Clinicopathological and mutational analysis of esophageal basaloid squamous cell carcinoma.

Esophageal basaloid squamous cell carcinoma (EBSCC) is a poorly differentiated variant of esophageal squamous cell carcinoma (ESCC). We aimed to investigate the clinicopathological and molecular biological characteristics of EBSCC and enrolled 58 patients with EBSCCs. Clinicopathological factors including age, sex, tumor size and location, gross tumor type (superficial, protrusive, ulcerative, and unclassifiable), lymphovascular invasion, infiltrative growth, intramural invasion, TNM stage, and dominant histological type were examined. EBSCCs were classified into four types (solid, cribri, microcystic, and tubular) according to the dominant histology. Next-generation sequencing (NGS) of a cancer hotspot panel was performed in 19 cases. NGS identified TP53 as the most frequently mutated gene, and copy number variation analysis revealed the most frequent loss of heterozygosity (LOH) at the ataxia telangiectasia mutated (ATM) and retinoblastoma 1 (RB1) loci. Target sequencing for TP53 was performed for the remaining 39 cases. We also performed LOH analysis for TP53, ATM, and RB1 and immunohistochemical staining for p53, ATM, and Rb in all cases. The rates of TP53 mutations and LOH and p53 aberrant expression were high (79.3%, 63.2%, and 72.4%, respectively); however, the frequencies were similar to those reported for ESCC. LOH rates of the RB1 and ATM loci were also high (55.3% and 67.2%, respectively). Overall survival rate was 66.5%, and recurrence-free survival rate was 55.0%. Only conventional clinicopathological factors had a prognostic impact in EBSCC; the microcystic type had the poorest prognosis. Our findings could be useful in developing novel treatment strategies for EBSCC.

Outcomes of esophagectomy for patients with esophageal squamous cell carcinoma accompanied by recurrent laryngeal nerve palsy at diagnosis.

BACKGROUND: Hoarseness is one of the classical symptoms in patients with locally advanced thoracic esophageal squamous cell carcinoma (ESCC), and it results from recurrent laryngeal nerve palsy, which is caused by nodal metastasis along the recurrent laryngeal nerve or by main tumors. We reviewed the short-term and long-term results of esophagectomy for patients with locally advanced ESCC and hoarseness at diagnosis. PATIENTS: Patients who initially presented with hoarseness from recurrent laryngeal nerve palsy between 2009 and 2018 and underwent esophagectomy for thoracic ESCC were eligible for this study. Pharyngolaryngectomy or cervical ESCC were exclusionary. RESULTS: A total of 15 patients were eligible, and 14 underwent resection of the recurrent laryngeal nerves. The remaining patient had nerve-sparing surgery. Nine patients (60%) had post-operative complications ≥ Clavien-Dindo class II and, pulmonary complications were most common. Two patients (13%) died in the hospital. The 5-year overall survival rate for all patients was 16%. Age (≤ 65 years), cT1/T2 tumor, and remarkably good response to neoadjuvant treatment were likely related to longer survival; however, these relationships were not statistically significant. CONCLUSIONS: Esophagectomy for ESCC patients who are diagnosed with recurrent laryngeal nerve paralysis at initial presentation could be a treatment option if the patient is relatively young, has a cT1/T2 tumor, or shows a remarkably good response to neoadjuvant treatment. However, clinicians should be aware of the possibility of postoperative pulmonary complications, which were frequently observed with the procedure.

Development of a Non-invasive Diagnostic Method for Esophageal Squamous Cell Carcinoma by Gas Chromatographic Analysis of Exhaled Breath.

