Effectiveness of intervention with a perioperative multidisciplinary support team for radical esophagectomy.

PURPOSE: We aimed to evaluate the effectiveness of intervention by a perioperative multidisciplinary support team for radical esophagectomy for esophageal cancer. METHODS: We retrospectively reviewed 85 consecutive patients with esophageal cancer who underwent radical esophagectomy via right thoracotomy or thoracoscopic surgery with gastric tube reconstruction. Twenty-one patients were enrolled in the non-intervention group (group N) from May 2011 to September 2012, 31 patients in the perioperative rehabilitation group (group R) from October 2012 to April 2014, and 33 patients in the multidisciplinary support team group (group S) from May 2014 to September 2015. RESULTS: Morbidity rates were 38, 45.2, and 42.4% for groups N, R, and S, respectively. Although there were no significant differences in the incidence of pneumonia among the groups, the durations of fever and C-reactive protein positivity were shorter in group S. Moreover, postoperative oral intake commenced earlier [5.9 (5-8) days] and postoperative hospital stay was shorter [19.6 (13-29) days] for group S. CONCLUSIONS: The intervention by a perioperative multidisciplinary support team for radical esophagectomy was effective in preventing the progression and prolongation of pneumonia as well as earlier ambulation, oral feeding, and shortening of postoperative hospitalization.

Association between genomic alterations and metastatic behavior of colorectal cancer identified by array-based comparative genomic hybridization.

Colorectal cancers (CRCs) exhibit multiple genetic alterations, including allelic imbalances (copy number alterations, CNAs) at various chromosomal loci. In addition to genetic aberrations, DNA methylation also plays important roles in the development of CRC. To better understand the clinical relevance of these genetic and epigenetic abnormalities in CRC, we performed an integrative analysis of copy number changes on a genome-wide scale and assessed mutations of TP53, KRAS, BRAF, and PIK3CA and DNA methylation of six marker genes in single glands isolated from 39 primary tumors. Array-based comparative genomic hybridization (array-CGH) analysis revealed that genomic losses commonly occurred at 3q26.1, 4q13.2, 6q21.32, 7q34, 8p12-23.3, 15qcen and 18, while gains were commonly found at 1q21.3-23.1, 7p22.3-q34, 13q12.11-14.11, and 20. The total numbers and lengths of the CNAs were significantly associated with the aberrant DNA methylation and Dukes' stages. Moreover, hierarchical clustering analysis of the array-CGH data suggested that tumors could be categorized into four subgroups. Tumors with frequent DNA methylation were most strongly enriched in subgroups with infrequent CNAs. Importantly, Dukes' D tumors were enriched in the subgroup showing the greatest genomic losses, whereas Dukes' C tumors were enriched in the subgroup with the greatest genomic gains. Our data suggest an inverse relationship between chromosomal instability and aberrant methylation and a positive association between genomic losses and distant metastasis and between genomic gains and lymph node metastasis in CRC. Therefore, DNA copy number profiles may be predictive of the metastatic behavior of CRCs.

Axillary schwannoma mimicking lymph node metastasis-associated breast cancer: a case report.

BACKGROUND: Axillary schwannoma associated with breast cancer is an extremely rare disease, and previous reports have been limited. In this setting, there is great concern about whether a tumor in the axillary region is lymph node metastasis. Herein, we report a unique case of axillary schwannoma that mimicked lymph node metastasis associated with breast cancer. CASE PRESENTATION: A 68-year-old woman who underwent mastectomy and axillary lymph node dissection for right breast cancer over 20 years ago presented to our hospital with numbness and weakness in the right arm for 6 months. Ultrasonography, computed tomography, and magnetic resonance imaging showed a 20-mm well-circumscribed round tumor in the right axillary region. Initially, she was suspected of having lymph node metastasis-associated breast cancer, but the result of the core needle biopsy was a schwannoma. The patient underwent tumor enucleation. The patient has had no recurrence 1 year after the operation. CONCLUSION: Axillary schwannomas often mimic lymph node metastasis in patients with a history of malignancy, particularly breast cancer. To select the optimal treatment, the clinicians should make as accurately as possible a diagnosis, with histopathological examinations, when examining patients with cancer who develop tumors in the axillary region.

Geriatric nutritional risk index as a risk-factor for Clostridioides difficile infection relapse in elderly Japanese patients.

