A case of internal hernia in the pararectal fossa.

BACKGROUND: Internal hernias are relatively rare and difficult to diagnose. Diagnostic delays lead to the progression of strangulation. In particular, pararectal fossa hernias are extremely rare. We encountered a case in which internal hernia occurred in the pararectal fossa. CASE PRESENTATION: An 87-year-old woman was referred to our hospital because of persistent lower abdominal pain and vomiting. Contrast-enhanced computed tomography revealed findings of intestinal ischemia, such as closed loop formation with reduced contrast effect on the left side of the rectum in the pelvis. Strangulation small bowel obstruction was diagnosed, and emergency laparotomy was performed. The small intestine was found to invade the peritoneal reflection on the left side of the rectum. The patient was finally diagnosed with pararectal fossa hernia. The incarcerated small intestine was released with no bowel resection. The 4-cm hernia phylum was observed and closed by simple suture. The patient had a good postoperative course without recurrence. CONCLUSIONS: We encountered a very rare case of internal hernia in the left pararectal fossa. Preoperative diagnosis of this disease is difficult, but it should nevertheless be considered in cases in which the cause of the intestinal obstruction is unknown.

Microsatellite Instability-high Signet Ring Cell Carcinoma of the Colon Treated With Immunotherapy: Report of a Case.

BACKGROUND: Immune checkpoint inhibitors (ICIs) are attracting increasing attention as a novel and potentially curative therapy for microsatellite instability-high (MSI-H) colorectal cancer (CRC). CASE REPORT: An 80-year-old female visited our hospital with complaints of lower abdominal pain due to bowel obstruction caused by descending colon cancer. After 1 month of metallic stent detention, she underwent radical surgery, although laparotomy showed broad peritoneal dissemination. Based on the genetic finding of MSI-H status, pembrolizumab therapy was administered in two cycles. Unfortunately, the therapy was ineffective, and the patient died after being discharged 5 months after surgery. CONCLUSION: The findings in this case of MSI-H CRC with a poor response to an ICI suggest the importance of confirming HLA status, including beta-2-microglobulin and HLA expression, before starting ICI therapy in cases of MSI-H CRC.

Chronic Appendicitis Caused by a Perforating Fish Bone: Case Report and Brief Literature Review.

BACKGROUND: Appendicitis caused by a foreign body is extremely rare. We report a case of chronic appendicitis caused by a perforating fish bone. CASE REPORT: The patient was a 50-year-old Japanese man. He felt dull lower abdominal pain for 2 months and diagnosed as appendicitis caused by a perforating fish bone. He underwent emergency laparoscopic surgery. The fish bone had perforated through the appendix wall. The fish bone was initially removed followed by laparoscopic appendectomy. Pathological investigation revealed a transmural cut line of approximately 0.5 mm that was surrounded by fibrous tissue with inflammation. CONCLUSION: This is the first reported case of fish bone-induced chronic appendicitis that underwent laparoscopic appendectomy. For optimum outcome, a correct diagnosis based on a detailed consultation and imaging tests, and an operation performed after careful planning are needed.

A rare case of perforation of a colorectal tumor by a fish bone.

The accidental ingestion of foreign bodies is a common clinical issue. While most foreign bodies pass through the gastrointestinal (GI) tract without complications, a few cases unfortunately result in GI perforation. Fish bones are one of the most frequent foreign bodies found in the GI tract, and they are high-risk objects for GI perforation due to their hard and sharp-pointed ends. Here, we present a rare case of a 64-year-old man with perforation of a colorectal tumor by a fish bone. The patient received emergency Hartmann's operation with lymph node dissection. Although the patient experienced recurrence in the liver rather than peritoneal dissemination, systemic chemotherapy was considerably effective, and conversion therapy with hepatectomy was successfully performed; the patient achieved 5-year relapse-free survival after the operation. To our knowledge, this is the first report of the perforation of a GI tumor by a fish bone. This rare case suggests the significant clinical implication that proper preoperative diagnosis and prompt surgical treatment lead to better postoperative outcomes for patients with tumor perforation by a foreign body.

A Case of Mesenteric Desmoid Tumor Causing Bowel Obstruction After Laparoscopic Surgery.