Objectives: Since esophageal carcinoma progresses asymptomatically, for many patients the disease is already advanced at the time of diagnosis. The main methods that are currently used to diagnose esophageal carcinoma are upper gastrointestinal radiographic contrast examinations and upper gastrointestinal endoscopy, but early discovery of this disease remains difficult. There is a need to develop a diagnostic method using biomarkers that is non-invasive while both highly sensitive and specific. Materials and Methods: Exhaled breath was collected from 17 patients with esophageal squamous cell carcinoma (ESCC), as well as 9 control subjects without history of any cancer. For each fasting subject, 1L of exhaled breath was collected in a gas sampling bag. Volatile organic compounds (VOCs) were then extracted from each sample using Solid phase micro-extraction (SPME) fibers and analyzed by gas chromatography-mass spectrometry (GC-MS). Results: Levels of acetonitrile, acetic acid, acetone, and 2-butanone in exhaled breath were significantly higher in the patient group than in the control group (p = 0.0037, 0.0024, 0.0024 and 0.0037, respectively). ROC curves were drawn for these 4 VOCs, and the results for the area-under-the-curve (AUC) indicated that ESCC patients can be identified with a high probability of 0.93. Conclusion: We found distinctive VOCs in exhaled breath of ESCC patients. These VOCs have a potential as new clinical biomarkers for ESCC. The measurement of VOCs in exhaled breath may be a useful, non-invasive method for diagnosis of ESCC.

Examination of a Low-density Lipoprotein Receptor Relative with 11 Ligand-binding Repeats (LR11) as a Biomarker in Esophageal Cancer.

Objectives: Some previous studies reported that the levels of a low-density lipoprotein receptor relative with 11 ligand-binding repeats (LR11) was a prognostic marker in some malignant tumors; however, whether LR11 is related to survival in patients with esophageal cancer remains unclear. Methods: In this study, we measured LR11 in the preoperative serum of 46 patients of esophageal cancer who undergoing surgery using a sandwich enzyme-linked immunosorbent assay (ELISA) method with anti-LR11 monoclonal antibodies. We investigated the correlation between the level of LR11 and survival of patients with esophageal cancer. Clinicopathological data were retrospectively retrieved from our institution's database. Results: The patients were divided into two groups (low LR11 and high LR11) based on the level of LR11. There was no statistical difference in clinicopathological factors between these two groups. The low LR11 group had a significantly longer overall survival than the high LR11 group. Conclusions: LR11 can be measured with a relatively simple ELISA and is potentially a new prognostic marker for esophageal cancer.

Clinical Significance of Circulating Tumor Cells in Patients with Esophageal Cancer.

Objective: In recent years, circulating tumor cells (CTCs) have attracted attention for prediction of metastasis in breast, prostate, and colon cancers. This study aimed to investigate whether detection of CTCs could be prognostic factor in esophageal cancer. Methods: This study involved 38 patients treated at Juntendo University from May 2010 to April 2013 who provided consent. CTCs were measured using CellSearch® system in preoperative peripheral blood. Clinicopathological parameters and prognostic factors were retrieved from our medical records. Results: CTCs were detected in 6 of 38 patients (15.8%). Among patients' characteristics and clinicopathological features, CTC-positive group had higher serum SCC levels and tended to have more advanced cStages than the CTC-negative group. The CTC-negative group showed better survival curves than CTCs positive-group in both overall survival (OS) and disease-free survival (DFS) although the differences were not statistically significant. CTCs positivity has a possibility to be prognostic marker according to multivariable analysis of OS and DFS. Conclusion: Although this study has some limitations, our results suggest that CTCs in preoperative peripheral blood has potential to be a prognostic marker for esophageal cancer.

Degree of Differentiation of Esophageal Squamous Cell Carcinoma and Micrometastasis to Lymph Nodes.

Objectives: The goal of the study was to examine the relationships among micrometastasis, pathological degree of differentiation and survival in patients with esophageal squamous cell carcinoma (SCC). Design: A single-center retrospective study of patients diagnosed with thoracic esophageal SCC. Methods: Immunostaining using CK13 was carried out for all lymph nodes resected by radical esophagectomy with three-field lymphadenectomy. The relationships among micrometastasis to lymph nodes, degree of differentiation and survival were investigated. Results: The 25 patients included 14 (56.0%) well-differentiated and 11 (44.0%) moderately differentiated cases. In multivariate analysis, well-differentiated cases were not related to micrometastasis (odds ratio (OR): 1.5, confidence interval (CI): 0.2-12, p=0.7). In multivariate analysis of survival, cases in pStage III or higher were likely to have shorter survival (hazard ratio (HR): 2.8, CI: 0.7-12, p=0.16), and those with micrometastasis also tended to have shorter survival (HR: 2.7, CI: 0.8-9, p=0.11)); however, well-differentiated cases were not significantly related to survival (HR: 1.5, CI: 0.4-5.5, p=0.5). Conclusion: Micrometastasis to lymph nodes may be a prognostic factor even in advanced esophageal cancer. The degree of differentiation was not related to micrometastasis or survival.