Objective: Old age is a risk factor for Clostridioides difficile infection (CDI). As the world's aging population increases, identifying risk factors for CDI in elderly patients is a matter of urgency. This study examined the relationship between CDI relapse and nutritional status using the geriatric nutritional risk index (GNRI). Patients and Methods: Between January 2016 and December 2021, 108 patients were diagnosed with CDI. Of the 108 patients, 19 were excluded because of younger age (<65 years), early death within 14 days of the initial CDI diagnosis, and insufficient data. The patients were divided into low- (<75) and high-GNRI groups (≥75) based on the receiver operating characteristic curve analysis. Variables associated with CDI relapse were also analyzed. Results: The median GNRI scores in all patients and in the low- and high-GNRI groups were 74.9, 68.9, and 83.9, respectively. Of the 89 patients, 28 (31.8%) experienced a CDI relapse. The log-rank test showed a significantly better relapse-free survival (RFS) in the high GNRI group (P=0.002). Univariate analysis revealed that low GNRI (P=0.004), chronic kidney disease (CKD) (P=0.004), and beta-lactamase inhibitor administration before the initial diagnosis of CDI (P=0.025) were significantly correlated with RFS. Multivariate analysis revealed that low GNRI (P=0.008) and CKD (P=0.010) were independent prognostic factors for RFS. Conclusion: Among elderly patients, a low GNRI was strongly associated with CDI relapse. Our study may help clinicians to consider therapeutic strategies for elderly patients with CDI.

Analysis of somatic copy number alterations in biliary tract carcinoma using a single nucleotide polymorphism array.

AIM: Biliary tract carcinoma (BTC), including gall bladder carcinoma (GBC) and biliary duct carcinoma (BDC), has a poor prognosis. Comprehensive genomic profiling has important roles in evaluation of the carcinogenesis of BTC. MATERIALS & METHODS: We examined somatic copy number alterations (SCNAs) using a single nucleotide polymorphism array system to analyze 36 BTC samples (11 GBCs and 25 BDCs). RESULTS: In hierarchical cluster analysis, two clusters were identified (subgroup 1 with low SCNAs and subgroup 2 with high SCNAs). GBC was predominant in subgroup 1, whereas BDC was predominant in subgroup 2, suggesting that GBC and BDC had different genetic backgrounds in terms of SCNAs. CONCLUSION: These findings could be helpful for establishing the molecular carcinogenesis of BTCs.

Analysis of cell cycle-related proteins in gastric intramucosal differentiated-type cancers based on mucin phenotypes: a novel hypothesis of early gastric carcinogenesis based on mucin phenotype.

BACKGROUND: Abnormalities of cell cycle regulators are common features in human cancers, and several of these factors are associated with the early development of gastric cancers. However, recent studies have shown that gastric cancer tumorigenesis was characterized by mucin expression. Thus, expression patterns of cell cycle-related proteins were investigated in the early phase of differentiated-type gastric cancers to ascertain any mechanistic relationships with mucin phenotypes. METHODS: Immunostaining for Cyclins D1, A, E, and p21, p27, p53 and beta-catenin was used to examine impairments of the cell cycle in 190 gastric intramucosal differentiated-type cancers. Mucin phenotypes were determined by the expressions of MUC5AC, MUC6, MUC2 and CD10. A Ki-67 positive rate (PR) was also examined. RESULTS: Overexpressions of p53, cyclin D1 and cyclin A were significantly more frequent in a gastric phenotype than an intestinal phenotype. Cyclin A was overexpressed in a mixed phenotype compared with an intestinal phenotype, while p27 overexpression was more frequent in an intestinal phenotype than in a mixed phenotype. Reduction of p21 was a common feature of the gastric intramucosal differentiated-type cancers examined. CONCLUSIONS: Our results suggest that the levels of some cell cycle regulators appear to be associated with mucin phenotypes of early gastric differentiated-type cancers.

Primary retroperitoneal spindle cell liposarcoma: pathological and immunohistochemical findings.

Spindle cell liposarcoma (SCLS) is presently regarded as a rare variant of well-differentiated liposarcoma (WDLPS), which has the potential for aggressive clinical behavior. WDLPS occurs most frequently in the limbs and retroperitoneum. The most common site of SCLS occurrence is the upper limbs or shoulder girdle. Herein we report the first case of primary retroperitoneal SCLS. A 60-year-old Japanese man presented with a right inferior abdominal mass. Complete excision of the mass displayed a yellowish spherical tumor with a well-circumscribed appearance measuring 98 x 95 mm. Pathological examination of the tumor revealed a neural-like spindle cell proliferation set in a fibrous background that was associated with an atypical lipomatous component, which usually included lipoblasts. Mitotic cells were scarce. Immunohistochemical analysis demonstrated that lipoblasts were S100 positive, spindle cells were CD34 positive, and both spindle cells and lipoblasts were MDM2 negative. The Ki-67 labeling index was <2%. At one year follow up, the patient was alive without local recurrence or metastasis. Although the proliferative activity of this tumor did not indicate strong malignancy, retroperitoneal liposarcoma generally has a poor prognosis. Accumulation of cases of SCLS is necessary to facilitate a more accurate evaluation of the pathology and clinical behavior of this tumor.

