Application of convolutional neural networks for evaluating the depth of invasion of early gastric cancer based on endoscopic images.

BACKGROUND AND AIM: Recently, artificial intelligence (AI) has been used in endoscopic examination and is expected to help in endoscopic diagnosis. We evaluated the feasibility of AI using convolutional neural network (CNN) systems for evaluating the depth of invasion of early gastric cancer (EGC), based on endoscopic images. METHODS: This study used a deep CNN model, ResNet152. From patients who underwent treatment for EGC at our hospital between January 2012 and December 2016, we selected 100 consecutive patients with mucosal (M) cancers and 100 consecutive patients with cancers invading the submucosa (SM cancers). A total of 3508 non-magnifying endoscopic images of EGCs, including white-light imaging, linked color imaging, blue laser imaging-bright, and indigo-carmine dye contrast imaging, were included in this study. A total of 2288 images from 132 patients served as the development dataset, and 1220 images from 68 patients served as the testing dataset. Invasion depth was evaluated for each image and lesion. The majority vote was applied to lesion-based evaluation. RESULTS: The sensitivity, specificity, and accuracy for diagnosing M cancer were 84.9% (95% confidence interval [CI] 82.3%-87.5%), 70.7% (95% CI 66.8%-74.6%), and 78.9% (95% CI 76.6%-81.2%), respectively, for image-based evaluation, and 85.3% (95% CI 73.4%-97.2%), 82.4% (95% CI 69.5%-95.2%), and 83.8% (95% CI 75.1%-92.6%), respectively, for lesion-based evaluation. CONCLUSIONS: The application of AI using CNN to evaluate the depth of invasion of EGCs based on endoscopic images is feasible, and it is worth investing more effort to put this new technology into practical use.

[A Case Report on Laparoscopic Duodenal Sleeve Resection of GIST at a Distal Portion from the Papilla Vater].

A 21-year-old woman was admitted for preshock due to severe anemia. A 5 cm gastrointestinal stromal tumor(GIST)at the jejunal flexure of her duodenum was diagnosed by enhanced CT examination. We performed a total laparoscopic pancreas- preserving duodenal sleeve resection with a 2 cm margin from the tumor. Functional end-to-end anastomosis was done with the patient lying in a right half lateral decubitus position in order to shift the weight of the tumor and duodenal mesentery to the right to prevent surgical capsule damage. We experienced one case(5.5%)of peritoneal(recurrent)GIST after laparoscopic gastrectomy. However, this is generally a safe and useful procedure for laparoscopic duodenal sleeve resection of duodenal GIST at a distal portion from the papilla Vater, when performed by a skilled team.

[Inflammatory Breast Cancer Treated with Multidisciplinary Treatment-A Report of Two Cases].

Case 1: A 77-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast. She was diagnosed with inflammatory breast cancer(T4dN1M0, stage ⅢB of the basal-like subtype). Four courses of FEC followed by 4 courses of docetaxel as the primary systemic therapy were effective. She underwent mastectomy and axillary dissection, and pathological examination revealed a partial response. She received radiation therapy after surgery. At present, 5 years after surgery, the patient is alive without recurrence. Case 2: A 46-year-old woman presented with redness and swelling with a peau d'orange appearance in the whole left breast and edema of the left arm. She was diagnosed with inflammatory breast cancer(T4dN3M1, stage Ⅳ of the HER2 subtype)with bone metastasis and cancerous pleurisy. After 4 courses of FEC as the primary systemic therapy, the breast tumor disappeared, but pleural effusion persisted. Subsequent chemotherapy with pertuzumab, trastuzumab, and docetaxel was effective, as computed tomography showed no lesions. She underwent mastectomy and axillary dissection, and pathological examination revealed a complete response. She received radiation therapy after surgery. At present, 2 years after surgery, the patient is alive without recurrence.

[Study of Phyllodes Tumor of the Breast in 44 Cases of Resection].

Phyllodes tumor is a rare interstitial and epithelial mixed tumor which constitutes 0.3-0.9% of all breast tumors. It is classified into benign, borderline malignant, and malignant. Differentiating this from fibroadenoma is difficult, however, when diagnosed, complete surgical resection is recommended. Patients and results: Forty-four patients who underwent surgery between April 2009 and April 2020 and were diagnosed with phyllodes tumors and the median observation period was 44 months. The average tumor diameter was 39.2 mm, and the surgical procedures performed were mastectomy in 3 cases, partial resection in 26 cases, and extirpation in 15 cases. The surgical margin was positive in 6 cases. Intra-breast recurrence occurred in 4 cases, of which the initial surgery in 3 cases was extirpation. The pathological diagnosis was malignant in 4 cases, malignant in 15 cases, and benign in 25 cases. Conclusion: In this study, intra-breast recurrence occurred in many cases treated by extirpation, and it was considered that the surgical technique for complete resection such as partial resection should be selected.