Endoscopic and Clinicopathological Features of Superficial Non-Ampullary Duodenal Tumor Based on the Mucin Phenotypes.

AIMS: We aimed to clarify the endoscopic/clinicopathological features of superficial non-ampullary duodenal epithelial tumors (SNADETs) based on their mucin phenotypes. METHODS: We analyzed 62 SNADET lesions and classified them based on mucin phenotypic expression. Endoscopic and clinicopathological findings were compared according to mucin phenotypes. RESULTS: Eleven lesions had the gastric phenotype (GP) and 43 lesions had the intestinal phenotype (IP). All GP lesions were located in the first portion of the duodenum, while most IP lesions (72.1%) were located in the second portion (p < 0.01). Tumor size was significantly larger in the GP than in the IP group (14.4 mm vs. 10.2 mm, p < 0.05). Reddish color (72.7% in GP vs. 37.2% in IP, p < 0.05), type 0-I (72.7% vs. 11.6%, p < 0.01), lobular/granular pattern (81.8% vs. 4.7%, p < 0.01), and category 4/5 in Vienna classification (81.8% vs. 30.2%, p < 0.01) were observed significantly more often in the GP than in the IP group. Regarding findings of magnifying endoscopy with narrow-band imaging (M-NBI), white opaque substance (22.2% in GP vs. 89.7% in IP, p < 0.01) and light blue crest (0% vs. 43.6%, p < 0.05) were significantly less frequently observed in the GP group. Oval-shaped marginal epithelium (66.7% vs. 17.9%, p < 0.01), dense pattern (55.6% vs. 2.6%, p < 0.01), and dilatation of the intervening part (100% vs. 12.8%, p < 0.01) were more frequently observed in the GP group. CONCLUSIONS: SNADETs showed distinct endoscopic/clinicopathological features according to the mucin phenotype. Tumor location, coloration, macroscopic type, and endoscopic findings including M-NBI are useful to distinguish the mucin phenotypes of SNADETs.

Comprehensive clinicopathological and molecular analysis of primary malignant melanoma of the oesophagus.

AIMS: This study was performed to elucidate the clinicopathological characteristics, genetic alterations and therapeutic targets of primary malignant melanoma of the oesophagus (PMME). METHODS AND RESULTS: The clinicopathology and molecular pathology of 13 PMME cases and 10 skin malignant melanoma (SKMM) cases were analysed with next-generation sequencing (NGS) and immunohistochemistry. The 3-year overall survival rate and the median survival time for PMME patients were 23.1% and 11.9 months, respectively. Three (23.1%) and eight (61.5%) PMME cases showed a papillary structure and lymph node metastasis, respectively. DNA and RNA hybridization capture-based NGS analysis revealed that NF1 was the most frequently mutated gene (30%) in 10 of the PMME cases. Other mutations detected in PMME included SF3B1 (20%), KRAS (10%), BRCA2 (10%), KIT (10%) and TP53 (10%) mutations. Commonly detected BRAF mutations in SKMM were not detected in PMME. Immunohistochemistry and mutation status were concordant between p53/c-Kit and TP53/KIT, respectively. Focal expression of programmed death-ligand 1 was observed in one PMME sample. The tumour mutation burden in PMME was significantly lower than that in SKMM (P = 0.030). No PMME case showed high microsatellite instability. RNA sequencing revealed a distinctive pattern with respect to RNA expression. T-cell co-stimulation differed between PMME and SKMM. CONCLUSIONS: The RAS-mitogen-activated protein kinase pathway is one of the main pathways involved in PMME. The genetic profile of PMME was similar to that of mucosal/acral melanoma, but differed from the SKMM profile. A subset of PMMEs may contain actionable mutations. Immunotherapy seemed to be less effective for most PMMEs in this series.

