Novel and efficient method for culturing patient-derived gastric cancer stem cells.

Experimental techniques for patient-derived cancer stem-cell organoids/spheroids can be powerful diagnostic tools for personalized chemotherapy. However, establishing their cultures from gastric cancer remains challenging due to low culture efficiency and cumbersome methods. To propagate gastric cancer cells as highly proliferative stem-cell spheroids in vitro, we initially used a similar method to that for colorectal cancer stem cells, which, unfortunately, resulted in a low success rate (25%, 18 of 71 cases). We scrutinized the protocol and found that the unsuccessful cases were largely caused by the paucity of cancer stem cells in the sampled tissues as well as insufficient culture media. To overcome these obstacles, we extensively revised our sample collection protocol and culture conditions. We then investigated the following second cohort and, consequently, achieved a significantly higher success rate (88%, 29 of 33 cases). One of the key improvements included new sampling procedures for tumor tissues from wider and deeper areas of gastric cancer specimens, which allowed securing cancer stem cells more reproducibly. Additionally, we embedded tumor epithelial pieces separately in both Matrigel and collagen type-I as their preference to the extracellular matrix was different depending on the tumors. We also added a low concentration of Wnt ligands to the culture, which helped the growth of occasional Wnt-responsive gastric cancer stem-cell spheroids without allowing proliferation of the normal gastric epithelial stem cells. This newly improved spheroid culture method may facilitate further studies, including personalized drug-sensitivity tests prior to drug therapy.

A novel method of anvil placement of circular stapler for esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: results of consecutive 200 cases.

BACKGROUND: Laparoscopic total gastrectomy for gastric cancer is still a demanding operation because of technical difficulties, especially of intracorporeal esophago-jejunal anastomosis. METHODS: We introduced a newly designed method of anvil placement of circular stapling devices (CS) for laparoscopic esophagojejunostomy (EJS). A small incision was made on the anterior wall of the stomach, from which the anvil was inserted into the stomach and proceeded to the thoracic esophagus. Then, the abdominal esophagus was transected by a linear stapler, and the anvil into the esophagus was drawn back to the esophageal stump by pulling out the cotton tape pre-attached to the anvil. Intracorporeal EJS by Roux-en-Y reconstruction was performed by CS inserted into the abdominal cavity from the umbilical wound. RESULTS: A total of consecutive 200 gastric cancer patients underwent laparoscopic total gastrectomy using this method. There was no operative mortality. Anastomotic complications occurred in 12 cases (6.0%): 9 cases of stenosis (4.5%) and 3 cases of bleedings (1.5%). Anastomotic leakage was not observed. As for non-anastomotic complications, there occurred 2 pulmonary complications (1.0%), 3 pancreatic leakages (1.5%), and 8 bowel obstructions due to internal hernia (4.0%). With a median follow-up period of 47.1 months, 5-year overall survival for assessable patients (n = 193) was 60.3% (95% CI 52.6-67.2). The total rate of peritoneal recurrence was 9.8%. CONCLUSION: Our new method of anvil placement for laparoscopic EJS with CS is safe and feasible with favorable survival outcomes. It eliminates the need for suturing, and will promote the clinical application of laparoscopic total gastrectomy for gastric cancer. CLINICAL TRIALS: UMIN000046119.

Re-do laparoscopic esophagojejunostomy for anastomotic stenosis after laparoscopic total gastrectomy in gastric cancer.

PURPOSE: Anastomotic stenosis of esophagojejunostomy after total gastrectomy has a substantial impact on the postoperative quality of life of the patient. If conservative treatment doesn't work, surgical intervention should be considered. However, redoing esophagojejunostomy is an extremely demanding procedure. Especially in the case where the primary surgery was performed laparoscopically, it is an unmet problem to maintain minimal invasiveness in re-do surgery. METHODS: We report 3 cases of re-do esophagojejunostomy laparoscopically performed for anastomotic stenosis after laparoscopic total gastrectomy in gastric cancer, in whom endoscopic balloon dilation did not work. RESULTS: Each patient underwent a re-do esophagojejunostomy laparoscopically. The mean operation time was 293 min, and the mean blood loss was 56 ml. There was no anastomosis-related complication, and they were discharged from hospital on 11-16 postoperative days. At the time of discharge, oral food intake was 100% in each patient. One year after the operation, follow-up endoscopic exams showed no anastomotic stenosis. CONCLUSION: Re-do laparoscopic esophagojejunostomy for anastomotic stenosis after laparoscopic total gastrectomy was safely and successfully performed. It brings patients minimal invasiveness continuously from the initial surgery. Re-do laparoscopic esophagojejunostomy could be one of the options for anastomotic stenosis resistant to conservative treatment.