[Laparoscopic Hepatectomy of Metastases from Breast Cancer-A Case Report].

A 53-year-old woman, who had been operated with Bt plus Ax plus Ic for right breast cancer 2 years before, revealed an isolated hepatic metastasis at the S4 edge on follow-up computed tomography. The surgical approach is not recommended for distant metastases from breast cancer because of the lack of survival benefits according to the breast cancer guidelines. Nevertheless, the operation could be performed safely and easily for this patient owing to the location and size of the tumor. In addition, the case was a good indication for laparoscopic hepatectomy. We could perform the operation safely with a laparoscope, and the patient was discharged from the hospital on postoperative day 6. Hepatectomy is controversial for metastases from breast cancer. However, in select cases, hepatectomy with a laparoscope can be the therapeutic option as it can improve the survival of patients with hepatic metastases from breast cancer.

[A Case of Gastric Neuroendocrine Carcinoma with Rapidly Increasing Liver Metastasis].

The patient was a 72-year-old man. A gastrointestinal endoscopy was performed because of his anemia and revealed semicircular type 3 tumor in the lower body of the stomach. Biopsy was performed to diagnose adenocarcinoma. Computed tomography(CT)showed no distant metastasis, and the operation was performed 3 weeks after first visit. During operation multiple liver metastasis were recognized, and we performed distal gastrectomy and partial liver resection. The final diagnosis was neuroendocrine carcinoma(NEC). EOB-MRI after surgery revealed multiple liver metastases of 10-20 mm in size, similar to the intraoperative findings, and chemotherapy with cisplatin(CDDP)plus S-1 was started. A significant reduction was recognized after 3 courses of chemotherapy. Gastric NEC has a high proliferative capacity, and distant metastasis may become apparent in a short period of time. Although there is no clear guideline for chemotherapy, CDDP plus S-1 could be 1 treatment option.

[Intraoperative Pancreatoscopy to Assess the Resection Margin in Intraductal Papillary Mucinous Neoplasm-A Case Report].

Intraductal papillary mucinous neoplasm(IPMN)of the pancreas often presents with multifocal lesions. Complete resection without residual skip lesions is essential for complete eradication of the disease. We experienced a case of IPMC in which intraoperative pancreatoscopy was used to determine the surgical margin. Intraoperative pancreatoscopy is a useful and easy method to evaluate the remnant duct and exclude residual tumor. A cystic lesion was incidentally detected in the pancreatic head of a 78-year-old man. Ultrasonography, abdominal computed tomography, magnetic resonance imaging, and endoscopic ultrasound revealed enhancing mural nodules in the pancreatic head and dilation of the entire main pancreatic duct. We performed pancreaticoduodenectomy for mixed IPMN. Intraoperative pancreatoscopy, which was performed to rule out skip lesions, showed no mucosal abnormalities in the remnant duct. The pathological diagnosis was non-invasive intraductal papillary-mucinous carcinoma(IPMC). No signs of recurrence were seen for 6 postoperative months.

[A New Projection-Marking Technique for Breast-Conserving Surgery Using a Radiation Treatment Planning System and Multi-Leaf Collimator in Patients with Breast Cancer-A Pilot Study].

In this study, a breast-conserving surgery(BCS)was performed involving the new image projection technique, using a radiation treatment planning system(RTPS)and a multi-leaf collimator(MLC), for patients with ductal carcinoma in situ (DCIS)and invasive ductal carcinoma(IDC)with ductal components. This study aimed to evaluate the feasibility of this procedure as a pilot study. From June 2014 to May 2017, 27 patients diagnosed with DCIS and IDC with ductal components underwent BCS. In the RTPS, the design of tumor resection was simulated, and the extent of resection was projected to the breast surface using the MLC. BCS was performed using this skin marking. Among 27 patients, 4(14.8%)had carcinoma in the surgical margins. As a pilot study, the simplicity and usefulness of this procedure was confirmed in BCS for patients with DCIS and IDC with ductal components. Further evaluation of its safety and efficacy will be conducted in more patients.

[A Case of Gastrointestinal Stromal Tumor Re-Resected Ten Years after the Resection of Its Recurrence].

