Paratracheal air cyst and bronchogenic cyst in patients with esophageal cancer who received thoracoscopic esophagectomy: A case series of three patients.

INTRODUCTION AND IMPORTANCE: Mediastinal cystic lesions, such as paratracheal air cyst (PTAC) and bronchogenic cyst (BC), are rare anomaly usually found incidentally in thoracic imaging. Special attention is needed in the case of thoracic surgery. CASE PRESENTATION: All three patients were male, 71, 73, and 76 years old. Preoperative CT showed each had a lobular cystic lesion at the right posterolateral side of trachea in the thoracic outlet 11, 14, and 19 mm in size, respectively, with air density and tracheal communication, leading to a diagnosis of PTACs. An oval cystic lesion, 7 mm in size, was found in one patient at the right lateral side of the upper esophagus with low density and without tracheal communication, leading to a diagnosis of paraesophageal BC. Intraoperative findings of the three PTACs demonstrated a soft bulge from the membranous portion of trachea that was left intact. The BC had an oval elastic structure, mimicking a metastatic lymph node, and was removed with the mediastinal lymph nodes. Histological examination showed ciliated columnar epithelium, confirming a diagnosis of BC. CLINICAL DISCUSSION: PTACs are associated with increased intraluminal pressure due to chronic lung disease. BCs are congenital anomalies that originate from abnormal budding of the embryonic foregut. CONCLUSION: PTACs and BCs need to be considered in preoperative image diagnosis in patients with esophageal cancer. PTACs should be left intact to avoid tracheal injury, while removal of isolated BCs is recommended as a diagnostic and therapeutic measure.

Reference range of clinical blood tests in physically independent patients of advanced age with groin hernia in a Japanese hospital.

AIM: The present study was carried out to determine the reference ranges of 43 frequently used blood tests in daily practice for physically independent patients of advanced age. METHODS: We identified all patients aged ≥20 years who underwent groin hernia repair at Itoigawa General Hospital in Niigata, Japan. The patients' characteristics, preoperative data and prescribed medications were obtained by reviewing the electronic medical records. RESULTS: Of 284 patients, 266 with independence in activities of daily life were included in the present study: 72 were assigned to the younger adult group (age 20-64 years), 86 were assigned to the older adult group (age 65-74 years) and 108 were assigned to the advanced age group (age ≥75 years). Patients in the advanced age group had a lower body mass index, less alcohol consumption, more hypertension, lower respiratory function and higher frequency of multidrug therapy. The multiple regression analysis showed significant differences in albumin, gamma-glutamyl transpeptidase, cholinesterase, estimated glomerular filtration rate, uric acid, triglyceride, calcium, phosphate, magnesium and peripheral blood cell counts between the advanced age group and the other two age groups. CONCLUSIONS: We identified age-dependent changes in several blood tests among physically independent adults. These results will help to guide accurate interpretation of laboratory results and properly manage patients in geriatric medicine. Geriatr Gerontol Int 2019; 19: 780-785.

[Very elderly case of spontaneous esophageal rupture successfully treated by conservative treatment;report of a case].

A 94-year-old female patient presenting with vomiting and hematemesis, was transferred to our hospital. On a chest computed tomography (CT) image, mediastinal emphysema was seen with a little amount of bilateral pleural effusion, therefore, a diagnosis of spontaneous esophageal rupture was made. It took 6 hours to make a definite diagnosis of this disease, and conservative therapies were done including administration of antibiotics and proton-pump inhibitor. The patient was able to drink water on 4th hospital day, and was discharged on 19th hospital day. At about 2 months after the onset, a gastrointestinal fiberscope showed just only scar at the lower thoracic esophagus.

Adenocarcinoma in long-segment Barrett's esophagus 44 years after total gastrectomy.

