[A Case of Resected Pancreatic Adenosquamous Carcinoma with Early Hepatic Metastatic Recurrence].

A 73-year-old man was presented with epigastric pain and indicated high CA19-9 levels, and computed tomography detected a tumor in the uncinate process of the pancreas infiltrated duodenum and superior mesenteric artery. The patient was diagnosed with borderline resectable pancreatic carcinoma and received neoadjuvant chemotherapy with gemcitabine and S-1. During neoadjuvant chemotherapy, the patient also received radiotherapy to control duodenal bleeding. After neoadjuvant chemotherapy, stable disease(SD)was proven on the Response Evaluation Criteria in Solid Tumors(RECIST), and subtotal stomach-preserving pancreaticoduodenectomy was performed. The pathological findings showed pancreatic adenosquamous carcinoma. After 7 days postoperatively, hepatic metastasis was detected, and after 78 days postoperatively, the patient died.

[A Case of Scirrhous Gastric Cancer Not Diagnosed by Endoscopy but by Staging Laparoscopy].

A 71-year-old female was referred to our hospital for abdominal distention and anorexia. Gastrointestinal endoscopy revealed wall thickening of the entire circumference. Abdominal CT scan showed diffuse thickening of the stomach, but there was no obvious metastasis. Scirrhous gastric cancer was strongly suspected, but endoscopic biopsies could not demonstrate malignant features. Staging laparoscopy was performed. There was a small amount of ascites and numerous peritoneal dissemination. She was diagnosed with gastric cancer pStage Ⅳ(pT4a, NX, H0, M1, P1, CY1)without HER2 positivity. We experienced a case of scirrhous gastric cancer in which staging laparoscopy was useful for histological diagnosis and staging.

Duodenal neuroendocrine tumor after bilateral breast cancer with type 1 neurofibromatosis: a case report.

BACKGROUND: Young women with NF1 are at a high risk of developing breast cancer. Although they are at risk for abdominal tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors, follow-up strategies for other tumors after breast cancer have not yet been established. Here, we present a case of duodenal neuroendocrine tumor found during follow-up after bilateral mastectomy for breast cancer with type 1 neurofibromatosis (NF1), for which pancreaticoduodenectomy (PD) and lymphadenectomy were performed. CASE PRESENTATION: A 46-year-old woman with NF1 was referred to our hospital for treatment of a duodenal submucosal tumor. Her previous operative history included bilateral mastectomy for breast cancer: right total mastectomy and left partial mastectomy performed 9 and 5 years ago, respectively. Her daughter was confirmed to have NF1, but her parents were unclear. Although she had no recurrence or symptoms during the follow-up for her breast cancer, she wished to undergo 18-fluorodeoxyglucose-positron emission tomography (FDG-PET) for systemic screening. FDG-PET demonstrated FDG accumulation in the duodenal tumor with a maximum standardized uptake value of 5.78. Endoscopy revealed a 20-mm-diameter tumor in the second duodenal portion, and endoscopic biopsy suggested a NET G1. We performed PD and lymphadenectomy for complete. She was doing well without recurrence and was followed up with PET tomography-computed tomography. CONCLUSIONS: Early detection of gastrointestinal tumors is difficult, because most of them are asymptomatic. Gastrointestinal screening is important for patients with NF1, and PD with lymphadenectomy is feasible for managing duodenal neuroendocrine tumors, depending on their size.

Isolated Pancreatic Metastasis From Renal Clear Cell Renal Cell Carcinoma 29 Years After Radical Nephrectomy.

Isolated metastatic tumors of the pancreas from other origins are only 2-3% of pancreatic cancers, and renal cell carcinoma is the most common origin of metastasis. It is challenging to differentiate between pancreatic tumors and those with a history of renal cancer to optimize treatment and management of this tumor. Here, we present a case of isolated renal cell cancer metastasis to the pancreas, which occurred 29 years after the radical nephrectomy. Surgical resection and pancreatectomy is a feasible treatment because of the low rate of complication and favorable prognosis. However, isolated metastatic pancreatic cancer from renal cell cancer is rare and has relatively high risk of recurrence. Therefore, a larger sample size is necessary to evaluate long-term oncologic outcomes and to optimize diagnostic and therapeutic strategies.