BACKGROUND: A desmoid tumor is a rare neoplasm that is derived from soft tissues. Although it shows benign characteristics pathologically, local recurrence can occur. CASE REPORT: We herein report the case of a patient with an intraabdominal desmoid tumor that developed 3 years after laparoscopic appendectomy for acute appendicitis. A 59-year-old male visited our emergency room with complaints of abdominal pain and fullness. Abdominal computed tomography revealed distention of the small intestine with a point of obstruction by an intraabdominal tumor-like region. Pathological findings showed that the tumor was compatible with desmoid fibromatosis. CONCLUSION: In cases with an intraabdominal tumor after laparoscopic surgery, it is important to consider the possibility of a desmoid tumor, since it is difficult to diagnose it accurately before surgery.

Perirectal abscess with dysuria.

Perirectal abscesses often occur in the dorsal portion of the perirectal tissues. We report a patient who presented with fever, pain on defecation, and dysuria. He was found to have a perirectal abscess in the anterior perineum pressing on the urethra. After emergency surgery to drain the abscess, the symptoms improved.

[Jejunal duplication in an adult presenting with hematochezia].

A 56-year-old man was admitted to our hospital with appetite loss, palpitations, orthostatic syncope, and hematochezia. Contrast-enhanced abdominal computed tomography (CT) revealed a proximal jejunal diverticulum with contrast extravasation. We immediately performed transoral double balloon enteroscopy (DBE) to treat the bleed in the jejunum, and this revealed a small ulcer with an exposed vessel at the opening of the jejunal diverticulum. Hemostasis was achieved endoscopically with argon plasma coagulation (APC) and hemoclips. During subsequent surgery, the diverticulum was found on the mesenteric side of the jejunum. We performed laparoscopy-assisted partial resection of the jejunum, and pathological examination showed that the diverticulum shared a common proper muscle layer with the jejunum and was covered by jejunal mucosa with no ectopic mucosa. Therefore, we diagnosed jejunal duplication. After hospital discharge, the patient had no recurrence of hematochezia or anemia. We report a rare case of jejunal duplication presenting with hematochezia, which was diagnosed as jejunal diverticular bleeding by CT and DBE before surgery. Pathological analysis confirmed jejunal duplication after surgery. We suggest that intestinal diverticular bleeding, as well as duplication of the gastrointestinal tract, should be considered as part of the differential diagnosis of obscure gastrointestinal bleeding.

[Two cases of recurrent GIST successfully treated with imatinib mesylate at 100mg/day].

Case 1: Recurrent tumors from gastric GIST in the liver and the abdominal wall showed partial response with 200mg/day imatinib and maintained partial response at 100mg/day. Case 2: Metastatic liver tumors from the jejunal GIST showed partial response with 200mg/day imatinib. The tumors have been enlarged for interruption of imatinib administration, however, re- treatment with imatinib resulted in partial response again and kept partial response at 100mg/day of imatinib. The two cases seldom encountered adverse events at 100mg/day of imatinib. There are some cases successfully treated with low-dose imatinib mesylate for recurrent GIST.

[Clinical efficacy of octreotide acetate in cancer patients with malignant bowel symptoms depend on terminal stage].

There are many reports that octreotide acetate(SMS)is effective for terminally ill cancer patients with malignant bowel obstructions such as nausea, vomiting and abdominal distension. We retrospectively found that the clinical efficacy of SMS in 23 patients with these symptoms depended on the early terminal stage(about six months until death)or middle terminal stage(within one month until death). SMS was more effective to relieve abdominal distension(p=0. 01)and these bowel symptoms occurred among cancer patients in the early terminal stage rather than in the middle terminal stage(p<0. 001).

[A case of recurrent breast cancer with lung metastasis resection showing four disease-free years under trastuzumab treatment].

We report a case of recurrent breast cancer with solitary lung metastasis that has shown no recurrence with treatment by trastuzumab alone after partial resection of the right lung upper lobe. A 56-year-old woman, who presented with left breast cancer, underwent quadrantectomy and axillar lymph node dissection in March 2004. Pathological findings were as follows: invasive ductal carcinoma, 3. 7 cm in size, histological grade 3, positive invasion of lymphatic and blood vessels, negative nodal status, negative ER/PgR status, and overexpression of HER2/ neu. She had received adjuvant radiotherapy followed by cyclophosphamide, methotrexate and fluorouracil combination chemotherapy; however, a lung nodule developed 14 months after first operation, which had grown gradually. Partial resection of the lung with thoracoscope assistance revealed metastatic lung cancer from breast cancer. Trastuzumab treatment for 6 months after second operation has maintained no recurrence for 4 years.

Safety, efficacy and pharmacokinetics of S-1 in a hemodialysis patient with advanced gastric cancer.