Peripheral vein infusions of amino acids facilitate recovery after esophagectomy for esophageal cancer: Retrospective cohort analysis.

BACKGROUND: To investigate the efficacy of amino acid administration via peripheral veins in addition to conventional enteral feeding following esophagectomy. MATERIALS AND METHODS: Retrospective analysis of data pertaining to 33 patients with esophageal cancer who underwent radical esophagectomy and satisfied the required nutrition control. Patients were divided into the amino acid group (n = 17) and control group (n = 16). Primary outcomes were albumin (Alb) and prealbumin (PreAlb) levels, urinary 3-methylhistidine/creatinine (3-MeHis/Cre) ratios, nitrogen balance, and weight; postoperative complications were noted as secondary outcomes. RESULTS: Alb levels were significantly higher in the amino acid group on postoperative day (POD)-14 (3.4 ± 0.3 vs. 3.1 ± 0.4 mg/dL in the control group, p = 0.018) and at 1 month after surgery (3.8 ± 0.4 vs. 3.5 ± 0.3 mg/dL, p = 0.045). No significant differences were observed in PreAlb and urinary 3-MeHis/Cre rates between the treatment groups. Body weights at 3 months postoperatively were decreased by 6% and 3% in the control and amino acid groups, respectively. CONCLUSION: Peripheral venous administration of amino acids soon after surgical stress is an effective method for nutritional control.

Downregulation of ST6GALNAC1 is associated with esophageal squamous cell carcinoma development.

Tylosis is an inherited disorder characterized by abnormal palmoplantar skin thickening and a highly elevated risk of esophageal squamous cell carcinoma (ESCC). Analyses of tylosis in families have localized the responsible gene locus to a region of chromosome 17q25.1. Frequent loss of heterozygosity (LOH) in 17q25.1 was also observed in the sporadic form of ESCC. A putative tumor suppressor gene for ESCC may exist at this locus. We investigated the expression patterns of genes on 17q25.1 in tumor and corresponding normal tissues from patients with sporadic ESCC using RNA sequence analysis. For candidate genes, quantitative real-time reverse transcription-PCR (qRT-PCR), direct sequence, LOH and methylation analyses were performed using 93 clinical ESCC samples and 10 cell lines. A significant downregulation of ST6GALNAC1 was demonstrated in ESCC tissues compared to its expression in normal tissues by qRT-PCR (n=93, p<0.0001). Frequent LOH (17/27, 62.9%) and hyper­methylation in ST6GALNAC1 were also observed in all cell lines. Our results indicated that ST6GALNAC1 was downregulated in sporadic ESCC via hyper-methylation and LOH, and it may be a candidate responsible gene for ESCC. Furthermore, recent studies suggest that multiple genes on chromosome 17q25 are involved in ESCC development.

Two-stage surgery to repair a dissecting abdominal aortic aneurysm in a severely obese patient: Open bifurcated graft replacement after laparoscopic sleeve gastrectomy.

With the increasing prevalence of severe obesity worldwide, surgical treatment for severely obese patients is becoming more popular. Bariatric surgery has occasionally been performed as a precursor to major operations for serious diseases to make these difficult surgeries safer for severely obese patients. We present the case of a severely obese patient with a dissected abdominal aortic aneurysm and left iliac artery aneurysm. Initially, we performed bariatric surgery on this patient to reduce perioperative risk and then subsequently performed bifurcated graft replacement. A 54-year-old man presented at our hospital for bariatric surgery before open abdominal aortic aneurysm repair. Laparoscopic sleeve gastrectomy was performed; 15 months later, the patient's weight and BMI had decreased from 139.0 kg to 97.6 kg and from 48.7 kg/m(2) to 34.2 kg/m(2) , respectively. Bifurcated graft replacement was performed safely without postoperative complications. Bariatric surgery was also effective in controlling the patient's blood pressure during the interval between surgeries.

Successfully treated advanced esophageal cancer with left axillary lymph node metastasis and synchronous right breast cancer: a case report.