Esophagectomy using a thoracoscopic approach with an open laparotomic or hand-assisted laparoscopic abdominal stage for esophageal cancer: analysis of survival and prognostic factors in 315 patients.

UNLABELLED: Survival and prognostic factors were analyzed in 315 patients with esophageal cancer undergoing thoracoscopic-assisted esophagectomy (TAE). The 5-year survival rate of 57.8% was satisfactory, indicating the oncological feasibility of TAE. Perioperative outcomes affected overall survival in the whole cohort but not in the subgroup treated with 2 endoscopic stages. OBJECTIVE: To estimate the oncological feasibility of thoracoscopic-assisted esophagectomy (TAE) for esophageal cancer and to clarify the prognostic impact of perioperative factors after TAE. BACKGROUND: Favorable perioperative outcomes of TAE versus open surgery have been demonstrated. However, survival data after TAE in a large cohort are limited, and no information on the prognostic influence of perioperative factors after TAE is available. METHODS: Prospectively collected data for 315 patients undergoing TAE for esophageal cancer were analyzed. Survival was compared with the Kaplan-Meier analysis and Cox regression analysis between 2 surgical approaches: thoracoscopic and hand-assisted laparoscopic esophagectomy (THLE) and thoracoscopic and open laparotomic esophagectomy (TOE). Factors affecting overall survival were identified with Cox multivariate regression analysis in the whole cohort and the THLE subgroup. RESULTS: THLE and TOE were performed in 153 and 162 patients, respectively. The overall 5-year survival of the whole cohort was 57.8%, with no difference between the THLE and the TOE group. Multivariate analysis of the 315 patients identified the following prognostic factors: blood loss, blood transfusion, intensive care unit stay, cardiovascular complications, pathological T and N stages, lymphatic invasion, intramural metastasis, and number of metastatic nodes. In the THLE subgroup, cerebral comorbidity, histological subtype, pathological T stage, and number of metastatic nodes were independent prognostic factors. CONCLUSIONS: TAE was oncologically feasible. Perioperative factors affected survival in the whole cohort, but did not in the THLE subgroup. However, the reduced perioperative factor effect in this subgroup would be small because the survival rates of the 2 surgical approaches were equal.

[Noticeable clinical response to S-1/CDDP combination therapy for Virchow node recurrence after surgery for advanced gastric carcinoma with marked involvement of the esophagus - report of a case].

We have recently experienced a case in which S-1/CDDP combination therapy proved remarkably efficacious for a rapid, extensive lymph node recurrence with metastasis into a Virchow node that had developed after resection of advanced gastric carcinoma accompanied with a marked invasion of the esophagus. The patient, a woman aged 73, underwent a total gastrectomy upon left thoracolaparotomy for a gastric carcinoma at the cardia with a 5-cm involvement of the esophagus. On day 65 post-operation, a diagnosis of Virchow node and para-aortic lymph node recurrence was made on the basis of CT scan findings. Of tumor markers checked, CEA and CA19-9 were noted to be increased to as high as 37.55 ng/mL and 3,235 U/mL, respectively. The patient received three courses of S-1/CDDP combination therapy, with a consequent noticeable contraction of the Virchow node and enlarged para-aortic lymph node. Further, she was given two courses of S-1 therapy, which resulted in normalization of tumor markers. The patient has since been on continued chemotherapy without any sign of recurrence.

Amyand's hernia complicated with appendix perforation treated by two-stage surgery consisting of laparoscopic appendectomy followed by elective inguinal hernioplasty: A case report.