Pancreaticoduodenectomy with reconstructing blood flow of the gastric conduit after esophagectomy with concomitant celiac axis stenosis: a case report.

BACKGROUND: Pancreaticoduodenectomy after esophageal resection is technically difficult, because blood flow of the gastric conduit should be preserved. Celiac axis stenosis (CAS) is also a problem for pancreaticoduodenectomy, because arterial blood supply for the liver comes mainly through the collateral route from the superior mesenteric artery (SMA) via the gastroduodenal artery (GDA). Herein, we report the case of a patient with pancreatic head cancer who underwent a pancreaticoduodenectomy after esophagectomy with concomitant CAS. CASE PRESENTATION: A 76-year-old man with pancreatic head cancer was referred to our department. He had a history of esophagectomy with retrosternal gastric conduit reconstruction for esophageal cancer. Computed tomography showed severe CAS and a dilated collateral route between the SMA and the splenic artery (SPA). We prepared several surgical options depending on the intraoperative findings, and performed radical pancreaticoduodenectomy with concomitant resection of the distal gastric conduit. The right gastroepiploic artery (RGEA) of the remnant gastric conduit was fed from the left middle colic artery (MCA) with microvascular anastomosis. Despite CAS, when the GDA was dissected and clamped, good blood flow was confirmed, and the proper hepatic artery did not require reconstruction. The patient was discharged on postoperative day 90. CONCLUSIONS: We successfully performed radical pancreaticoduodenectomy after esophagectomy with concomitant CAS, having prepared multiple surgical options depending upon the intraoperative findings.

Esophagectomy performed at institutes certified by the Japan Esophageal Society provide long-term survival advantages to esophageal cancer patients: second report analyzing 4897 cases with propensity score matching.

BACKGROUND: It will be important for the Japan Esophageal Society (JES) to show an evident advantage of its institution certification system. To achieve this essential task, we used nationally acquired big data to re-analyze 5-year survival information. METHODS: In 2008-2009, there were 4897 thoracic esophageal cancer patients who underwent esophagectomy and were registered in the National Database of Hospital-based Cancer Registries. We divided these patients into two groups, those who underwent surgery at an Authorized Institute for Board Certified Esophageal Surgeons (AIBCES) or a Non-AIBCES. We then compared the patient backgrounds and 5-year survival rates between these two groups, with and without propensity score matching. RESULTS: There were 3080 (63%) patients who underwent esophagectomy at an AIBCES and 1817 (37%) who underwent surgery at a Non-AIBCES. Comparison of the Kaplan-Meier survival curves using log-rank tests indicated a significant difference between the AIBCES and Non-AIBCES groups at all cStages (cStages I-IV). Multivariable Cox proportional hazard analysis stratified by clinical stage and adjuvant treatment revealed that AIBCES vs. Non-AIBCES is a significant independent factor (adjusted HR 0.78) for survival. After propensity score matching ensuring the backgrounds of the two groups being equivalent, there were significant differences in the 5-year survival rates for patients with cStages I-III disease between the AIBCES and Non-AIBCES groups. CONCLUSIONS: There is a survival advantage to undergoing esophagectomy at an AIBCES. The institute certification system from the JES will contribute to the future establishment of a more appropriate surgery delivery system for thoracic esophageal cancer.

Impact of certification status of the institute and surgeon on short-term outcomes after surgery for thoracic esophageal cancer: evaluation using data on 16,752 patients from the National Clinical Database in Japan.