Although Barrett's esophagus may occur without gastric acid, Barrett's adenocarcinoma after total gastrectomy is rare. Here, we present Barrett's adenocarcinoma in long-segment Barrett's esophagus after total gastrectomy. The patient was a 74-year-old male who underwent total gastrectomy 44 years ago. An endoscopic examination revealed long-segment Barrett's esophagus starting 17 cm from the incisors and continuing 20 cm to esophagojejunostomy, with irregular mucosa 27-31 cm from the incisors. Pathological diagnosis of a biopsied specimen was adenocarcinoma. We performed subtotal esophagectomy with lymph node dissection in the prone position and reconstructed the esophagus with ileocolic interposition. Postoperative pathological diagnosis from a Barrett's epithelial section was well differentiated adenocarcinoma. This case had the longest interval from total gastrectomy and smallest oral margin of Barrett's epithelium. Our case suggested that careful surveillance is needed for patients exhibiting recurrent bile reflux following total gastrectomy.

[Left traumatic diaphragmatic hernia in the postoperative state of lung cancer: report of a case].

We report a case of left traumatic diaphragmatic hernia in the postoperative state of the lung cancer. A 68-year-old man underwent video-assisted partial resection of the left lung for lung cancer. One year after the operation, he experienced an accident of falling from a tree. Chest radiograph and chest computed tomography revealed the stomach herniating into the left thoracic cavity. An emergent operation was performed by the abdominal approach. The stomach was returned into the abdominal cavity, and the hiatus in the central tendon of the left diaphragm was primarily sutured. The postoperative course was uneventful.

[Effective chemotherapy with S-1 alone in a patient with lung metastases of breast cancer].

We report a 50-year-old female with pulmonary metastases from breast cancer who responded to S-1. In September 2003, she underwent surgery for breast cancer. Four years 8 months after the operation, lung relapse was detected. After the treatment failure of FEC60 (5-FU 500 mg/m², epirubicin 60 mg/m², cyclophosphamide 500 mg/m²) and taxane antitumor drugs, oral administration of S-1 80 mg/body/day was initiated. At the end of three courses, thoracic CT revealed the disappearance of the lung metastasis. Advanced reactions during the administration period were mild. After 14 courses of S-1 therapy (during 11 months), a complete response was clinically maintained. S-1 showed a good antitumor effect and tolerance, and it might be useful for treating metastatic and recurrent breast cancers.

[An elderly advanced breast cancer with a good response to anastrozole].

The patient was an 86-year-old woman. In December 2005, she became aware of a tumor in her right breast at the nipple, gradually increasing in size and bleeding, and visited our department in April 2006. Roughly 3.5 cm in size, the tumor had a prominent large skin surface, bled profusely, and a dark red-colored was found at the E area of the right breast. Ultrasonography and mammography revealed that the tumor had invaded the skin and pectoralis major muscle (T4b). Core needle biopsy examination indicated invasive breast cancer (pap-tub), ER(+), PgR(+), HER2(3+). Chest CT scan and bone scintigraphy revealed swollen changes at the right axillary lymph nodes and osteoblastic changes in the 7th thoracic vertebra. We started anastrozole 1mg/day treatment. Tumor blood loss after one month was confirmed. After six months, the primary tumor size was reduced to 2 cm and the axillary lymph nodes disappeared. Administration continued about three years, and the tumor showed only the scar-like changes, and was unclear from ultrasonography (cPR). We report the long-term effect of aromatase inhibitor for elderly breast cancer patients without operation.

[A successfully resected case of colorectal cancer with multiple liver metastases treated with FOLFIRI after failure of mFOLFOX6].