INTRODUCTION: An inguinal hernia with an incarcerated appendix is defined as Amyand's hernia, and it is relatively rare. Amyand's hernia complicated with appendicitis, especially perforated appendicitis, is even rarer. Postoperative surgical site infection (SSI) is a dangerous complication, especially in Amyand's hernia with appendix perforation. The selection of an appropriate surgical approach is necessary to prevent postoperative SSI. Here, we report a case of Amyand's hernia complicated with appendix perforation that was successfully managed using a two-stage surgical approach consisting of laparoscopic appendectomy followed by elective inguinal hernioplasty. PRESENTATION OF CASE: A 70-year-old male presented with fever and right lower quadrant pain from the day before. After the patient was diagnosed with acute appendicitis within a right inguinal hernia, emergency laparoscopy was performed. The appendix was incarcerated in the right internal inguinal ring and perforated at the base. We decided to take a two-stage surgical approach to avoid postoperative SSI and performed only laparoscopic appendectomy. No postoperative complications occurred. Inguinal hernioplasty was performed 1 month after the first operation. There were no adhesions in the preperitoneal space, and no adverse events occurred postoperatively. CONCLUSIONS: A two-stage surgical approach consisting of laparoscopic appendectomy followed by elective inguinal hernioplasty was used successfully to treat Amyand's hernia complicated with appendix perforation without causing postoperative SSI.

Treatment of nonocclusive mesenteric ischemia with type B aortic dissection using intra-arterial catheterization after trauma surgery: case report.

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) is a mesenteric arterial spasm and intestinal ischemia. This disease is a highly lethal disease because diagnosis and decision of appropriate treatments are often difficult. Operations cannot resolve the spasms and may worsen the situation. However, the safety and effectiveness of catheterization for NOMI with aortic dissection (AD) have not yet been elucidated. Here, we report a successful case of early diagnosis and treatment of NOMI with type B AD involving the superior mesenteric artery (SMA) using the intra-arterial infusion of a vasodilator via the SMA. CASE PRESENTATION: An 83-year-old man was admitted to our hospital because of abdominal pain after a motor accident. We performed intestinal resection and splenectomy for intestinal perforation and splenic hemorrhage and treated conservatively for acute AD, liver injury, renal hematoma, and pneumothorax. On postoperative day (POD) 2, the patient had localized abdominal pain. Follow-up computed tomography suggested a smaller superior mesenteric vein sign and segmental lack of enhancement in the intestinal wall and ascites without SMA occlusion. Thus, the patient was diagnosed with NOMI. Although the patient had type B AD including the SMA, we performed selective mesenteric arteriography and transcatheter papaverine infusion via the SMA and prostaglandin via the peripheral vein. Seven days post treatment, mesenteric blood flow improved and intestinal wall enhancement was restored. CONCLUSION: The intra-arterial infusion of a vasodilator is highly efficient and safety treatment option for NOMI with type B AD. Prompt and accurate management can prevent massive small bowel resection, and this procedure is essential in resolving a spasm independent of whether a necrotic bowel has been resected.

Heterogeneous expression of DNA-dependent protein kinase in esophageal cancer and normal epithelium.

Esophageal cancer tissues and adjacent normal mucosae in 13 patients with primary esophageal cancer were examined for quantitative differences in DNA-dependent protein kinase (DNA-PK) activity and for expressions of Ku70, Ku80 and DNA-PKcs proteins by Western blotting and immunohistochemistry. The tumor tissues showed higher DNA-PK activity than the normal mucosae. Protein levels of Ku70, Ku80 and DNA-PKcs correlated with DNA-PK activities in the tumor tissues. Immunohistochemical analysis revealed that Ku70, Ku80 and DNA-PKcs located predominantly in the nuclei in both the tumor tissues and normal mucosae. In the normal epithelium, Ku70, Ku80 and DNA-PKcs were expressed only in the nuclei of the basal cell layers and not in those of the lumenal cell layers. In the tumor tissues, the expressions of DNA-PK proteins showed intratumoral heterogeneity. The different portions in the same tumor showed different expression levels of DNA-PK proteins, and even each tumor cell showed different expression levels. These results suggest that cell differentiation and tumor progression affect cellular DNA-PK protein levels and its activity. Furthermore, the intratumoral heterogeneity of DNA-PK protein expression in esophageal cancer cells/ tissues also suggests the difficulty in prediction of radio- or chemo-sensitivity of the tumor through estimation of DNA-PK activity/protein levels in tumor specimens.