The patient was a 75-year-old man who was diagnosed as having jejunal gastrointestinal stromal tumor(GIST)and underwent partial resection of the small intestine including the tumor 12 years ago. Two years after the first resection, recurrence was detected, and a second resection was performed. Ten years after the second resection following recurrence, he took imatinib, and computed tomography(CT)revealed abdominal and liver tumors. We was diagnosed as having GIST recurrence, and a third resection, which included an abdominal tumor resection and partial hepatectomy, was performed. The pathological findings were metastatic abdominal GIST and angiomyolipoma of the liver. The Japanese Clinical Practice Guidelines for GIST suggest a surgical indication only for local recurrence of GIST and resectable liver metastases. Recurrent GIST cannot be completely cured with antineoplastic drugs alone. Multidisciplinary treatment is necessary for long-term survival of patients with recurrent GIST.

[A Case of Transverse Colon Cancer with Liver Metastasis and Tumor Thrombosis of Portal Vein Effectively Treated with Chemotherapy].

The patient was a 70-year-old man. He was diagnosed with advanced transverse colon cancer. A computed tomography (CT)revealed liver metastasis and tumor thrombosis of portal vein. We started combination chemotherapy with capecita- bine/oxaliplatin(CapeOX). Perforation of the tumor was observed 5 days after CapeOX therapy was started. Treatment with abscess drainage and ileostmy, infection was controlled and general condition was improved. After 9 courses of CapeOX, we changed chemotherapy regimen to irinotecan/tegafur-gimeracil-oteracilpotassium (IRIS)due to strong side effects. In CT and FDG-PET examination after 8 courses of IRIS, the tumor of transverse colon, liver metastasis, and the tumor thrombosis of portalvein became unclear. A year and 6 months have passed since chemotherapy was started, recurrence was not observed. For the patients with unresectable colorectal cancer, it is necessary to consider multidisciplinary treatments including chemotherapy while considering the general condition of them.

[Four Cases of Occult Breast Cancer Treated with Breast Conserving Therapy after Neoadjuvant Chemotherapy].

We report 4 patients with occult breast cancer(OBC)who underwent breast conserving therapy(BCT)after neoadjuvant chemotherapy(NAC). All patients complained of axillary tumor and were diagnosed by core needle biopsy. Pathological examination of the axillary lymph nodes proved that 3 cases were adenocarcinomas and 1 case was squamous cell carcinoma, but imaging studies could not depict any primary lesions in the breast and other organs. Since distant metastasis was not observed, BCT with axillary lymph node dissection(ALND)was performed after NAC. All patients were undergoing whole breast irradiation. There were no residual cancer cells in the axillary lymph nodes in case 1 due to the treatment effect of NAC, but lymph node metastasis remained in other 3 cases. In the second case, she followed a rapid outcome, and pulmonary metastasis appeared in 7 months after surgery and died in 10 months. In the other 3 cases, there has not been found local and distant recurrence. Although OBC requires appropriate systemic treatment, present observation indicated that ALND with breast irradiation after NAC could be a useful option.

[A Case Report of Long-Term Survival after Excision for Needle Tract Implantation of Biopsy and Hepatectomy for Cholangiocarcinoma with Gall Bladder Hemorrhage].

A 77-year-old men with abdominal pain suffered from gall bladder hemorrhage and liver abcess was admitted for intensive care of severe acute cholangitis. He had hemobilia which was treated by the endoscopic retrograde bile duct drainage. After 2 months treatment with rest for purulent myelitis, he had neoplastic change of liver abcess diagnosed as intrahepatic bile duct cancer by percutaneous core needle biopsy. He underwent surgery as central bisegmentectomy and left the hospital at home 3 months later after rehabilitation for surgical site infection. He noticed growing mass on right chest 6 months later after hepatectomy and was diagnosed as needle tract implantation in chest wall by CT examination. Pathological exam revealed cholangiocarcinoma by radical excision. He have disease free for 5 years after second operation. Although percutaneous biopsy for hepatic tumor increases risks of needle tract implantation and dissemination, there is an advantage of radical resection for tract implantaion.

[Four cases of operations for malignant disease in elderly patients].