A sixty-year-old man was admitted with anorexia and abdominal mass. Colonoscopy revealed type 2 tumor at sigmoid colon. Computed tomography (CT) demonstrated multiple liver metastases. The patient was diagnosed as sigmoid colon cancer with multiple liver metastases. The patient was treated with mFOLFOX6 as neoadjuvant chemotherapy because the liver metastases were unresectable. However, after 2 cycles of mFOLFOX6, the level of CEA and CA19-9 much increased. The regimen was replaced by FOLFIRI. The level of CEA and CA19-9 decreased after 2 cycles of FOLFIRI. CEA and CA19-9 further decreased and colonoscopy and CT revealed a partial response after 5 cycles of FOLFIRI. The patient was subjected to curative resection. Sigmoidectomy and liver resection were performed. Histological response was Grade 1b at liver metastasis. The patient was discharged and had an uneventful recovery. Six months after surgery, CEA and CA19-9 decreased to normal level, and the patient is free of recurrence. Neoadjuvant chemotherapy for metastatic colorectal cancer may render some unresectable patients resectable, affording these patients the possibility of prolonged survival. However, the optimal approach is unknown.

[A case of unresectable gastric cancer presenting pylorus stenosis treated orally with S-1 therapy after gastrojejunostomy].

We reported a case of unresectable gastric cancer presenting pylorus stenosis treated orally by S-1 therapy in a 72-year-old man who underwent gastrojejunostomy. He was admitted to our hospital complaining of appetite loss and body weight loss. Detailed examination showed gastric cancer with pylorus stenosis. After insertion of the naso-gastric tube with washing, a laparotomy was done. The operative findings revealed sT3, sN2, sP1, sH0 and sM1 (metastases of No. 14a lymph nodes invading the super mesenteric artery and pancreas) as an unresectable case with stage IV. Gastrojejunostomy and Braun anastomosis were made through the antecolic route. After the operation, intake therapy of S-1 was started (80-100 mg/body/dayx28 days). After 2 courses of the therapy, gastrointestinal fiber showed clinically a partial response of the main tumor. After 3 courses of this treatment, the tumor presented multiple liver metastases as a clinically progressive disease state. Paclitaxel therapy was conducted at a dose of 80 mg/body/weekx3 timesx2 courses. The patient had no effective benefits from the treatment and died of the cancer. He had survived 9 months, and the intervals of the intake and home stay were 7.5 months and five months, respectively, after the operation with no side effect of the chemotherapy. Survival was no longer than for patients only operated without S-1 therapy.

A new guide technique for limited partial hepatectomy using a transhepatic tube.

In order to maintain the adequate tumor margin in partial hepatectomy, we developed a new guide technique using a fine transhepatic tube. For instance, in a case of anterior segment tumor, a fine needle following a tube was inserted into the liver beside the anterior portal pedicle at hepatic hilus, and was put forward to the confluence of right and middle hepatic veins. After the needle was pulled out, both edges of the tube were tugged to the Rex Cantlie line. A separation was then started from the liver surface down to the transhepatic tube. Subsequently, the tube was pulled to the right side, and another separation was done. Adequate disease-free surgical margins were kept in thirteen out of 15 various types of partial hepatectomies. There were no complications including injury to the vessels and stabbing of the tumor. This technique facilitates cutting of the deep parenchyma.

[A case of gastric carcinoma with metachronous liver metastases that responded to percutaneous ethanol injection therapy (PEIT) and TS-1].

A 57-year-old male underwent a total gastrectomy with D1 lymph node dissection for gastric carcinoma. The main tumor was located in area UM, measuring 15 x 6 cm and was classified as type 5. Histopathologically, the cancer cells invaded the subserosal layer with a moderately differentiated tubular pattern. Lymph node metastases (No. 1, 3, 7 and 9) were detected. Lymphatic involvement was revealed (ly 2). Three years after the first surgery, a liver metastasis (area S4) with a diameter of 30 mm was detected by abdominal ultrasonography. Percutaneous ethanol injection therapies (PEIT) were performed twice for the lesion. After PEIT, a TS-1 intake program (80 mg/day, for 4 weeks) was started for the metastatic lesion. Both treatments were effective. The patient has survived without recurrence for over 5 years after the total gastrectomy.