Tumor-associated tissue eosinophilia in human esophageal squamous cell carcinoma.

BACKGROUND: Inflammatory cell infiltration around the sites of carcinoma invasion is believed to play important roles in carcinoma biological behavior. MATERIALS AND METHODS: The status of inflammatory cell infiltration at the sites of frank invasion in 97 cases of esophageal squamous cell carcinoma (SCC) were examined, with special emphasis on the status of tumor-associated tissue eosinophilia (TATE). Infiltration of the CD4+T-cells, CD8+T-cells, CD68+macrophages, L26+B-cells, mast cells and eosinophils was quantitatively evaluated in histological tissue sections. The results were then statistically correlated with clinicopathological factors. RESULTS: Among tumor-associated inflammatory cells, the number of tumor-associated eosinophils was significantly correlated with the presence or absence of vascular invasion, lymph node (LN) metastasis and recurrence. The cases were tentatively classified into 2 categories, small and large groups, according to the median and/or average number of tissue eosinophils. The survival curve of the patients was evaluated according to this classification. No statistically significant differences were detected between these 2 groups in the cases without LN metastasis. However, the large group was associated with a statistically significant better prognosis in cases associated with LN metastasis, especially in those with invasion to adventitia (T3) of the esophagus. CONCLUSION: The possible function of tumor-associated eosinophils has not yet been elucidated, but these findings indicate the importance of TATE in the biological behavior of SCC of the esophagus.

AFP-producing hepatoid adenocarcinoma in association with Barrett's esophagus with multiple liver metastasis responding to paclitaxel/CDDP: a case report.

A case of alpha-fetoprotein (AFP)-producing hepatoid adenocarcinoma in association with Barrett's esophagus with multiple liver metastases, responding to chemotherapy, is reported. A 47-year-old man was admitted to our hospital with abdominal pain after subtotal esophagectomy for an esophageal adenocarcinoma in association with Barrett's esophagus, and was diagnosed as having multiple liver tumors. Most tumor markers were normal, but the serum AFP level was markedly elevated. Dynamic computed tomography and ferumoxide enhanced magnetic resonance imaging did not provide evidence of any primary hepatocellular carcinoma. Since microscopic examination of the resected tumor showed a poorly-differentiated adenocarcinoma with hepatoid features displaying AFP-immunoreactivity, the liver tumors were thus considered to be metastatic deposits. Surgery was not feasible so chemotherapeutic agents were tried, and the combination of paclitaxel (TXL) and cisplatin (CDDP) gave a partial response and good control for a period. This is the first report, to our knowledge, of effective chemotherapy for liver metastases from an AFP-producing hepatoid adenocarcinoma of the esophagus.

Radiation therapy combined with cis-diammine-glycolatoplatinum (Nedaplatin) and 5-fluorouracil for untreated and recurrent esophageal cancer.

From January 1999 to November 2000, a total of 24 esophageal cancer patients (17 untreated and 7 recurrent cases) were treated with radiation therapy (60-70 Gy) combined with cis-diammine-glycolatoplatinum (Nedaplatin) (80-120 mg/body) and 5-fluorouracil (5-FU) (500-1,000 mg/body/24 h, continuous infusion for 5 days). Grade III leukocytopenia was observed in 6 (25%) of the patients. Grade III and IV thrombocytopenia was observed in one patient each. The 1-year and 2-year survival rates for definitively irradiated patients were 59% and 39%, respectively, and for patients with postoperative recurrence 69% and 69%, respectively. High-dose radiation combined with Nedaplatin and 5-FU is a safe and effective method for treating esophageal cancer.

[Definitive chemoradiotherapy and salvage esophagectomy for squamous cell carcinoma of the esophagus].