The incidence of double cancer of the esophagus and breast is rare, and axillary lymph node metastasis (ALM) in esophageal cancer is also very rare. We report a case of advanced esophageal cancer with left ALM and synchronous right breast cancer. A 64-year-old woman was admitted to our hospital with dysphagia. The clinical diagnosis was esophageal cancer (T3N0M1 stage IV) and right breast cancer (T1cN0M0 stage I). She was initially treated with triple chemotherapy with docetaxel, cisplatin, and 5-fluorouracil. The primary lesion in the esophagus achieved almost complete response as assessed by esophageal endoscopy. A computed tomography scan showed that the left ALM reduced in size and that stable disease was achieved for the right breast cancer. She underwent partial mastectomy of the right breast and bilateral axillary lymph node dissection. The histopathological diagnosis of the breast cancer was T1cN1M0 stage IIA. The lymph nodes from the left axilla contained metastatic cells from the squamous cell carcinoma of the esophagus. Complete response was achieved for the primary lesion in the esophagus following chemoradiotherapy (CRT), and the patient has been relapse free 2 years after treatment. Thus, we report the successful treatment of synchronous double cancers of the esophagus with left ALM and right breast by combination therapy with chemotherapy, CRT, and surgery.

Effectiveness of neoadjuvant chemotherapy with cisplatin and irinotecan followed by surgery on small-cell carcinoma of the esophagus: A case report.

INTRODUCTION: Small-cell carcinoma of the esophagus (SCCE) is a rare disease with aggressive progression and a poor prognosis. A standard treatment strategy for SCCE is yet to be established. PRESENTATION OF CASE: A 40-year-old woman with dysphagia was admitted to our hospital. A clinical diagnosis of SCCE (T3N1N0 stage IIIA) was established. She was initially treated with chemotherapy using cisplatin (CDDP) and irinotecan (CPT-11). After two courses of treatment, the primary lesion in the esophagus was not detectable by esophageal endoscopy. Likewise, swelling of the right recurrent nerve lymph node present prior to treatment could not be detected. The chemotherapy resulted in a complete response. One month after the conclusion of chemotherapy, radical esophagectomy with three-field lymph node dissection was performed. Histopathological examination of the excised specimen revealed no residual tumor or lymph node metastasis. The patient was discharged from hospital 29 days after surgery with no complications. The patient is alive and has remained cancer-free for 48 months after the surgery. DISCUSSION: Systemic chemotherapy for SCCE in combination with surgery was treated after surgery in most reports. Neoadjuvant chemotherapy is advantageous from three viewpoints, namely achievement of downstaging, increasing complete resection rates, and a better completion of treatment compared with postoperative chemotherapy. Neoadjuvant chemotherapy following esophagectomy could be a useful treatment option for patients with limited disease (LD) of SCCE. CONCLUSION: We report a case of SCCE achieving a pathologically complete response with neoadjuvant chemotherapy using CDDP and CPT-11, and long-term survival followed by surgery.

Curative two-stage resection for synchronous triple cancers of the esophagus, colon, and liver: Report of a case.

INTRODUCTION: Cases of synchronous triple cancers of the esophagus and other organs curatively resected are rare. PRESENTATION OF CASE: A 73-year-old man was admitted to our hospital with bloody feces. He was diagnosed with synchronous triple cancers of the esophagus, colon, and liver. We selected a two-stage operation to safely achieve curative resection for all three cancers. The first stage of the operation comprised a laparoscopy-assisted sigmoidectomy and partial liver resection via open surgery. The patient was discharged without complications. Thirty days later, he was readmitted and thoracoscopic esophagectomy was performed. Although pneumonia-induced pulmonary aspiration occurred as a postoperative complication, it was treated conservatively. The patient was discharged on postoperative day 24. DISCUSSION: Esophagectomy is a highly invasive procedure; thus, simultaneous surgery for plural organs, including the esophagus, may induce life-threatening, severe complications. Two-stage surgery is useful in reducing surgical stress in high-risk patients. For synchronous multiple cancers, the planning of two-stage surgery should be considered for each cancer to maintain organ function and reduce the stress and difficulty of each stage. CONCLUSION: We successfully treated synchronous triple cancers, including esophageal cancer, by a two-stage operation.

Long-term complete remission of metastatic breast cancer, induced by a steroidal aromatase inhibitor after failure of a non-steroidal aromatase inhibitor.