The management of elderly patients with malignant disease is determined by their condition, complications, and living environment. Sometimes it is difficult to judge surgical indications for elderly patients. We report 4 cases of patients, 80 years or older, who underwent an operation for malignancy. In the first case we performed a bile duct excision for bile duct cancer, and in the second case we performed distal pancreatectomy for pancreatic cancer. Both operations were non-curative, and the patients were alive and maintained quality of life for 12 months after the operation. In the third non-curative operation, we performed total gastrectomy for remnant gastric cancer. The patient died of cancer 4 months after the surgery. In the fourth case we performed pancreaticoduodenectomy for bile duct cancer; it was a curative operation. The patient was in very good condition 4 months post-operation, but died suddenly due to acute myocardial infarction. In operations treating malignancy in elderly patients, it is important for the patients and their families to fully understand the significance of the operations.

Duodenal tuberculosis with gastric outlet obstruction: a case report of successful diagnosis and treatment, with review of literature.

BACKGROUND: Duodenal tuberculosis (TB) is extremely rare, and its diagnosis is challenging owing to the lack of specific symptoms and radiological or endoscopic findings. When it leads to gastric outlet obstruction (GOO), diagnosing it accurately and providing appropriate treatment is crucial. However, this is often overlooked. CASE PRESENTATION: A 35-year-old man presented with abdominal pain, fullness, vomiting, and weight loss. Upper gastrointestinal endoscopy and radiography revealed nearly pinpoint stenosis with edematous and reddish mucosa in the D1/D2 portion of the duodenum. Computed tomography (CT) showed the duodenal wall thickening, luminal narrowing, multiple enlarged abdominal lymph nodes, and portal vein stenosis. Conventional mucosal biopsy during endoscopy revealed ulcer scars. We initially suspected stenosis due to peptic ulcers; however, chest CT revealed cavitary lesions in both lung apices, suggesting tuberculosis. Due to the suspicion of duodenal TB and the need to obtain deeper tissue samples, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed. The tissue sample showed caseating granulomas with multinucleated giant cells, and acid-fast bacilli were positive by Ziehl-Neelsen staining. The patient was diagnosed with duodenal TB and subsequent GOO. Because the patient had difficulty eating, surgical intervention was prioritized over antitubercular drugs, and laparoscopic gastrojejunostomy was performed. The patient started an oral diet on the 3rd postoperative day and began antitubercular treatment immediately after discharge on the 11th day. During the 6th month of treatment, endoscopic examination revealed residual duodenal stenosis; however, the bypass route functioned well, and the patient remained asymptomatic. CONCLUSIONS: An aggressive biopsy should be performed to diagnose duodenal TB. EUS-FNA has proven to be a useful tool in this regard. Both nutritional improvement and antitubercular treatment were achieved early and reliably by performing laparoscopic gastrojejunostomy for duodenal TB with GOO.

A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy.

BACKGROUND: We devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure. PATIENTS AND METHODS: Twenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device. RESULTS: In 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm3 (range, 12.8-62.8 cm3), and percent breast volume excised was 6.8% (range, 2.5-15.7%). CONCLUSIONS: This pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.

Preoperative immunonutrition decreases postoperative complications by modulating prostaglandin E2 production and T-cell differentiation in patients undergoing pancreatoduodenectomy.

BACKGROUND: An immune-enhancing diet has been used to alter eicosanoid synthesis, cytokine production, and immune function in an attempt to limit the undesired immune reactions after injury from surgery. This prospective randomized study was designed to investigate the effect of preoperative immunonutrition on operative complications, and the participation of prostaglandin E2 (PGE2) on T-cell differentiation in patients undergoing a severely stressful surgery. METHODS: The enrolled patients who were scheduled to undergo pancreatoduodenectomy were randomized into two groups. Patients in the immunonutrition group (n = 25) received oral supplementation containing arginine, ω-3 fatty acids, and RNA for 5 days before the procedure in addition to a 50% reduction in the amount of regular food. Patients in the control group (n = 25) received no artificial nutrition and were allowed to consume regular food before surgery. All patients received early postoperative enteral infusion of a standard formula intended to provide 25 kcal/kg/day. The primary endpoint was the rate of infectious complications; the secondary endpoint was immune responses. This study is registered with ClinicalTrials.gov (NCT01256034). RESULTS: Infectious complication rate and severity of complications (Clavien-Dindo classification) were lesser in the immunonutrition group than in the control group. mRNA expression levels of T-bet were greater in the immunonutrition group than in the control group (P < .05). Serum eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratios were greater in the immunonutrition group than in the control group (P < .05). The levels of plasma PGE2 were lesser in the immunonutrition group than in the control group (P < .05). CONCLUSION: Preoperative immunonutrition modulates PGE2 production and T-cell differentiation and may protect against the aggravation of operative complications in patients undergoing pancreatoduodenectomy.