BACKGROUND: In 2009, the Japan Esophageal Society (JES) established a system for certification of qualified surgeons as "Board Certified Esophageal Surgeons" (BCESs) or institutes as "Authorized Institutes for Board Certified Esophageal Surgeons" (AIBCESs). We examined the short-term outcomes after esophagectomy, taking into consideration the certifications statuses of the institutes and surgeons. METHODS: This study investigated patients who underwent esophagectomy for thoracic esophageal cancer and who were registered in the Japanese National Clinical Database (NCD) between 2015 and 2017. Using hierarchical multivariable logistic regression analysis adjusted for patient-level risk factors, we determined whether the institute's or surgeon's certification status had greater influence on surgery-related mortality or postoperative complications. RESULTS: Enrolled were 16,752 patients operated on at 854 institutes by 1879 surgeons. There were significant differences in the backgrounds and incidences of postoperative complications and surgery-related mortality rates between the 11,162 patients treated at AIBCESs and the 5590 treated at Non-AIBCESs (surgery-related mortality rates: 1.6% vs 2.8%). There were also differences between the 6854 patients operated on by a BCES and the 9898 treated by a Non-BCES (1.7% vs 2.2%). Hierarchical logistic regression analysis revealed that surgery-related mortality was significantly lower among patients treated at AIBCESs. The institute's certification had greater influence on short-term surgical outcomes than the operating surgeon's certification. CONCLUSIONS: The certification system for surgeons and institutes established by the JES appears to be appropriate, as indicated by the improved surgery-related mortality rate. It also appears that the JES certification system contributes to a more appropriate medical delivery system for thoracic esophageal cancer in Japan.

Molecular and clinicopathological analyses of esophageal carcinosarcoma with special reference to morphological change.

The molecular pathogenesis of esophageal carcinosarcoma (ECS) has not been fully investigated. This study includes 16 consequent cases of surgically resected ECS. Genetic alterations were independently examined for carcinoma in situ, carcinomatous, and sarcomatous areas. Six cases were analyzed by next-generation sequencing, and the remaining cases were analyzed by Sanger sequencing for TP53, PTEN, and INI1. Sarcomatous components in 3 cases showed histologically heterogenous feature of osteosarcoma. Lymph node metastasis was found in 12 out of 16 cases. Survival analysis revealed 5-year overall survival rate of 59.9%, and the median survival time was 5.37 years. TP53 was the most frequently mutated gene, being identified in 11 of 16 patients (68.8%), 7 of whom (63.6%) had the same mutations in both carcinomatous and sarcomatous areas. Almost complete concordance was found between p53 immunohistochemistry and TP53 missense mutations. Five-year overall survival tended to be worse for patients with p53 overexpression, although the data was not significant (p = 0.186). Nine of 16 patients (56.3%) showed loss of heterozygosity (LOH) at the INI1 locus, and this LOH status was consistent with both components. However, interestingly, INI1 expression was preserved in all cases. In addition, copy number variation analysis revealed gene amplification in several tyrosine kinase receptors. Accumulation of mutations in tumor suppressor genes such as TP53 and INI1 seemed to occur during ECS development.

[A Case of Advanced Gastric Cancer with Pathological Complete Response after Chemotherapy(S-1/Cisplatin)].

A 68-year-old female patient presented with advanced gastric cancer and multiple hepatic tumors. Upper GI endoscopy showed a type 3 lesion in the posterior wall of the gastric body. Abdominal computed tomography revealed multiple liver metastases, and staging laparoscopy identified peritoneal dissemination. She was diagnosed with clinical Stage Ⅳ gastric cancer(cT3N2M1H1). She received 3 courses of combined chemotherapy containing S-1 and cisplatin. The therapeutic response was PR. We performed total gastrectomy with D2 lymph node dissection and splenectomy. Histopathological examination revealed no residual cancer cells, indicating pCR. She continued S-1 adjuvant chemotherapy and has remained free from recurrence for 18 months.

Case report of perineal hernia after laparoscopic abdominoperineal resection.

Perineal hernia (PH) is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present a case report of perineal hernia after laparoscopic APR and discuss its management. The patient was a 77-year-old man who was diagnosed with lower rectal cancer. He underwent laparoscopic APR and bilateral lateral lymph node dissection. Two months after the surgery, pain and bulging in the perineal region developed, and PH was diagnosed by CT. Repair with a polypropylene mesh was performed using a combination of laparoscopic abdominal and transperineal approaches. Reportedly, the incidence of secondary PH after APR has increased along with the rate of laparoscopic surgery. Treatment of secondary PH with transperineal repair alone may cause injuries to other organs because of adhesion of the pelvic viscera. In the present case, we safely repaired the hernia repair using a laparoscopy-assisted perineal approach.