Surgical resection has widely accepted as the first-choice treatment for esophageal carcinoma in Japan, and it has improved the survival of patients with esophageal carcinoma during the past decades. However, the survival rate remains relatively poor compared with that of other gastrointestinal carcinomas. Physical handicaps after esophagectomy also cannot be ignored. Definitive chemoradiation has become an accepted treatment for esophageal carcinoma. Persistent or recurrent local disease is often the problem to be solved. In this case, selected patients with local failures can be salvaged by esophagectomy. In this paper we discuss recent improvements in definitive chemoradiotherapy and the definition of salvage esophagectomy. We also present our short-term results of a prospective phase II study of definitive chemoradiotherapy and salvage esophagectomy in patients with resectable squamous cell carcinoma of the esophagus.

[Endoscopic surgery for malignant esophageal disease].

Endoscopic surgery for benign esophageal disease has been well established and is widely performed. On the other hand, endoscopic surgery for malignant esophageal disease has not yet been well established. However, we have developed and have been performing thoracoscopic esophagectomy with lymphadenectomy for esophageal cancer. We introduce here the results of our endoscopic surgery for esophageal cancer. In the early period of this surgery, more operative complications occurred, such as recurrent nerve palsy, chirothorax, bleeding, etc. However, these complications have gradually decreased. The survival rates of patients in each pathological stage who underwent this surgery are comparable to those of patients who underwent conventional surgery. In conclusion, thoracoscopic esophagectomy has become safe and will be acknowledged as the standard procedure for the treatment of esophageal cancer.

Two cases of 18 F-FDG PET/CT findings in acinar cell carcinoma of the pancreas.

The patients consisted of a 60-year-old woman and a 72-year-old man with no significant symptoms, who were both referred to the hospital due to the presence of large pancreatic tumors. They underwent F-18 FDG PET/CT and subsequently a pancreaticoduodenectomy and acinar cell carcinoma in the pancreas was proven histopathologically. In one case, the tumor consisted of a solid component presenting intense FDG uptake and necrotic tissue. In another case, the tumor consisted of cystic and papillary components presenting with weak FDG uptake. This report thus documents 2 cases of acinar cell carcinoma that showed contrasting histopathologic and F-18 FDG PET/CT findings.

Prospective comparison of surgery alone and chemoradiotherapy with selective surgery in resectable squamous cell carcinoma of the esophagus.

PURPOSE: Esophagectomy remains the mainstay treatment for esophageal cancer, although retrospective studies have suggested that chemoradiotherapy (CRT) is as effective as surgery. To determine whether CRT can substitute for surgery as the primary treatment modality, we performed a prospective direct comparison of outcomes after treatment in patients with resectable esophageal cancer who had received CRT and those who had undergone surgery. METHODS AND MATERIALS: Eligible patients had resectable T1-3N0-1M0 thoracic esophageal cancer. After the surgeon explained the treatments in detail, the patients selected either CRT (CRT group) or surgery (OP group). The CRT course consisted of two cycles of cisplatin and fluorouracil with split-course concurrent radiotherapy of 60Gy in 30 fractions. Patients with progressive disease during CRT and/or with persistent or recurrent disease after CRT underwent salvage resection. RESULTS: Of 99 eligible patients with squamous cell carcinoma registered between January 2001 and December 2005, 51 selected CRT and 48 selected surgery. Of the patients in the CRT group, 13 (25.5%) underwent esophagectomy as salvage therapy. The 3- and 5-year survival rates were 78.3% and 75.7%, respectively, in the CRT group compared with 56.9% and 50.9%, respectively, in the OP group (p = 0.0169). Patients in the OP group had significantly more metastatic recurrence than those in the CRT group. CONCLUSIONS: Treatment outcomes among patients with resectable thoracic esophageal squamous cell carcinoma were comparable or superior after CRT (with salvage therapy if needed) to outcomes after surgery alone.

Successful management of esophagoparaprosthetic fistula after aortic surgery.

Aortoesophageal fistula is a relatively rare but highly fatal condition, especially in the case of secondary aortoesophageal fistulas after previous thoracic aortic surgery in which the aortic prosthetic graft itself may be involved in the infection, resulting in an esophagoparaprosthetic fistula. In this report, we describe a complicated case of esophagoparaprosthetic fistula arising after descending thoracic aortic replacement and endovascular pseudoaneurysm repair that was successfully treated by surgical resection and in situ aortic graft replacement using a homograft completely covered with an omental flap, combined with subtotal esophagectomy and staged reconstruction of the alimentary tract. The patient has been doing well for 24 months without signs of recurrent infection.