PURPOSE: The safety and efficacy of S-1 in hemodialysis patients have not been established. We evaluated the safety and efficacy and pharmacokinetics of S-1 in a hemodialysis patient with advanced gastric cancer. PATIENT: A 66-year-old Japanese man with chronic renal failure, who had undergone hemodialysis three times a week for 3 years. Based on the diagnosis of stage IV gastric cancer, S-1 therapy was started. S-1 was administered 11 times at a daily dose of 23.5 mg/m(2) (40 mg/body)after hemodialysis, followed by a rest. One course was a period of 28 days. Blood samples were obtained after the first administration of S-1 and before beginning the fourth course. The concentration of 5-FU was determined by high-performance liquid chromatography. RESULTS: Area under the concentration-time curve (AUC)of 5-FU was 2647.2 ng h/mL after administration of S-1 of 23.5 mg/m(2) (40 mg/body). During the S-1 treatment,serious adverse events such as neutropenia were not observed; however, decreases in hemoglobin level were observed (grade 3). The treatment was well tolerated. After the second course of chemotherapy, the primary lesion showed a partial response and lymph node metastases and liver metastases showed stable disease. CONCLUSIONS: Our results suggest that S-1 is an important treatment option for patients with hemodialysis with advanced gastric cancer.

[A case of gastric gastrointestinal stromal tumor operated after low-dose chemotherapy with imatinib mesylate].

A 76-year-old man was admitted to our hospital because of tarry motions. Endoscopic findings showed an ulcer on a large submucosal tumor in the stomach. Abodminal CT scan showed a protruding lesion of approximately 13 cm at the lumen of the gastric body. FDG-PET imaging revealed FDG uptake in the gastric body and abdominal cavity. We diagnosed it as GIST with peritoneal dissemination clinically, and treatment with 300 mg of imatinib mesylate was started in December 2006. The main tumor was reduced(reduction rate of 27%)and FDG-PET imaging revealed a decrease in FDG uptake in the main tumor and all disseminated tumors after 5 months of treatment. However, the drug was discontinued for arthritis(grade 3). Partial gastrectomy with sampling peritoneal nodules was performed in June 2007. The present case suggests that low-dose chemotherapy with imatinib mesylate may be useful as a preoperative therapy for a minimal surgery.

[Good response in ARDS treated with sivelestat sodium hydrate during chemotherapy for cholangiocarcinoma].

We experienced a case of good response in acute respiratory distress syndrome (ARDS) treated with sivelestat sodium hydrate during chemotherapy for cholangiocarcinoma. A 66-year-old male treated with combined paclitaxel (PTX) and S-1 suffered from ARDS following neutropenia. Sputum and blood culture examinations demonstrated an unknown origin, so sivelestat sodium hydrate was considered more effective than antibiotics. Sivelestat sodium hydrate ought to be used for ARDS treatment even during administration of anti-cancer agent.

[A case of partial response in liver metastatic lesion from gastric endocrine cell carcinoma treated with TS-1].

Endocrine cell carcinoma (ECC) of the stomach is a rare pathological type with a poor outcome. Standard chemotherapy has not yet been established. We experienced a case of partial response in the liver metastasis from the gastric ECC treated with TS-1. The patient was a 68-year-old female. An upper GI series and gastroendoscopy revealed pyrolus stenosis and CT-scan showed liver metastasis. A non-curative total gastrectomy was performed to allow oral intake. Since the histopathological examination revealed that tumor cells were partially positive for chromogranin A on immunohistochemical study, we diagnosed tumor ECC of the stomach. The patient with liver metastasis was treated using TS-1, and CT-scan showed a remarkable decrease (PR) in the metastatic lesion. TS-1 administration can improve the clinical outcome for ECC of the stomach.

[A case of recurrent GIST successfully treated with low-dose imatinib mesilate].

A 75-year-old man underwent partial resection of the small intestine for GIST in January 2000. A recurrent tumor revealed in the intra pelvic space was removed by two operations, and imatinib (400 mg/day) was given after the third operation. As successive administration was not able to be continued due to side effects such as anorexia and fatigue, the recurrent tumor enlarged. After imatinib was given at 200 mg/day, the defecation trouble was improved and the tumor decreased partially on CT image. His partial response has continued over one year. Mutation analysis revealed deletion and point mutation in exon 11 of c-kit gene. Low-dose imatinib administration should be considered in case of side effects at the standard dose.

Co-regulation of B-Myb expression by E2F1 and EGF receptor.