Intrahepatic bile duct rupture associated with IgG4-related sclerosing cholangitis presenting hepatic inflammatory pseudotumor.

A 67-year-old man with a low-grade fever was found to have a 25-mm diameter tumor of the left hepatic umbilical portion. The tumor was accompanied by occlusion of the left portal vein. Positron emission tomography using fluorodeoxyglucose showed that the tumor had abnormally high metabolic activity. Magnetic resonance imaging revealed the left hepatic duct segmental narrowing. There was a mild elevation in serum IgG4 (206 mg/dL). Intrahepatic cholangiocarcinoma was suspected. Instead of planned hepatectomy, the patient was forced to undergo emergency surgery for biliary panperitonitis caused by intrahepatic bile duct rupture. Intraoperative ultrasonography revealed a hypoechoic tumor-like thickened Glissonean sheath and needle biopsy was performed. Histologic examination confirmed fibrous tissue with IgG4-positive plasma cell infiltration without neoplastic proliferation. He was diagnosed with IgG4-related sclerosing cholangitis (IgG4-SC) presenting hepatic inflammatory pseudotumor. After his general condition improved, he underwent left hepatectomy. Macroscopic findings showed extreme fibrosis of the Glissonean sheath of the umbilical portion, and diffuse granular lesion aggregated in the left lateral segment. Microscopic examination confirmed chronic cholangitis and dense portal fibrosis in the umbilical portion and diffuse xanthogranulomatous inflammation. This is the first case report of spontaneous rupture of the intrahepatic bile duct in patient with IgG4-SC.

[A Case of Type 1A Charcot-Marie-Tooth Disease Manifested by Oxaliplatin Administration of Neoadjuvant Chemotherapy in a Gastric Cancer Patient].

Herein, we report the manifestation of type 1A Charcot-Marie-Tooth disease(CMT)in a 54-year-old female gastric cancer patient caused by oxaliplatin(L-OHP)of neoadjuvant chemotherapy containing S-1 plus L-OHP(G-SOX). In this case, peripheral sensory neuropathy(PSN)appeared in both upper limbs immediately after the administration of L-OHP. Subsequently, we observed sensory neuropathy of gloves-socks type in both the upper and lower limbs and motor neuropathy in both lower limbs, which caused the patient to be unable to sit up. Physical examination revealed upside-down champagnebottle- like mild atrophy in both lower limbs and hollow feet in both legs, as well as the disappearance of deep tendon reflexes in both lower limbs. In her family history, her eldest daughter had undergone Achilles tendon elongation surgery for suspected CMT at the age of 3 years. Considering these, she was suspected to have CMT and was finally diagnosed with type 1A CMT based on genetic testing. In anti-cancer treatments that cause PSN(not just by L-OHP), possible involvement of occult peripheral nerve disease like CMT should be considered when more rapid and untypical PSN appears after the administration of anti-cancer drugs.

[Rupture of Ovarian Metastasis from Cecal Cancer during Chemotherapy - A Case Report Suggestive of Bilateral Salpingo-Oophorectomy].

A 66-year-old woman was diagnosed with advanced cecal cancer with metastases to her right ovary, peritoneum, and liver. Ileocecal resection and right salpingo-oophorectomy were performed as cytoreduction surgery before systemic chemotherapy. The colon cancer metastasized to her left ovary during chemotherapy and grew rapidly until it ruptured spontaneously, although the other metastases sites continued to respond to treatment. Emergent left salpingo-oophorectomy was performed. Pathological findings confirmed ovarian metastasis from colon cancer. Ovarian metastases are less responsive to systemic chemotherapy compared to extra-ovarian metastasis and the rapid growth sometimes occurs as a related symptom. Bilateral salpingo-oophorectomy might be recommended in cytoreduction surgery even if the ovarian metastasis is unilateral.