Autologous buccal keratinocyte implantation for the prevention of stenosis after EMR of the esophagus.

BACKGROUND: EMR is a minimally invasive and well-accepted therapy for early esophageal cancer. However, extensive or circumferential EMR induces stricture formation. Cultured skin is now clinically applicable by using the technology of regenerative medicine. Esophageal mucosa also consists of keratinocytes, the same as with skin. We, therefore, hypothesized that, by applying the technology of regenerative medicine, the stricture occurring in the esophagus after EMR on broad lesions could be prevented. OBJECTIVE: The aim of this study was to evaluate, in a swine model, the effect of autologous keratinocyte implantation at the site after EMR to prevent stricture. DESIGN: With the pig under general anesthesia, EMR was carried out by using the cap technique. Two separate areas were resected by EMR. One area was left as a control. For the other area, autologous buccal keratinocytes were injected endoscopically. MAIN OUTCOME MEASUREMENTS: The outcome, after 2 weeks, was evaluated by endoscopy, macroscopy, and histology. RESULTS: At 2 weeks after EMR, scar formation and stricture were observed in the control lesion. However, in the keratinocyte implanted lesion, the lesion was covered with an epithelium and the luminal surface of the lesion was flat, without ulceration. CONCLUSIONS: These results showed the feasibility of performing autologous keratinocyte implantation after EMR and the effect for early reepithelialization.

Systemic sarcoidosis associated with double cancers of the esophagus and stomach.

To discriminate between sarcoidosis and sarcoid reaction in the lymphadenopathy of malignancy is sometimes clinically important. We describe a case of sarcoidosis associated with double cancers of the esophagus and stomach. A patient who six months previously was found to have early gastric cancer, was then found to have esophagus cancer. The chest radiography demonstrated bilateral hilar lymphadenopathy. Pathological analysis of the lymph nodes and lungs showed non-caseating epithelioid cell granuloma, revealing the existence of sarcoidosis. The findings suggest that the possibility of systemic sarcoidosis should be considered in cases with established malignancy and newly disclosed radiographic findings.

Dose escalation study of docetaxel and nedaplatin in patients with relapsed or refractory squamous cell carcinoma of the esophagus pretreated using cisplatin, 5-fluorouracil, and radiation.

BACKGROUND: Definitive chemoradiation with cisplatin (CDDP) and 5-fluorouracil (5FU) has been playing an important role in the treatment of esophageal cancer, but some patients are not curable or have recurrent lesions. However, few chemotherapeutic regimens are available for such patients. Docetaxel and nedaplatin are active for esophageal cancer. We conducted a dose-escalation study of docetaxel and nedaplatin as second line-chemotherapy after definitive chemoradiation in patients with relapsed or refractory squamous cell carcinoma of the esophagus after chemoradiation. METHODS: Nedaplatin was administered on day 1 and docetaxel was administered on days 1 and 15, every 4 weeks. Dose escalation was based on the dose-limiting toxicity (DLT) observed during the first cycle. RESULTS: Twelve patients were enrolled. At a docetaxel dose of 30 mg/m(2) and a nedaplatin dose of 80 mg/m(2), one grade 4 neutropenia occurred and caused one treatment break longer than 2 weeks, but there were few DLTs. At doses of 35 and 80 mg/m(2), respectively, two grade 4 neutropenias and one grade 2 thrombopenia occurred and caused three treatment breaks longer than 2 weeks. Therefore, the maximum tolerated dose was established at this dose level. Two grade 3 anorexias and one grade 3 nausea occurred, but other non-hematological toxicities were generally mild. Responses were seen in one-fourth of the 12 patients, including one complete remission. CONCLUSION: The recommended doses of docetaxel and nedaplatin were 30 and 80 mg/m(2), respectively. This combination could be a potential second-line treatment for this target population.