Epidermal growth factor receptor (EGFR) is a receptor tyrosine kinase that is frequently over-expressed in human cancers and is associated with tumorigenesis, and increased tumor proliferation and progression. Also found in breast tumors with high levels is B-Myb, a transcription factor whose expression is activated by E2F1/3 at the late G1 phase and the level is sustained through the S phase. Recent reports suggest a casual correlation between EGFR and B-Myb expression in primary breast carcinomas. However, the mechanism for such co-expression remains un-investigated. Here, we report that EGFR is important for B-Myb expression and the underlying mechanism involves cooperated effects from EGFR and E2F1. EGF stimulation and forced expression of EGFR significantly increase B-Myb gene activity and such increase occurs in the G1 phase. EGF-induced B-Myb expression was not significantly suppressed following inhibition of PI-3K and ERK, two major EGFR downstream pathways. In contrast, we observed EGF-induced in vivo association of nuclear EGFR to the B-Myb promoter and the association is only detected at the G1/S phase and is abolished by EGFR kinase inhibitor. As EGFR lacks DNA-binding domain but contains transactivational activity and E2F1 activates B-Myb expression in the G1/S phase, we further reasoned that nuclear EGFR might cooperate with E2F1 leading to activation of B-Myb. Indeed, we found that EGFR co-immunoprecipitated with E2F1 in an EGF-dependent manner and that EGF activated in vivo binding of E2F1 to the B-Myb promoter. Consistently, forced expression of both EGFR and E2F1 in EGFR-null CHO cells greatly enhanced B-Myb promoter activity, compared to the vector control and expression of EGFR or E2F1 alone. Promoter mutagenesis studies showed that EGF-induced activation of B-Myb promoter required both E2F and EGFR target sites. In summary, our data suggest that deregulated EGFR signaling pathway facilitate tumor cell proliferation partly via EGFR interaction with E2F1 and subsequent activation of B-Myb gene expression.

IkappaB kinase promotes tumorigenesis through inhibition of forkhead FOXO3a.

Nuclear exclusion of the forkhead transcription factor FOXO3a by protein kinase Akt contributes to cell survival. We investigated the pathological relationship between phosphoylated-Akt (Akt-p) and FOXO3a in primary tumors. Surprisingly, FOXO3a was found to be excluded from the nuclei of some tumors lacking Akt-p, suggesting an Akt-independent mechanism of regulating FOXO3a localization. We provide evidence for such a mechanism by showing that IkappaB kinase (IKK) physically interacts with, phosphorylates, and inhibits FOXO3a independent of Akt and causes proteolysis of FOXO3a via the Ub-dependent proteasome pathway. Cytoplasmic FOXO3a correlates with expression of IKKbeta or Akt-p in many tumors and associates with poor survival in breast cancer. Further, constitutive expression of IKKbeta promotes cell proliferation and tumorigenesis that can be overridden by FOXO3a. These results suggest the negative regulation of FOXO factors by IKK as a key mechanism for promoting cell growth and tumorigenesis.

Production, characterization, and interspecies reactivities of monoclonal antibodies against human class A macrophage scavenger receptors.

Class A macrophage scavenger receptor (SR-A) is one of the major receptors of macrophages and plays important roles in atherogenesis and host defense mechanisms. To assess the role of SR-A, monoclonal antibodies were generated by immunizing SR-A-deficient mice with a recombinant protein of human type I SR-A as immunogen. Four antibodies (SRA-C6, SRA-D10, SRA-E5, and SRA-F8) were confirmed to be specific for SR-A by Western blot analysis. In early atherosclerotic lesions, these antibodies recognized scattered macrophages in intima and foamy macrophages in the periphery of atheromatous cores. Interestingly, foamy macrophages in the core lesion were only weakly stained. In other organs, the antibodies recognized tissue macrophages such as alveolar macrophages, Kupffer cells in the liver, red pulp macrophages in the spleen, sinus macrophages in lymph nodes, and interstitial macrophages in various organs. Perivascular macrophages in the brain (Mato cells) were also positive for these antibodies. Freshly isolated blood monocytes were negative; however, they became positive for these antibodies after 1 day in culture. At 3-5 days in culture, the reaction intensity became stronger along their differentiation towards macrophages. Dendritic cells such as interdigitating cells of lymphoid tissues and epidermal Langerhans cells were invariably negative. In the reaction with animal tissues, each antibody showed a unique reaction pattern. Among four antibodies, SRA-E5 recognized SR-A molecules in all animal species examined, including rats and mice. These antibodies will be useful tools for the study of SR-A in atherogenesis and various other pathological conditions in humans and animal species.