Efficacy and safety of endoscopic submucosal dissection for superficial cancer of the cervical esophagus.

BACKGROUND AND STUDY AIMS: Cervical esophageal cancer (CEC) is a less common form of cancer and often locally advanced at the time of diagnosis; thus, survival rates for patients with CEC remain poor. However, no reports exist on results of endoscopic submucosal dissection (ESD) for superficial cancer at the cervical esophagus. The aim of this retrospective study was to elucidate the clinicopathological features and clinical outcomes of ESD for superficial CEC. PATIENTS AND METHODS: ESD was performed on 891 lesions (in 662 patients) for superficial esophageal cancer from January 2008 to December 2015. Of these, 45 lesions (45 patients) were enrolled in the case group (CEC), and 405 lesions (375 patients) were enrolled in the control group (superficial cancer in the middle thoracic esophagus). The safety of ESD, including R0 resection rate and adverse events, and the efficacy, such as the local recurrence rate and overall survival rate, were evaluated. RESULTS: The R0 resection rate was 91.1 % in the case group and 96 % in the control group. The rate of esophageal stricture was significantly higher in the case group (20 %) than in the control group (6.6 %). There was no local recurrence, and the 3-year survival rate was 88.4 % in the case group and 96.7 % in the control group. CONCLUSIONS: ESD for superficial cancer in the cervical esophagus was achieved safely, and successful local control was also confirmed. However, the esophageal stricture after ESD was more frequent.

Superior Thoracic Aperture Size is Significantly Associated with Cervical Anastomotic Leakage After Esophagectomy.

BACKGROUND: The size of the superior thoracic aperture (STA) may be associated with the incidence of cervical anastomotic leakage after esophagectomy. Using computed tomography (CT) images, we retrospectively investigated relationships between the size of the STA and anastomotic leakage following esophagectomy using the retrosternal or posterior mediastinal reconstruction routes. METHODS: Patients who underwent cervical esophagogastrostomy after esophagectomy between 2009 and 2015 were enrolled in this retrospective study (n = 326). The size of the STA was measured at the level of the sternal notch using preoperative CT images, and it was determined as the anteroposterior diameter of the STA minus the diameter of the trachea. Associations between clinical factors, including the size of the STA, and anastomotic leakage were determined. RESULTS: Anastomotic leakage occurred in 44 patients (13.5%). The size of the STA ranged from 0 to 49 mm (median, 16 mm). In univariate analyses, the duration of the operation, tumor location, anastomotic procedure, and the size of the STA were significantly associated with anastomotic leakage. In multivariate analysis, only the size of the STA was independently related to leakage (odds ratio 1.05; 95% confidence interval 1.002-1.107; p = 0.027). The size of the STA affected the incidence of leakage more frequently with the posterior mediastinal route than with the retrosternal route. CONCLUSIONS: The size of the STA was significantly associated with the incidence of anastomotic leakage after esophagectomy, especially when using the posterior mediastinal route.

The loss of CASP4 expression is associated with poor prognosis in esophageal squamous cell carcinoma.

Esophageal squamous cell carcinoma (ESCC) has high biological malignant potential among the various digestive tract cancers and is associated with a poor prognosis. To identify novel genes involved in tumor progression, the present study analyzed the genetic and transcriptional alterations in two clinical cohorts, totaling 157 cases of ESCC (78 cases from the discovery set and 79 cases from the validation set). From the discovery set, gene expression and copy number profiles were analyzed using expression arrays and array-comparative genomic hybridization, respectively. Notably, a copy number loss of caspase-4 (CASP4) was observed in 82% of ESCC cases and CASP4 expression levels were significantly associated with copy number levels. Gene set enrichment analysis demonstrated that the upregulation of CASP4 expression levels was associated with the signaling pathways involved in apoptosis, inflammatory responses and immune responses. The present study demonstrated that CASP4 expression levels were significantly associated with the expression levels of the endoplasmic reticulum (ER) stress marker glucose-regulated protein 78, indicating that CASP4 has a role in cell death induced by ER stress in ESCC. In the survival analysis the CASP4 low expression group exhibited a poor prognosis, compared with the CASP4 high expression group in the discovery set (P=0.003); this observation was reproduced in the validation set (P=0.037). Therefore, the results of the current study suggest that CASP4 may function as a tumor-suppressor gene and may have applications as a biomarker for the prediction of the prognosis in ESCC.