PATIENT: Female, 56 FINAL DIAGNOSIS: Breast cancer Symptoms: Solid mass in the right breast Medication: Exemestane Clinical Procedure: - Specialty: Oncology. OBJECTIVE: Unusual clinical course. BACKGROUND: The efficacy of third-generation aromatase inhibitors for hormone receptor-positive postmenopausal metastatic breast cancer is well established. Although several clinical trials have reported incomplete cross-resistance between different aromatase inhibitors, few cases of complete responses of recurrent metastatic breast cancer occurring after substituting a second aromatase inhibitor have been reported. We here present a rare case of non-steroidal aromatase inhibitor-tolerant metastatic breast cancer with long-term complete remission following substitution of a steroidal aromatase inhibitor. CASE REPORT: We present the case of a 56-year-old Japanese woman who underwent right breast-conserving surgery for breast cancer, TNM staging T1, N0, M0, Stage I. She received adjuvant chemotherapy with 6 cycles of FEC100 and radiation therapy, and then began hormonal therapy with anastrozole. Twelve months postoperatively, computed tomography (CT) revealed multiple lung metastases. Exemestane was substituted for anastrozole. After 3 months of exemestane, CT showed that all lung metastases had completely resolved. Her complete response was maintained for 5 years: she died during a tsunami 6 years after the initial surgery. CONCLUSIONS: Substitution of a steroidal for a non-steroidal aromatase inhibitor produced a sustained complete remission in a patient with hormonal receptor-positive postmenopausal recurrent breast cancer. Achieving complete response after switching from a non-steroidal to a steroidal aromatase inhibitor in a hormonal receptor-positive postmenopausal recurrent breast cancer contributed to a higher quality of life for the patient. Further investigation is needed to identify the predictors of long-term remission following such a switch.

Nipple adenoma arising from axillary accessory breast: a case report.

Nipple adenoma is a relatively rare benign breast neoplasm, and cases of the disease arising from the axillary accessory breast have very seldom been reported in the English literature. We report a case of nipple adenoma arising from axillary accessory breast including clinical and pathological findings. An 82-year-old woman presented with the complaint of a small painful mass in the right axilla. Physical examination confirmed a well-defined eczematous crusted mass that was 8 mm in size. The diagnosis of nipple adenoma was made from an excisional specimen on the basis of characteristic histological findings. Microscopic structural features included a compact proliferation of small tubules lined by epithelial and myoepithelial cells, and the merging of glandular epithelial cells of the adenoma into squamous epithelial cells in the superficial epidermal layer. Because clinically nipple adenoma may resemble Paget's disease and pathologically can be misinterpreted as tubular carcinoma, the correct identification of nipple adenoma is an important factor in the differential diagnosis for axillary tumor neoplasms. VIRTUAL SLIDES: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1186821489769063.

A case of gallstone ileus displaying spontaneous closure of cholecystoduodenal fistula after enterolithotomy.

INTRODUCTION: Gallstone ileus, a rare complication of cholelithiasis and cholecystitis, is a relatively rare cause of alimentary tract obstruction. It is usually associated with a cholecystoenteric fistula through which a gallstone has passed into the gastrointestinal tract. Cholecystoenteric fistula uncommonly closes spontaneously, the period between formation and closure having rarely been reported. In addition, endoscopic detection of cholecystoenteric fistulous closure has seldom been reported. PRESENTATION OF CASE: We report a 51-year-old Japanese man with gallstone ileus in whom spontaneous closure of a cholecystoduodenal fistula was observed by endoscopy 2 weeks after laparoscopy-assisted enterolithotomy. DISCUSSION: Laparoscopy-assisted enterolithotomy for gallstone ileus allows direct diagnosis of gallstone ileus and assessment of the status of adhesions affecting the biliary tract. CONCLUSION: Endoscopic confirmation of fistulous closure after laparoscopy-assisted enterolithotomy is a minimally invasive approach that may avert the need for biliary surgery.

Autopsy case of acute liver failure due to scrub typhus.

Scrub typhus (Tsutsugamushi disease) is an acute febrile disease caused by infection with Orientia tsutsugamushi transmitted by mites. Although patients with scrub typhus commonly display mild liver injury, few die of acute liver failure. We describe herein an autopsy case of acute liver failure due to scrub typhus, which was complicated by disseminated intravascular coagulation and showed rapid progression of liver injury just before death. Histopathological findings revealed submassive hepatocellular necrosis, inflammatory cell infiltration in Glisson's capsules, and sporadic fibrin thrombi in the hepatic sinusoids. Cause of death was primarily associated with acute liver failure related to disseminated intravascular coagulation.