment. The symp-toms related to the metabolic bone disorder were also analyzed through patient interview. RESULTS: The severity of the metabolic bone disorder analyzed by the MD-MS method improved after 1 alpha hydroxy vitamin D3 treatment in 56.3% of patients. The deviation degree of the cortical bone density was also significantly improved. The symptoms related to metabolic bone disorder disappeared in 80% of patients after treatment. CONCLUSIONS: The administration of 1 alpha hydroxy vitamin D3 may be useful for the metabolic bone disorder in the treatment of patients after gastrectomy.

Helicobacter pylori of remnant stomach and optimal dose of amoxicillin for eradicating Helicobacter pylori.

BACKGROUND/AIMS: The optimal dose of antibiotics for Helicobacter pylori eradication is not known. The aim of this study was to evaluate optimal dose of antibiotics (amoxicillin) for eradication of H. pylori in the remnant stomach. METHODOLOGY: Biopsy specimens were obtained from 77 patients who underwent gastrectomy for gastric cancer. H. pylori was subsequently diagnosed by rapid urease test and culture. Gastritis was assessed by scoring. Patients with positive H. pylori were eligible for the eradication study. Amoxicillin 750 mg per day for 2 weeks and omeprazole 20 mg per day for 8 weeks were administered to them. Endoscopic reexamination and 13C-urea breath test were performed 12 weeks after the initiation of treatment. RESULTS: The positive rate of H. pylori was 38.9% in the remnant stomach. Eradication rate was 50.0%. Mean dose of amoxicillin in effective cases was 14.1 +/- 1.5 mg/kg/day. This was significantly higher than that in non-effective cases (12.5 +/- 1.5 mg/kg/day). Remnant gastritis was significantly improved after complete eradication. CONCLUSIONS: H. pylori was present in 38.9% of patients who underwent gastrectomy for gastric cancer. The optimal dose of amoxicillin was 15.6 mg/kg/day for 14 days with omeprazole-amoxicillin therapy.

Hemostasis of colonic diverticular bleeding with hemoclips under endoscopic control: report of a case.

This paper reports a case in which endoscopic hemostasis of a bleeding colonic diverticula was successful with endoscopic hemoclip. The patient, a 53 year-old man with painless hematochezia, was urgently admitted to our institute. After colonic cleaning preparation, colonoscopic examination was performed. At the bottom of the diverticulum of the ascending colon, a vessel with oozing blood was endoscopically noted. Hemoclips were placed on and around the visible vessel and immediate hemostasis was completed. Endoscopic clipping method for management of bleeding diverticular vessel is an effective, simple, and safe procedure.