Superior Mesenteric Artery Syndrome Improved by Enteral Nutritional Therapy according to the Controlling Nutritional Status Score.

Superior mesenteric artery syndrome (SMAS) is a relatively rare disease that involves bowel obstruction symptoms, such as vomiting and gastric distension, owing to the compression of the third portion of the duodenum from the front by the superior mesenteric artery (SMA) and from the rear by the abdominal aorta and the spine. SMAS is diagnosed on the basis of an upper gastrointestinal examination series indicating the obstruction of the third portion of the duodenum or a computed tomography scan indicating the narrowing of the branch angle between the aorta and the SMA (i.e., the aorta-SMA angle). Here, we report the case of a 78-year-old woman diagnosed with SMAS after a laparoscopic right hemicolectomy for cecal cancer, whose condition was improved by enteral nutritional therapy. We used her controlling nutritional status (CONUT) score as a nutrition assessment and noted the changes in the aorta-SMA angle over the course of the disease. This patient appeared to develop SMAS, on the basis of a worsened CONUT score and a decreased aorta-SMA angle, owing to the inflammation resulting from the intraoperative dissection of the tissues around the SMA and prolonged postoperative fasting. After the initiation of enteral nutritional therapy, the patient exhibited body weight gain and an improved aorta-SMA angle and CONUT score. Hence, assessment of the aorta-SMA angle and CONUT score is an important preoperative consideration.

Clinicopathological features of alpha-fetoprotein producing early gastric cancer with enteroblastic differentiation.

AIM: To investigate clinicopathological features of early stage gastric cancer with enteroblastic differentiation (GCED). METHODS: We retrospectively investigated data on 6 cases of early stage GCED and 186 cases of early stage conventional gastric cancer (CGC: well or moderately differentiated adenocarcinoma) who underwent endoscopic submucosal dissection or endoscopic mucosal resection from September 2011 to February 2015 in our hospital. GCED was defined as a tumor having a primitive intestine-like structure composed of cuboidal or columnar cells with clear cytoplasm and immunohistochemical positivity for either alpha-fetoprotein, Glypican 3 or SALL4. The following were compared between GCED and CGC: age, gender, location and size of tumor, macroscopic type, ulceration, depth of invasion, lymphatic and venous invasion, positive horizontal and vertical margin, curative resection rate. RESULTS: Six cases (5 males, 1 female; mean age 75.7 years; 6 lesions) of early gastric cancer with a GCED component and 186 cases (139 males, 47 females; mean age 72.7 years; 209 lesions) of early stage CGC were investigated. Mean tumor diameters were similar but rates of submucosal invasion, lymphatic invasion, venous invasion, and non-curative resection were higher in GCED than CGC (66.6% vs 11.4%, 33.3% vs 2.3%, 66.6% vs 0.4%, 83.3% vs 11% respectively, P < 0.01). Deep submucosal invasion was not revealed endoscopically or by preoperative biopsy. Histologically, in GCED the superficial mucosal layer was covered with a CGC component. The GCED component tended to exist in the deeper part of the mucosa to the submucosa by lymphatic and/or venous invasion, without severe stromal reaction. In addition, Glypican 3 was the most sensitive marker for GCED (positivity, 83.3%), immunohistochemically. CONCLUSION: Even in the early stage GCED has high malignant potential, and preoperative diagnosis is considered difficult. Endoscopists and pathologists should know the clinicopathological features of this highly malignant type of cancer.